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

Surgery. 2012 Jan 26;

Authors: Marangos IP, Buanes T, Røsok BI, Kazaryan AM, Rosseland AR, Grzyb K, Villanger O, Mathisen O, Gladhaug IP, Edwin B

Abstract

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

PMID: 22284762 [PubMed - as supplied by publisher]

Early surgical outcomes comparison between robotic and conventional open thyroid surgery for papillary thyroid microcarcinoma.

Surgery. 2012 Jan 26;

Authors: Lee S, Ryu HR, Park JH, Kim KH, Kang SW, Jeong JJ, Nam KH, Chung WY, Park CS

Abstract

BACKGROUND: Robotic operations have enabled a safer and more meticulous approach to thyroidectomy with the notable benefit of improved cosmesis and decreases in postoperative pain and swallowing discomfort. The aim of this study was to document the early surgical outcomes of robotic thyroidectomy in patients with papillary thyroid carcinoma (PTC) by comparing it with conventional open thyroidectomy. METHODS: From October 2007 to September 2008, 458 patients with PTC underwent thyroidectomy at the Yonsei University Health System. Of these patients, 266 patients were in the conventional open group and 192 patients were in the robotic group. These 2 groups were compared retrospectively with respect to clinicopathologic characteristics and surgical outcomes. RESULTS: The mean follow-up period was 29.1 months. Mean tumor size, incidence of capsular invasion, multiplicity, and central nodal metastasis showed no significant difference between the 2 groups. Total thyroidectomy was performed more frequently in the open group. In terms of operation times, the robotic group had a significantly greater length of time for total thyroidectomy and subtotal thyroidectomy. The total number of retrieved central lymph nodes was greater in the open group (5.7 versus 4.6, P = .004). The 2 groups showed no differences in intraoperative and postoperative complications. The postoperative serum thyroglobulin levels were similar in both groups (0.25 versus 0.22 ng/mL, P = .648) and 2-year follow-up sonography of 433 patients revealed no recurrences. No abnormal I(131) uptake was observed in whole-body scans in either group. CONCLUSION: Robotic thyroidectomy was similar to conventional open thyroidectomy in terms of early surgical outcomes but offers advantages. We conclude that robotic thyroidectomy offers a safe, feasible alternative to conventional open thyroidectomy in patients with PTC.

PMID: 22284763 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 26;

Authors: Ho CM, Lee PH, Shau WY, Ho MC, Wu YM, Hu RH

Abstract

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

PMID: 22284764 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 26;

Authors: Orr WS, Denbo JW, Saab KR, Myers AL, Ng CY, Zhou J, Morton CL, Pfeffer LM, Davidoff AM

Abstract

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

PMID: 22284765 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 27;

Authors: Abbott DE, Brouquet A, Mittendorf EA, Andreou A, Meric-Bernstam F, Valero V, Green MC, Kuerer HM, Curley SA, Abdalla EK, Hunt KK, Vauthey JN

Abstract

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

PMID: 22285778 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 20;

Authors: van Heumen BW, Nieuwenhuis MH, van Goor H, Mathus-Vliegen LE, Dekker E, Gouma DJ, Dees J, van Eijck CH, Vasen HF, Nagengast FM

Abstract

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

PMID: 22265391 [PubMed - as supplied by publisher]

Selection algorithm for posterior versus lateral approach in laparoscopic adrenalectomy.

Surgery. 2012 Jan 17;

Authors: Agcaoglu O, Sahin DA, Siperstein A, Berber E

Abstract

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

PMID: 22261293 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 17;

Authors: Cucchetti A, Ercolani G, Cescon M, Bigonzi E, Peri E, Ravaioli M, Pinna AD

Abstract

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

PMID: 22261294 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 17;

Authors: Nordstrand N, Hertel JK, Hofsø D, Sandbu R, Saltvedt E, Røislien J, Os I, Hjelmesæth J

Abstract

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

PMID: 22261295 [PubMed - as supplied by publisher]

Variations in surgical outcomes associated with hospital compliance with safety practices.

Surgery. 2012 Jan 17;

Authors: Brooke BS, Dominici F, Pronovost PJ, Makary MA, Schneider E, Pawlik TM

Abstract

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

PMID: 22261296 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 16;

Authors: Sonbare D

PMID: 22257831 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 11;

Authors: Moriya T, Fukatsu K, Maeshima Y, Ikezawa F, Hashiguchi Y, Saitoh D, Miyazaki M, Hase K, Yamamoto J

Abstract

BACKGROUND: Parenteral nutrition (PN) is indispensable for meeting caloric and substrate needs of patients who cannot receive adequate amounts of enteral nutrition; however, PN impairs hepatic immunity. We examined the effects of ω-3 and -6 polyunsaturated fatty acids, added individually to fat-free PN, on hepatic immunity in a murine model. We focused on serum liver enzymes, cytokine production, histopathology, and the outcomes after intraportal bacterial challenge. METHODS: Male Institute of Cancer Research mice were randomized into 4 groups; ad libitum chow (CHOW), fat-free PN (FF-PN), PN + fish oil (FO-PN), or PN + safflower oil (SO-PN). After the mice had been fed for 5 days, hepatic mononuclear cells (MNCs) were isolated. The number of MNCs was counted and cytokine production (tumor necrosis factor [TNF]-α and interleukin [IL]-10) by hepatic MNCs in response to lipopolysaccharide (LPS) was measured. Blood samples were analyzed for hepatobiliary biochemical parameters. Moreover, 1.0 × 10(7) pseudomonas aeruginosa were delivered by intraportal injection. Survival and histology were examined. RESULTS: Hepatic MNC numbers were significantly less in the FO-PN and FF-PN than in the CHOW group, whereas the SO-PN group showed moderate recovery of hepatic MNC numbers. The CHOW, FO-PN, and SO-PN groups showed LPS dose-dependent increases in TNF-α levels. These increases were blunted in the FF-PN group. IL-10 levels were increased LPS dose-dependently in the CHOW and FO-PN groups, but no marked changes were observed with LPS stimulation in the SO-PN and FF-PN groups. Plasma levels of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase were significantly greater in the FF-PN than in the FO- and SO-PN and CHOW groups. The FO-PN group showed significantly improved survival compared with the SO-PN and FF-PN groups, showing essentially no morphologic hepatic abnormalities. CONCLUSION: Addition of fish oil to PN was advantageous in terms of reversing PN-induced deterioration of hepatic immunity, as reflected by altered cytokine production. Fish oil administration was also useful for preventing PN-induced hepatobiliary dysfunction. These changes seem to result in better survival and to protect against severe tissue damage after intraportal bacterial challenge. This therapy may have the potential to ameliorate PN-induced impairment of host immunity and thereby decrease morbidity and mortality.

PMID: 22244177 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 11;

Authors: Mainthia R, Lockney T, Zotov A, France DJ, Bennett M, St Jacques PJ, Furman W, Randa S, Feistritzer N, Eavey R, Leming-Lee S, Anders S

Abstract

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

PMID: 22244178 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 11;

Authors: Falcone JL, Hamad GG

PMID: 22244179 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 11;

Authors: Tsujimoto H, Takahata R, Nomura S, Yaguchi Y, Kumano I, Matsumoto Y, Yoshida K, Horiguchi H, Hiraki S, Ono S, Yamamoto J, Hase K

Abstract

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

PMID: 22244180 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 11;

Authors: Nara S, Shimada K, Sakamoto Y, Esaki M, Kishi Y, Kosuge T, Ojima H

Abstract

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

PMID: 22244181 [PubMed - as supplied by publisher]

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

Surgery. 2012 Jan 11;

Authors: Roberts NK, Brenner MJ, Williams RG, Kim MJ, Dunnington GL

Abstract

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

PMID: 22244182 [PubMed - as supplied by publisher]

Melanoma-assocıated hypopıgmentatıon ın assocıatıon wıth locoregıonal relapse of melanoma.

Surgery. 2011 Nov;150(5):1011-2

Authors: Tas F

PMID: 20416916 [PubMed - indexed for MEDLINE]

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

Surgery. 2011 Dec 6;

Authors: Mihaescu A, Thornberg C, Santén S, Mattsson S, Jeppsson B, Thorlacius H

Abstract

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

PMID: 22153123 [PubMed - as supplied by publisher]

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

Surgery. 2011 Dec 7;

Authors: Zhang HY, James I, Chen CL, Besner GE

Abstract

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

PMID: 22153812 [PubMed - as supplied by publisher]

Papillary carcinoma of the thyroid: Balancing principles of oncology with emerging technology.

Surgery. 2011 Dec;150(6):1015-22

Authors: Evans DB

PMID: 22136816 [PubMed - in process]

Molecular pathways associated with mortality in papillary thyroid cancer.

Surgery. 2011 Dec;150(6):1023-31

Authors: Nilubol N, Sukchotrat C, Zhang L, He M, Kebebew E

Abstract

BACKGROUND: A better understanding of the molecular mechanisms involved in papillary thyroid cancer (PTC)-associated adverse outcome is needed to manage these patients effectively. Our objectives were to identify molecular pathways associated with unfavorable features and outcomes in patients with PTC.

METHODS: We performed genome-wide expression (GWE) analysis in 64 human tissue samples affected by PTC. Clinical, pathologic, and microarray data were analyzed to identify differentially expressed genes and pathways associated with unfavorable outcomes. Gene set enrichment analysis (GSEA) was used to determine which molecular pathways are associated with mortality.

RESULTS: GWE analysis identified 43, 115, and 40 genes that were significantly differentially expressed by gender, tumor differentiation status, and mortality, respectively, with a false-discovery rate of <5%. For mortality, GSEA revealed 7 enriched pathways, including transfer RNA synthesis, mitochondria and oxidative phosphorylation, porphyrin and chlorophyll metabolism, and fatty acid synthesis. Leading-edge analysis showed that 341 genes were significantly involved in the enriched pathways. Cluster analysis using 100 differentially expressed genes showed complete separation of patients by mortality.

CONCLUSION: To our knowledge, this is the first GWE analysis of PTC and adverse outcomes. We found 11 molecular pathways that were significantly associated with mortality resulting from PTC. A 100-gene signature completely separates patients with and without PTC-associated mortality.

PMID: 22136817 [PubMed - in process]

Necroptosis is a novel mechanism of radiation-induced cell death in anaplastic thyroid and adrenocortical cancers.

Surgery. 2011 Dec;150(6):1032-9

Authors: Nehs MA, Lin CI, Kozono DE, Whang EE, Cho NL, Zhu K, Moalem J, Moore FD, Ruan DT

Abstract

BACKGROUND: Necroptosis is a recently described mechanism of programmed cellular death. We hypothesize that necroptosis plays an important role in radiation-induced cell death in endocrine cancers.

METHODS: Thyroid and adrenocortical carcinoma cell lines were exposed to increasing doses of radiation in the presence of necroptosis inhibitor Nec-1 and/or apoptosis-inhibitor zVAD. H295R cells deficient in receptor interacting protein 1 (RIP1), an essential kinase for necroptosis, were used as controls. Survival curves were generated at increasing doses of radiation.

RESULTS: Nec-1 and zVAD increased cellular survival with increasing doses of radiotherapy in 8505c, TPC-1, and SW13. Both inhibitors used together had an additive effect. At 6 Gy, 8505c, TPC-1, and SW13 cell survival was significantly increased compared to controls by 40%, 33%, and 31% with Nec-1 treatment, by 53%, 47%, and 44% with zVAD treatment, and by 80%, 70%, and 65% with both compounds, respectively (P < .05). H295R showed no change in survival with Nec-1 treatment. The radiobiologic parameter quasithreshold dose was significantly increased in 8505c, TPC-1, and SW13 cells when both Nec-1 and zVAD were used in combination to inhibit necroptosis and apoptosis together, revealing resistance to standard doses of fractionated therapeutic radiation.

CONCLUSION: Necroptosis contributes to radiation-induced cell death. Future studies should investigate ways to promote the activation of necroptosis to improve radiosensitivity.

PMID: 22136818 [PubMed - in process]

Novel therapy for anaplastic thyroid carcinoma cells using an oncolytic vaccinia virus carrying the human sodium iodide symporter.

Surgery. 2011 Dec;150(6):1040-7

Authors: Gholami S, Haddad D, Chen CH, Chen NG, Zhang Q, Zanzonico PB, Szalay AA, Fong Y

Abstract

BACKGROUND: Anaplastic thyroid carcinoma (ATC) is fatal with resistance to radiotherapy because of the loss of intrinsic human sodium iodine symporter (hNIS). We determined whether vaccinia virus carrying hNIS kills and induces hNIS reexpression in ATC cells, facilitating deep-tissue imaging.

METHODS: Vaccinia virus (GLV-1h153) carrying hNIS was tested against ATC lines for killing and replication via cytotoxicity and viral plaque assays. Cellular radiouptake was determined using radiouptake assays. GLV-1h153-infected ATC xenografts were imaged via (99m)Tc-pertechnetate.

RESULTS: GLV-1h153 infected, replicated in, and killed all ATC cell lines. GFP expression confirmed viral infection by 24 hours. At a multiplicity of infection (MOI) of 1.0, GLV-1h153 reached near 100% cytotoxicity in 8305c and FRO by day 5 and 70% in the least sensitive cell line, 8505c. GLV-1h153-infected ATC cells had a 14-fold increase of hNIS-specific radiouptake compared with uninfected control 24 hours after infection at an MOI of 1.0. In vivo, GLV-1h153 facilitated imaging of hNIS expression in 8505c tumors using (99m)Tc-pertechnetate.

CONCLUSION: GLV-1h153 is an effective oncolytic agent against ATC. The results show hNIS-specific radiouptake in infected ATC cells, facilitating deep-tissue imaging. GLV-1h153 is a promising candidate for treatment and imaging, and potentially enhancing susceptibility to radioiodine therapy by converting non-hNIS-expressing cells into hNIS-expressing ATC cells.

PMID: 22136819 [PubMed - in process]

A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer.

Surgery. 2011 Dec;150(6):1048-57

Authors: Popadich A, Levin O, Lee JC, Smooke-Praw S, Ro K, Fazel M, Arora A, Tolley NS, Palazzo F, Learoyd DL, Sidhu S, Delbridge L, Sywak M, Yeh MW

Abstract

BACKGROUND: The role of routine central lymph node dissection (CLND) for papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the impact of routine CLND after total thyroidectomy (TTx) in the management of patients with PTC who were clinically node negative at presentation with emphasis on stimulated thyroglobulin (Tg) levels and reoperation rates.

METHODS: This retrospective, multicenter, cohort study used pooled data from 3 international Endocrine Surgery units in Australia, the United States, and England. All study participants had PTC >1 cm without preoperative evidence of lymph node disease (cN0). Group A patients had TTx alone and group B had TTx with the addition of CLND.

RESULTS: There were 606 patients included in the study. Group A had 347 patients and group B 259 patients. Stimulated Tg values were lower in group B before initial radioiodine ablation (15.0 vs 6.6 ng/mL; P = .025). There was a trend toward a lower Tg at final follow-up in group B (1.9 vs 7.2 ng/mL; P = .11). The rate of reoperation in the central compartment was lower in group B (1.5 vs 6.1%; P = .004). The number of CLND procedures required to prevent 1 central compartment reoperation was calculated at 20.

CONCLUSION: The addition of routine CLND in cN0 papillary thyroid carcinoma is associated with lower postoperative Tg levels and reduces the need for reoperation in the central compartment.

PMID: 22136820 [PubMed - in process]

Prophylactic central compartment neck dissection for papillary thyroid cancer: The search for justification continues.

Surgery. 2011 Dec;150(6):1058-60

Authors: McHenry CR

PMID: 22136821 [PubMed - in process]

The effect of vitamin D levels on postoperative calcium requirements, symptomatic hypocalcemia, and parathormone levels following parathyroidectomy for primary hyperparathyroidism.

Surgery. 2011 Dec;150(6):1061-8

Authors: Press D, Politz D, Lopez J, Norman J

Abstract

BACKGROUND: Low vitamin D-25 is common in primary hyperparathyroidism but the effect of this deficiency on postparathyroidectomy calcium requirements is unclear.

METHODS: A prospective study was conducted on 4 groups based on preoperative vitamin D-25 levels: very low (<20 ng/mL, n = 500); low (21 to 30 ng/mL, n = 500); normal (>30 ng/mL, n = 500); and supplemented (<25 ng/mL supplemented to >40 ng/mL, n = 285). Patients were placed on identical postoperative oral calcium regimens, and hypocalcemia symptoms were recorded. Total calcium requirements for 2 weeks postoperation were calculated and parathormone (PTH) levels were measured for 2-6 months.

RESULTS: Mean vitamin D levels (ng/mL) for each group were: very low (14.2); low (24.4); normal (38.3); and supplemented (16.5 supplemented to 54.3). Postoperative oral calcium requirements (in grams) were identical for all groups (18.7, 18.2, and 18.6, and 19.0, respectively, all P = NS); the incidence and timing of hypocalcemia symptoms were nearly identical for all groups: 8.1%, 7.9%, and 7.8% (P = .8). Elevated postsurgical PTH was identical (below 8%) and was not influenced by vitamin D levels.

CONCLUSION: The incidence of hypocalcemic symptoms and the postoperative calcium requirements are identical for patients with very low, low, normal, or supplemented (high) vitamin D. The incidence of persistently elevated PTH postoperatively is also unrelated to preoperative vitamin D levels. Vitamin D supplementation from very low to high levels has no clinical benefit.

PMID: 22136822 [PubMed - in process]

Transient increases in intraoperative parathyroid levels related to anesthetic technique.

Surgery. 2011 Dec;150(6):1069-75

Authors: Hong JC, Morris LF, Park EJ, Ituarte PH, Lee CH, Yeh MW

Abstract

BACKGROUND: Parathyroid hormone (PTH) secretion is partially regulated by circulating catecholamines. We examined the effect of different anesthetic techniques on intraoperative PTH (IOPTH) levels in patients undergoing parathyroidectomy for primary hyperparathyroidism.

METHODS: We prospectively studied 132 patients divided into 3 anesthetic cohorts: monitored anesthetic care (MAC; n = 45), general anesthesia with laryngeal mask airway (LMA; n = 43), or general endotracheal anesthesia (GETA; n = 39). IOPTH levels were drawn before induction and at defined intervals postinduction.

RESULTS: All anesthetic techniques increased IOPTH levels from preinduction to 3 minutes postinduction (MAC, 28%; LMA, 45%; GETA, 65%; P < .001). Temporal trends in postinduction IOPTH levels were similar in patients receiving general anesthesia, characterized by a peak effect at 6 minutes. Using a multivariate logistic regression analysis, GETA was >7 times more likely to increase the preinduction IOPTH by ≥50% at 3 minutes postinduction compared with MAC (P < .0001). Using immediate postinduction IOPTH levels in surgical decision making would have led to failed surgery in 2 of 6 patients with multiple gland disease receiving GETA.

CONCLUSION: Preincision IOPTH samples should be drawn before induction to avoid incorporation of potentially misleading anesthetic-related IOPTH elevations into surgical decision making.

PMID: 22136823 [PubMed - in process]

Normocalcemic parathormone elevation after successful parathyroidectomy: Long-term analysis of parathormone variations over 10 years.

Surgery. 2011 Dec;150(6):1076-84

Authors: Goldfarb M, Gondek S, Irvin GL, Lew JI

Abstract

BACKGROUND: The long-term significance of normocalcemic parathormone elevation (NPE) after successful parathyroidectomy for sporadic primary hyperparathyroidism remains unclear.

METHOD: Of 239 consecutive patients who underwent targeted parathyroidectomy with intraoperative parathormone monitoring, 96 were followed for ≥10 years. NPE was defined as a normal serum calcium level and parathormone (PTH) above the normal reference range ≥6 months after successful parathyroidectomy. Recurrence was defined as elevated serum calcium and PTH levels ≥6 months after parathyroidectomy. Risk factors for NPE, patterns of postoperative PTH variation, and 10-year outcomes were analyzed.

RESULTS: Of 96 patients followed ≥10 years, 42 had postoperative NPE. Only male gender (P = .008) was a risk factor for NPE, and NPE did not predict recurrence. Three patterns of postoperative NPE were identified in patients with ≥3 PTH measurements over this 10-year period. Group 1 (n = 11): 1 to 2 consecutive PTH elevations; none recurred, and most were explained by physiologic variation. Group 2 (n = 23): multiple PTH fluctuations; 3 recurred, and almost all had physiologic variations. Group 3 (n = 4): PTH always elevated; 2 recurred.

CONCLUSION: Postoperative NPE may be a dynamic, reversible, and transient clinical entity that does not predict recurrence. Nevertheless, patients with postoperative NPE should be monitored and an attempt made to correct any obvious potential causes of PTH elevation.

PMID: 22136824 [PubMed - in process]

Risk stratification of indeterminate thyroid fine-needle aspiration biopsy specimens based on mutation analysis.

Surgery. 2011 Dec;150(6):1085-91

Authors: Filicori F, Keutgen XM, Buitrago D, Aldailami H, Crowley M, Fahey TJ, Zarnegar R

Abstract

BACKGROUND: Mutation analysis is potentially a powerful tool to enhance the diagnostic accuracy of thyroid fine-needle aspiration (FNA) biopsy specimens. However, some clinicians may rely on a negative mutation panel to exclude malignancy. We aimed to determine the malignancy rate in indeterminate lesions with negative mutation analysis.

METHODS: A literature review established a mutation analysis model using the prevalence of BRAF, RET, RAS, and PAX8/peroxisome proliferator-activated receptor-γ mutations in indeterminate lesions. This model was applied retrospectively to a study cohort of 466 consecutive indeterminate lesions that underwent hemi- or total thyroidectomy for definitive diagnosis, to evaluate its accuracy for identifying malignancy.

RESULTS: Of 466 indeterminate lesions in the study, 30% (139) were malignant. These included 66 cases of papillary thyroid cancer, 45 cases of follicular variant of papillary thyroid cancer, 18 cases of follicular thyroid cancer, and 10 others. The risk of malignancy was 42% when cytologic atypia was present vs 17% without. The mutation analysis model would correctly identify only 48 of 139 (34%) of malignant indeterminate lesions. Therefore, when mutation analysis is negative, the overall risk of malignancy would be 23%. When atypia is present, the risk of malignancy would be 31% vs 13% in lesions without.

CONCLUSION: Indeterminate lesions with a negative mutation analysis still carry a significant risk of malignancy, especially in the presence of atypia, requiring surgery for definitive diagnosis.

PMID: 22136825 [PubMed - in process]

Good question.

Surgery. 2011 Dec;150(6):1092-4

Authors: Carty SE, Zeiger MA

PMID: 22136826 [PubMed - in process]

Elevated parathyroid hormone predicts mortality in dialysis patients undergoing valve surgery.

Surgery. 2011 Dec;150(6):1095-101

Authors: Yan H, Sharma J, Weber CJ, Guyton RA, Perez S, Thourani VH

Abstract

BACKGROUND: Dialysis patients requiring valve surgery have high morbidity and mortality rates. Although elevated serum parathyroid hormone (PTH) levels are associated with increased mortality in dialysis patients, this correlation has not been investigated in patients undergoing cardiac valve operations. This study assesses the impact of PTH levels on mortality in dialysis patients undergoing valve operations.

METHODS: A retrospective analysis of 109 dialysis patients undergoing valve operation with preoperative PTH levels between 1996 and 2007 at a US academic center was performed. Cox regression analyses were done using PTH as a binary variable. The patients were followed from the date of the operative procedure until death or loss to follow-up.

RESULTS: Higher mortality risk was seen once preoperative PTH exceeded 200 pg/mL (hazard ratio [HR], 3.43; P = .003). Mean survival was improved in the PTH < 200 pg/mL group when compared with the PTH ≥ 200 pg/mL group (86.7 vs 40.3 months, respectively). Other independent predictors of mortality included serum phosphate (HR, 1.20; P = .017), calcium-phosphate product (HR, 1.02; P = .038), and history of myocardial infarction (HR, 2.12; P = .015).

CONCLUSION: Preoperative PTH level ≥ 200 pg/mL is predictive of increased mortality after valve surgery among dialysis patients. Hyperparathyroidism should be investigated further as a possible modifiable risk factor for postoperative mortality in this high-risk patient cohort.

PMID: 22136827 [PubMed - in process]

The phenotype of primary hyperparathyroidism with normal parathyroid hormone levels: How low can parathyroid hormone go?

Surgery. 2011 Dec;150(6):1102-12

Authors: Wallace LB, Parikh RT, Ross LV, Mazzaglia PJ, Foley C, Shin JJ, Mitchell JC, Berber E, Siperstein AE, Milas M

Abstract

BACKGROUND: While normocalcemic hyperparathyroidism is well recognized in primary hyperparathyroidism (PHP), less is known about patients with high calcium but normal intact parathyroid hormone (iPTH). We aimed to describe this entity and designated it normohormonal primary hyperparathyroidism (NHPHP).

METHODS: From a prospectively maintained database of patients undergoing bilateral parathyroid exploration for PHP, we identified and compared those with preoperative iPTH levels below (NHPHP) and above (typical PHP) normal reference peak (60 pg/mL).

RESULTS: NHPHP occurred in 46 of 843 patients (5.5%) undergoing initial parathyroidectomy for PHP. All had hypercalcemia (11.1 mg/dL). Regarding preoperative iPTH, 7 patients (15%) had values <40 pg/mL, 19 (41%) had values <60 pg/mL; and 20 (44%) had intermittent values >60 pg/mL. Unlike patients with elevated iPTH, nearly all NHPHP patients had additional testing delaying the operation. Imaging correctly localized NHPHP parathyroid disease in 80%. At the time of operation, 74% of NHPHP patients had single adenomas. Intraoperatively postmobilization, using the same assay that was used preoperatively, 82% had PTH levels >60 pg/mL (mean, 279 pg/mL). During the follow-up period, iPTH levels remained lower among NHPHP patients (21 pg/mL) compared to 41 pg/mL for patients with preoperative iPTH 60 to 100 pg/mL and 56 pg/mL for patients with preoperative iPTH 100 to 200 pg/mL (P < .0001).

CONCLUSION: Lower PTH set points may exist in some patients with otherwise typical PHP features. Although high normal iPTH is inappropriate for hypercalcemia and should suggest PHP, this disorder may occur with iPTH levels as low as 5 pg/mL. Awareness of the unusual phenotype of NHPHP may facilitate earlier diagnosis and surgery.

PMID: 22136828 [PubMed - in process]

Population-level predictors of persistent hyperparathyroidism.

Surgery. 2011 Dec;150(6):1113-9

Authors: Yeh MW, Wiseman JE, Chu SD, Ituarte PH, Amy Liu IL, Young KL, Kang SJ, Harari A, Haigh PI

Abstract

BACKGROUND: Systematic study of outcomes of initial surgery for primary hyperparathyroidism (PHPT) has been limited by selection and self-reporting biases. To avoid these biases, we evaluated parathyroidectomy (PTx) outcomes within an integrated health care system encompassing 3.25 million enrollees.

METHODS: All patients undergoing PTx for PHPT from 1995 to 2010 were studied. Persistent and recurrent disease were defined by a serum calcium level >10.5 mg/dL before or after 6 months postoperatively, respectively. The effect of demographic, clinical, and hospital volume-related variables was assessed by the use of multivariate logistic regression.

RESULTS: A total of 1,190 initial operations for PHPT were performed at 14 hospitals. Follow-up calcium levels were available in 97% of subjects. The overall success rate was 92%, and 5% of patients developed recurrent disease. Age ≥70 years was predictive of persistent disease (odds ratio 1.80, P < .05). High-volume hospital (>100 cases) predicted against persistent disease (odds ratio 0.42, P < .05) and carried 96% success rate. Negative or equivocal sestamibi scan was associated with a lower success rate (success rate 89% vs 95% for positive scan, P < .05). Reoperation was performed in 12% of patients with persistent or recurrent PHPT.

CONCLUSION: The success rate of PTx is influenced by patient age, hospital volume, and sestamibi scan result. Surgical outcomes may be optimized by designating high-volume centers in the community setting.

PMID: 22136829 [PubMed - in process]

Population-level predictors of persistent hyperparathyroidism.

Surgery. 2011 Dec;150(6):1120-1

Authors: Perrier ND, Evans DB

PMID: 22136830 [PubMed - in process]

Comparison of 6-(18)F-Fluoro-l-DOPA, (18)F-2-deoxy-d-glucose, CT, and MRI in patients with pancreatic neuroendocrine neoplasms with von Hippel-Lindau disease.

Surgery. 2011 Dec;150(6):1122-8

Authors: Kitano M, Millo C, Rahbari R, Herscovitch P, Gesuwan K, Webb RC, Venkatesan AM, Phan GQ, Hughes MS, Libutti SK, Nilubol N, Linehan WM, Kebebew E

Abstract

INTRODUCTION: There are limited data on the utility of 6-(18)F-fluoro-l-3,4-dihydroxyphenylalanine ((18)F-DOPA) and (18)F-2-deoxy-d-glucose ((18)F-FDG) in the workup of patients with pancreatic neuroendocrine tumors (PNETs). The aim of our study was to determine the accuracy of (18)F-DOPA and (18)F-FDG to detect PNETs in patients with von Hippel-Lindau disease (vHL).

METHODS: We studied prospectively 69 patients with a diagnosis of vHL and pancreatic lesion(s) using computed tomography (CT), magnetic resonance imaging (MRI), (18)F-FDG, and (18)F-DOPA. Clinical, genetic, and laboratory characteristics were analyzed to determine association with imaging study results.

RESULTS: In sum, 40 patients underwent evaluation by all 4 modalities; 98 PNETs and 55 PNETs were identified on CT and MRI, respectively. Only 11 of the 98 lesions (11%) were positive on (18)F-DOPA and 45 of the 98 (46%) lesions were positive on (18)F-FDG. There were 13 (18)F-DOPA and 26 (18)F-FDG avid extrapancreatic lesions. One patient underwent resection of an (18)F-DOPA avid extrapancreatic lesion in the lung, with pathology demonstrating a NET. There was no association between (18)F-DOPA and (18)F-FDG avidity and tumor size, age, gender, vHL mutation, or serum chromogranin A level.

CONCLUSION: (18)F-FDG and MRI may be adjuncts to CT in identifying PNETs and metastatic disease. (18)F-DOPA has limited value in identifying PNETs in patients with vHL, but may be useful for identifying extrapancreatic NET lesions.

PMID: 22136831 [PubMed - in process]

Zollinger-Ellison syndrome associated with a history of alcohol abuse: Coincidence or consequence?

Surgery. 2011 Dec;150(6):1129-35

Authors: Wilson SD, Doffek KM, Krzywda EA, Quebbeman EJ, Christians KK, Pappas SG

Abstract

BACKGROUND: This 47-year observational study suggests that sporadic Zollinger-Ellison (Z-E) syndrome, particularly duodenal wall gastrinomas (DWG), is associated with a history of alcohol abuse.

METHODS: Thirty-nine consecutive Z-E patients were followed from 1962 through 2010. The drinking patterns of these patients were assessed and compared with 3,786 community controls.

RESULTS: Thirty-five patients had extrapancreatic gastrinomas (34 DWG and/or paraduodenal lymph nodes, 1 antral gastrinoma). Total gastrectomy was done in 24; 9 underwent less extensive operations to remove DWG, and 2 patients had no operations. There were no deaths from tumor progression. Four patients presented with pancreatic gastrinoma (PG) and liver metastasis, all died from tumor progression. Alcohol abuse (>50 g/d) was documented in 81% of patients with DWG and/or paraduodenal lymph nodes. The drinking patterns (drinks per day) of DWG patients were significantly different: DWG vs community control-abstainers, 3% vs 24%; 1-2 drinks, 16% vs 62%; 3-5 drinks, 29% vs 12%; and ≥6 drinks, 52% vs 2.5% (P < .01).

CONCLUSION: Alcohol abuse is strongly associated with and may be a risk factor for sporadic Z-E with extrapancreatic DWG. Liver metastases and tumor deaths were not observed in this subgroup, supporting the concept that DWG and PG are different tumor entities.

PMID: 22136832 [PubMed - in process]

SSTR5 P335L monoclonal antibody differentiates pancreatic neuroendocrine neuroplasms with different SSTR5 genotypes.

Surgery. 2011 Dec;150(6):1136-42

Authors: Zhou G, Gingras MC, Liu SH, Sanchez R, Edwards D, Dawson D, Christensen K, Paganelli G, Gibbs R, Fisher W, Brunicardi FC

Abstract

BACKGROUND: Somatostatin receptor type 5 (SSTR5) P335L is a hypofunctional, single nucleotide polymorphism of SSTR5 with implications in the diagnostics and therapy of pancreatic neuroendocrine neoplasms. The purpose of this study is to determine whether a SSTR5 P335L-specific monoclonal antibody could sufficiently differentiate pancreatic neuroendocrine neoplasms (PNENs) with different SSTR5 genotypes.

METHODS: Cellular proliferation rate, SSTR5 mRNA level, and SSTR5 protein level were measured by performing MTS assay, a quantitative reverse transcription polymerase chain reaction study, Western blot analysis, and immunohistochemistry, respectively. SSTR5 genotype was determined with the TaqMan SNP Genotyping assay (Applied Biosystems, Foster City, CA).

RESULTS: We found that the SSTR5 analogue RPL-1980 inhibited cellular proliferation of CAPAN-1 cells more than that of PANC-1 cells. Only PANC-1 (TT) cells, but not CAPAN-1 (CC) cells expressed SSTR5 P335L. In 29 white patients with PNENs, 38% had a TT genotype for SSTR5 P335L, 24% had a CC genotype for WT SSTR5, and 38% hada CT genotype for both SSTR5 P335L and WT SSTR5. Immunohistochemistry using SSTR5 P335L monoclonal antibody detected immunostaining signals only from the neuroendocrine specimens with TT and CT genotypes, but not those with CC genotypes.

CONCLUSION: A SSTR5 P335L monoclonal antibody that specifically recognizes SSTR5 P335L but not WT SSTR5 could differentiate PNENs with different SSTR5 genotypes, thereby providing a potential tool for the clinical diagnosis of PNEN.

PMID: 22136833 [PubMed - in process]

Achieving eugastrinemia in MEN1 patients: Both duodenal inspection and formal lymph node dissection are important.

Surgery. 2011 Dec;150(6):1143-52

Authors: Dickson PV, Rich TA, Xing Y, Cote GJ, Wang H, Perrier ND, Evans DB, Lee JE, Grubbs EG

Abstract

BACKGROUND: Controversy exists regarding the role and extent of operation for patients with multiple endocrine neoplasia type 1 (MEN1) and hypergastrinemia.

METHODS: An institutional MEN1 database was reviewed to identify patients with evidence of hypergastrinemia. The relationship of extent of resection to achievement of eugastrinemia was evaluated.

RESULTS: Operation was performed in 20 patients with MEN1 and hypergastrinemia with a median follow-up of 71 months. Duodenal gastrinomas were identified in 85% of patients who underwent duodenal evaluation. Nodal metastases were identified in 80%. Patients who underwent anatomic regional lymph node dissection (RLND) had a median of 16 nodes removed, vs 1 in patients who did not undergo a formal regional lymphadenectomy. Eugastrinemia was achieved in 12 patients (60%), and 8 (40%) had persistent hypergastrinemia. Compared with patients with persistent hypergastrinemia, patients rendered eugastrinemic more often underwent duodenal evaluation (11/12 vs 2/8; P = .01) and RLND (11/12 vs 3/8; P = .03); there was no relationship between pancreatic resection and achievement of eugastrinemia (P = .32).

CONCLUSION: For patients with MEN1-associated hypergastrinemia selected for operative treatment, a strategy including duodenal evaluation and anatomic regional lymphadenectomy is associated with long-term eugastrinemia. In contrast, the extent of pancreatic resection should be dictated by the extent and distribution of pancreatic neuroendocrine neoplasms, rather than by the presence of hypergastrinemia.

PMID: 22136834 [PubMed - in process]

Case series of targeted parathyroidectomy with surgeon-performed ultrasonography as the only preoperative imaging study.

Surgery. 2011 Dec;150(6):1153-60

Authors: Deutmeyer C, Weingarten M, Doyle M, Carneiro-Pla D

Abstract

BACKGROUND: Targeted parathyroidectomy for treatment of sporadic primary hyperparathyroidism (SPHPT) has become the preferred approach in many centers. Therefore, preoperative localization studies are increasingly important. Although surgeon-performed ultrasonography (SUS) is equivalent to sestamibi scanning (MIBI), many surgeons still obtain either a MIBI or both studies before cervical exploration. The goal of this study was to demonstrate the feasibility of targeted parathyroidectomy guided by intraoperative PTH monitoring (IPM) based on SUS localization alone.

METHODS: We studied 136 consecutive patients with SPHPT undergoing parathyroidectomy guided by IPM. Ninety-six (71%) patients had only SUS, whereas 40 (29%) also had a negative MIBI (total n = 136). Pre-, intra- and postoperative data were analyzed to evaluate SUS accuracy in localizing abnormal glands.

RESULTS: SUS correctly identified ≥1 abnormal gland in 90% (123/136) of the patients. Sensitivity and overall accuracy of SUS was 87% and 88%, respectively. Operative success was 99% with multiglandular disease incidence of 10%. Unilateral neck exploration was possible in the majority of patients.

CONCLUSION: Preoperative SUS is accurate in localizing hypersecreting glands; however, IPM remains paramount in determining the extent of neck dissection. The use of SUS as a single imaging method obviates the need for MIBI in most patients and decreases costs of parathyroidectomy guided by IPM.

PMID: 22136835 [PubMed - in process]

The incidence of central neck micrometastatic disease in patients with papillary thyroid cancer staged preoperatively and intraoperatively as N0.

Surgery. 2011 Dec;150(6):1161-7

Authors: Teixeira G, Teixeira T, Gubert F, Chikota H, Tufano R

Abstract

BACKGROUND: In papillary thyroid cancer, the incidence of regional lymph node metastasis in the central compartment has been reported to be between 21% and 60%. This study sought to establish the rate of micrometastatic disease in the central neck in patients staged as N0 by preoperative and intraoperative assessment.

METHODS: We studied 72 consecutive patients with diagnoses of papillary thyroid cancer without preoperative or intraoperative evidence of central neck metastases. They underwent total thyroidectomies and were given elective central compartment neck dissection (CCND) ispsilateral to the lobe harboring the tumor or bilaterally in cases of primary tumor located in the isthmus.

RESULTS: Of the patients, 30 underwent right CCND, 30 underwent left CCND, and in 12 cases the dissection was bilateral. The incidence of lymph node micrometastasis was 25%. Male gender and histologic type showed association with lymph node micrometasis. Among these cases, 7% had temporary vocal cord palsy, and 8% had temporary hypoparathyroidism. No cases of definitive vocal cord palsy or definitive hypocalcemia were observed. After the procedure 8 patients were up-staged according to the American Joint Committee on Cancer staging system.

CONCLUSION: Despite being a safe procedure, this relatively low rate of micrometastatic disease emphasizes the need for a careful weighing of the risks and benefits of elective CCND.

PMID: 22136836 [PubMed - in process]

Preoperative basal calcitonin and tumor stage correlate with postoperative calcitonin normalization in patients undergoing initial surgical management of medullary thyroid carcinoma.

Surgery. 2011 Dec;150(6):1168-77

Authors: Yip DT, Hassan M, Pazaitou-Panayiotou K, Ruan DT, Gawande AA, Gaz RD, Moore FD, Hodin RA, Stephen AE, Sadow PM, Daniels GH, Randolph GW, Parangi S, Lubitz CC

Abstract

BACKGROUND: The optimal initial operative management of medullary thyroid cancer (MTC) and the use of biomarkers to guide the extent of operation remain controversial. We hypothesized that preoperative serum levels of calcitonin and carcinoembryonic antigen (CEA) correlate with extent of disease and postoperative levels reflect the extent of operation performed.

METHODS: We assessed retrospectively clinical and pathologic factors among patients with MTC undergoing at least total thyroidectomy; these factors were correlated with biomarkers using regression analyses.

RESULTS: Data were obtained from 104 patients, 28% with hereditary MTC. Preoperative calcitonin correlated with tumor size (P < .001) and postoperative serum calcitonin levels (P = .01) after multivariable adjustment for lymph node positivity, extent of operation, and hereditary MTC. No patient with a preoperative calcitonin level of <53 pg/mL (n = 20) had lymph node metastases. TNM stage (P = .001) and preoperative calcitonin levels (P = .04), but not extent of operation, independently correlated with the failure to normalize postoperative calcitonin. Postoperative CEA correlated with positive margins (adjusted P = 04). Neither preoperative nor postoperative CEA was correlated with lymph node positivity or extent of surgery.

CONCLUSION: Preoperative serum calcitonin and TMN stage, but not extent of operation, were independent predictors of postoperative normalization of serum calcitonin levels. Future studies should evaluate preoperative serum calcitonin levels as a determinate of the extent of initial operation.

PMID: 22136837 [PubMed - in process]

A quantitative tool to assess degree of sarcopenia objectively in patients with hypercortisolism.

Surgery. 2011 Dec;150(6):1178-85

Authors: Miller BS, Ignatoski KM, Daignault S, Lindland C, Gauger PG, Doherty GM, Wang SC,

Abstract

BACKGROUND: Muscle weakness and wasting are known manifestations of hypercortisolism (HC). Central sarcopenia is a marker of frailty and predicts mortality. The hypothesis of this study is that central sarcopenia can be used as a marker of disease severity and frailty in patients with HC.

METHODS: Psoas muscle area and psoas muscle density (PMD) were measured at specific points on CT scans of patients with HC using a defined protocol. We compared 24-hour urine cortisol (24HUC) levels by time point to each CT scan. A linear regression model was used to describe the relationship between 24HUC and morphometric variables. A comparison with matched non-HC patients was performed.

RESULTS: We identified 45 patients (34 female). The median age was 46 years (range, 14-80); the median 24HUC was 211 mg/dL (range, 9.5-39,500); the median PMD was 50.1 24HUC (range, 20-72). An inverse correlation (-0.29) between 24HUC levels and PMD was noted (P = .045). Intra-abdominal fat was also significantly and positively correlated with 24HUC: 27 non-HC patients matched for age, sex, and body-mass index showed higher (58 vs 51) PMD (P = .0127) compared to those with HC.

CONCLUSION: PMD and intra-abdominal fat are significantly related to 24HUC levels. Morphometric measures of the overall burden of HC may allow more precise assessment of disease severity.

PMID: 22136838 [PubMed - in process]

Comparison of clinical and imaging features in succinate dehydrogenase-positive versus sporadic paragangliomas.

Surgery. 2011 Dec;150(6):1186-93

Authors: Venkatesan AM, Trivedi H, Adams KT, Kebebew E, Pacak K, Hughes MS

Abstract

BACKGROUND: Limited data exist concerning the clinical and imaging features that distinguish sporadic from familial paragangliomas (PGLs).

METHODS: Clinical, genetic (succinate dehydrogenase [SDHB] vs no SDHx), and imaging (computed tomography [CT], magnetic resonance imaging, (18)F-fluoro-deoxy-glucose positron emission tomography [(18)F-FDG-PET]) features obtained during a decade in 124 PGL patients were studied. Data were analyzed by Fisher’s exact test or Wilcoxon rank-sum test.

RESULTS: Mean age at diagnosis was younger in the SDHB-positive (SDHB+) group compared with the sporadic (no SDHx) group (28 vs 39 years, respectively, P < .001). Rate of supradiaphragmatic neoplasms were greater in the SDHB+ group (16.7 vs 4.7%, P = .11). Metastasis rates were greater in the SDHB+ group (78.9 vs 48.3%, P < .001), as was the existence of metastases or multiple PGLs at presentation (38.5 vs 16.7%, P < .05). Tumor volumes >250 mL were exclusively observed in SDHB+ patients (P < .05). On CT, SDHB+ tumors were more enhanced (P < .05). On (18)F-FDG-PET, SDHB+ tumors’ had greater mean standard uptake values (12.3 vs 8.0, P < .05).

CONCLUSION: Clinically young age, large tumor volume, greater rate of metastatic and multifocal PGLs, greater SUV values on (18)F-FDG-PET, and increased CT enhancement are observed in SDHB+ PGLs. These findings may warrant genetic screening. Because SDHB+ patients demonstrate more supradiaphragmatic lesions, whole-body imaging may be of particular value in these patients.

PMID: 22136839 [PubMed - in process]

Is genetic screening indicated in apparently sporadic pheochromocytomas and paragangliomas?

Surgery. 2011 Dec;150(6):1194-201

Authors: Iacobone M, Schiavi F, Bottussi M, Taschin E, Bobisse S, Fassina A, Opocher G, Favia G

Abstract

BACKGROUND: Pheochromocytoma (Pheo) is usually considered a sporadic disease. Recently, an increasing rate of genetically based tumors has been reported. However, the need for systematic screening of unsuspected germline mutations in apparently sporadic forms is still debated. This study aimed to assess the effective rate of germline mutations causing Pheo and Paraganglioma (PGL), and the role of systematic genetic screening.

METHODS: Demographics, clinical, and genetic evaluation were performed in a series of 71 patients with Pheo and/or PGL.

RESULTS: Twelve patients had evident inherited/familial disease at presentation: NF1 (n = 4); MEN2 (n = 4), and familial Pheo/PGL (n = 4). Among 59 patients with apparently sporadic disease, unsuspected germline mutations occurred in 8 cases: TMEM127 (n = 4), SDHB (n = 2), VHL (n = 1), SDHC (n = 1). No differences were found between hereditary and sporadic disease concerning age, sex, and tumor size; bilateral Pheo and/or PGL and recurrences occurred most often in hereditary disease.

CONCLUSION: Hereditary Pheo and/or PGL are frequent (28.2%). Inheritance is evident at presentation only in 16.9% of cases; 13.6% of apparently sporadic variants are genetically determined. Despite increased costs, systematic genetic screening might be useful because it might lead to a stricter follow-up, early diagnosis of recurrences in index cases and presymptomatic detection of disease in relatives.

PMID: 22136840 [PubMed - in process]

Cardiovascular dysfunction and catecholamine cardiomyopathy in pheochromocytoma patients and their reversal following surgical cure: Results of a prospective case-control study.

Surgery. 2011 Dec;150(6):1202-11

Authors: Agarwal G, Sadacharan D, Kapoor A, Batra A, Dabadghao P, Chand G, Mishra A, Agarwal A, Verma AK, Mishra SK

Abstract

BACKGROUND: Cardiovascular (CV) dysfunction and cardiomyopathy can cause perioperative morbidity in pheochromocytoma patients, but have not been studied systematically. This prospective, case-control study evaluated nature and extent of CV dysfunctions and their reversal following curative pheochromocytoma surgery.

METHODS: Thirty-five pheochromocytoma patients, 9 normotensive nonpheochromocytoma adrenal tumors and 10 essential hypertensives were evaluated with 2-dimensional echocardiography, tissue Doppler, and serum N-terminal pro-brain natriuretic peptide (s-NTpro-BNP, a sensitive myocardial damage biomarker) serially before and after treatment.

RESULTS: Pheochromocytoma patients had systolic and diastolic dysfunction, reduced left ventricular (LV) ejection fraction (EF), increased LV end-diastolic and systolic dimensions and volumes, myocardial performance index, and decreased transmitral early/late velocity ratio, which were worse compared with controls. All indices improved significantly with α-blockade and after pheochromocytoma resection, and normalized over 3-6 months. Tissue Doppler early velocity was lower (P = .04) and s-NT-proBNP higher (P = .0001) in pheochromocytoma patients compared with controls. Seven pheochromocytoma patients (20%) had significant LV dysfunction (LVEF <45%; s-NTpro-BNP levels >500 pg/mL) and had more marked postoperative improvement.

CONCLUSION: Global LV diastolic and systolic dysfunctions specific to pheochromocytoma are common and improve early postoperatively, with sustained improvement upon follow-up. Detailed cardiac evaluation with echocardiography, tissue Doppler, and s-NTpro-BNP may help to reduce perioperative morbidity and monitor recovery in pheochromocytoma patients.

PMID: 22136841 [PubMed - in process]

Prospective application of our novel prognostic index in the treatment of anaplastic thyroid carcinoma.

Surgery. 2011 Dec;150(6):1212-9

Authors: Orita Y, Sugitani I, Amemiya T, Fujimoto Y

Abstract

BACKGROUND: We have previously performed retrospective analysis of patients with anaplastic thyroid carcinoma (ATC) treated between April 1976 and March 1999, revealing acute symptoms, large tumor (>5 cm), distant metastasis, and leukocytosis ≥10,000/mm(3) as the most important prognostic factors. We devised a novel prognostic index (PI) as the total number of these 4 factors present, giving a PI of 0-4.

METHODS: We have adopted this PI since April 1999. In principle, multimodal treatment has been encouraged for a PI of ≤1, whereas aggressive treatment has been avoided to maintain quality of life for a PI of ≥3. The validity of this therapeutic strategy was prospectively investigated in 74 patients with ATC.

RESULTS: Six-month survival rates for PI ≤ 1 and PI ≥ 3 were 72% and 12%, respectively. Among patients with a PI of ≤1,11 (42%) underwent multimodal treatment and showed significantly better survival than previous cases. Survival rates did not differ between stages. For patients with a PI of ≥3, survival rates were equally dismal, regardless of stage. Numbers of patients who underwent tracheostomy or died from local disease were significantly decreased compared with previous cases.

CONCLUSION: Our PI is valid for anticipating prognosis and aiding timely decisions on treatment policy for ATC patients.

PMID: 22136842 [PubMed - in process]

Anaplastic thyroid carcinoma: Hope on the horizon?

Surgery. 2011 Dec;150(6):1220-1

Authors: Grant CS, Thompson G

PMID: 22136843 [PubMed - in process]

Motor and sensory branching of the recurrent laryngeal nerve in thyroid surgery.

Surgery. 2011 Dec;150(6):1222-7

Authors: Kandil E, Abdelghani S, Friedlander P, Alrasheedi S, Tufano RP, Bellows CF, Slakey D

Abstract

INTRODUCTION: Recognition of extralaryngeal bifurcation of the recurrent laryngeal nerve (RLN) is crucial, because inadvertent intraoperative division may lead to significant morbidity. The purpose of this study was to examine the incidence of extralaryngeal bifurcation of the RLN and the distance that the initial bifurcation occurs from the cricothyroid insertion site of the RLN. We also sought to demonstrate the location of the RLN branches containing a predominance of motor fibers.

METHODS: This prospective study of 220 patients with data on 310 RLNs collected the type of operation, incidence of bifurcation, distance from the cricothyroid insertion point to the point of initial bifurcation, and location of the motor fibers by assessing a stimulus response on the Medtronic NIMS as they relate to the laryngeal muscles.

RESULTS: A total of 310 RLNs in 220 patients were studied. There were 133 RLNs (42.9%) that bifurcated before entering the larynx. These bifurcations occurred 51.1% on the right, 48.9% on the left, and 33.3% bilaterally. The median branching distance from the cricothyroid membrane on the right was 6.33 mm, and on the left was 6.37 mm. In all bifurcated RLNs, the motor fibers were located exclusively in the anterior branches.

CONCLUSION: Extralaryngeal bifurcation was found in 42.9% of the RLNs in this case series. The motor fibers are located in the anterior branches. Great caution is therefore required after the presumed identification of the RLN to ensure there is no unidentified anterior branch.

PMID: 22136844 [PubMed - in process]

Predictive factors of malignancy in pediatric thyroid nodules.

Surgery. 2011 Dec;150(6):1228-33

Authors: Roy R, Kouniavsky G, Schneider E, Allendorf JD, Chabot JA, Logerfo P, Dackiw AP, Colombani P, Zeiger MA, Lee JA

Abstract

BACKGROUND: Studies suggest that while most pediatric thyroid nodules are benign, there is a higher rate of malignancy than in adults. We investigate clinical factors that may predict malignancy in pediatric thyroid nodules.

METHODS: A retrospective review of 207 pediatric thyroidectomies was conducted over 15 years at 2 tertiary hospitals. Analyses examined predictive values of 16 clinicopathologic factors associated with cancer. Positive predictive values (PPVs) of fine-needle aspiration biopsy specimens (FNABs) were analyzed independently.

RESULTS: Malignancy occurred in 41% of patients. After excluding missing data, malignancy was more likely with family history of thyroid cancer (34.2% vs 17.7%; P = .111), palpable lymphadenopathy (34.2% vs 2.9%; P = .001), and hypoechoic nodules (52.2% vs 19.2%; P = .016). Palpable lymphadenopathy indicated greater than 2-fold increased risk for malignancy (relative risk, 2.18; 95% confidence interval, 1.56-3.05). PPVs of FNAB results were 0.94 for malignancy, 0.63 for suspicious for malignancy, and 0.55 for indeterminate lesions. PPV for benign FNAB to be benign on final pathology was 0.71.

CONCLUSION: While malignancy is associated with family history of thyroid cancer and hypoechoic lesions, palpable lymphadenopathy had the greatest risk. When compared to adults, a benign FNAB in children is not as accurate and the likelihood that an indeterminate nodule is cancer is greater.

PMID: 22136845 [PubMed - in process]

The impact of atypia/follicular lesion of undetermined significance on the rate of malignancy in thyroid fine-needle aspiration: Evaluation of the Bethesda System for Reporting Thyroid Cytopathology.

Surgery. 2011 Dec;150(6):1234-41

Authors: Broome JT, Solorzano CC

Abstract

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) was developed to refine definitions and improve clinical communication and management. This study evaluates the impact of the BSRTC in a large cohort of patients undergoing thyroidectomy before and after its adoption at a single institution.

METHODS: The records from 469 patients in the pre-BSRTC (n = 187) and post-BSRTC (n = 282) periods were reviewed. Cytologic categories in group 1 included nondiagnostic, benign, follicular/Hürthle neoplasm, suspicious for malignancy, and malignant. Atypia/follicular lesion of undetermined significance (AUS/FLUS) was included in group 2. The percentage of each fine-needle aspiration (FNA) category, malignancy rate per category, and rate of AUS/FLUS utilization were calculated.

RESULTS: Group 1 FNA results included 3% (n = 6) nondiagnostic, 48% (n = 89) benign, 17% (n = 32) follicular/Hürthle, 13% (n = 25) suspicious for malignancy, and 19% (n = 35) malignant. Group 2 results included 4% (n = 11) nondiagnostic, 34% (n = 96) benign, 29% (n = 82) AUS/FLUS, 12% (n = 33) follicular/Hürthle, 10% (n = 29) suspicious for malignancy, and 11% (n = 31) malignant. The rate of cancer changed from 25% to 36% for follicular/Hürthle lesions. AUS/FLUS was utilized in 154 of 1095(14%) FNAs reviewed with a malignancy rate of 20%.

CONCLUSION: The new AUS/FLUS category was used more often than recommended (14%) with a higher than expected rate of malignancy (20%). Rigorous cytopathology to histopathology correlation is needed to accurately reflect the malignancy rates of the different BSRTC categories at each individual institution. Clinical management should be tailored based on such institutional findings.

PMID: 22136846 [PubMed - in process]

The impact of microscopic extrathyroid extension on outcome in patients with clinical T1 and T2 well-differentiated thyroid cancer.

Surgery. 2011 Dec;150(6):1242-9

Authors: Nixon IJ, Ganly I, Patel S, Palmer FL, Whitcher MM, Tuttle RM, Shaha AR, Shah JP

Abstract

OBJECTIVE: To report the impact of microscopic extrathyroid extension (ETE) on outcome in patients with cT1/cT2 well-differentiated thyroid cancer (WDTC), and to determine the effect of extent of surgery and adjuvant radioactive iodine (RAI) treatment on outcome in patients with microscopic ETE.

PATIENTS AND METHODS: From an institutional database, we identified 984 patients (54%) who underwent surgery for cT1/T2N0 disease. Of these, 869 patients were pT1/T2 and 115 were upstaged to pT3 based on the finding of microscopic ETE. Disease-specific survival (DSS) and recurrence-free survival (RFS) were analyzed for each group using the Kaplan-Meier method. In the pT3 group, factors predictive of outcome were analyzed by univariate and multivariate analyses.

RESULTS: There was no difference in the 10-year DSS (99% vs 100%; P = .733) or RFS (98% vs 95%; P = .188) on comparison of the pT1/pT2 and pT3 cohorts. Extent of surgery and administration of postoperative RAI were not significant for recurrence on univariate or multivariate analysis in the pT3 cohort.

CONCLUSION: Outcomes in patients with cT1T2N0 WDTC are excellent and not affected by microscopic ETE. The extent of resection and administration of postoperative RAI in patients with microscopic ETE does not impact survival or recurrence.

PMID: 22136847 [PubMed - in process]

Effect of postoperative thyrotropin suppressive therapy on bone mineral density in patients with papillary thyroid carcinoma: A prospective controlled study.

Surgery. 2011 Dec;150(6):1250-7

Authors: Sugitani I, Fujimoto Y

Abstract

BACKGROUND: The influence of thyrotropin (thyroid-stimulating hormone [TSH]) suppressive therapy on bone mineral density (BMD) remains contentious. We have conducted a randomized controlled trial evaluating the effects of postoperative TSH suppressive therapy on disease-free survival for papillary thyroid carcinoma (PTC) since 1996, while prospectively verifying the effects of TSH suppression on BMD.

METHODS: Lumbar spine BMD as expressed by T-score was examined annually in female patients randomly assigned to receive TSH suppressive therapy (group A; n = 144) or no therapy (group B; n = 127).

RESULTS: The mean TSH level was 0.07 ± 0.10 mU/L in group A and 3.14 ± 1.69 mU/L in group B. Group B did not show any significant decrease in T-score until 5 years postoperatively, whereas group A had a significant deterioration from 1 year postoperatively. Among group A patients, significant decreases in T-score within 1 year were seen in patients ≥50 years of age, but not in those <50 years of age. After 5 years of TSH suppression, 20 patients had T-scores below -2.0 and 100 patients did not. These former patients were significantly older and had lower preoperative BMD measurements than the latter.

CONCLUSION: This prospective controlled trial suggests that TSH suppression after surgery for PTC has adverse effects on BMD in women ≥50 years of age.

PMID: 22136848 [PubMed - in process]

Activation of mTOR signaling in medullary and aggressive papillary thyroid carcinomas.

Surgery. 2011 Dec;150(6):1258-65

Authors: Kouvaraki MA, Liakou C, Paraschi A, Dimas K, Patsouris E, Tseleni-Balafouta S, Rassidakis GZ, Moraitis D

Abstract

BACKGROUND: Because mammalian target of rapamycin (mTOR) may be involved in thyroid carcinogenesis, we investigated the expression and activation patterns of mTOR signaling proteins in thyroid carcinoma cells and tumors and their association with tumor histology and aggressiveness.

METHODS: Tissue specimens from 50 patients with thyroid cancer were analyzed for eIF4E, a critical downstream target of the mTOR pathway, using immunohistochemistry. In addition, fresh-frozen samples from patients, and primary tumor cell cultures were analyzed for expression and activation of mTOR signaling proteins by Western blot. Moreover, pharmacologic studies with rapamycin were performed.

RESULTS: High expression of eIF4E was observed in medullary thyroid carcinomas (MTC) and in aggressive variants of papillary thyroid carcinomas (PTC) as compared with conventional PTC and follicular thyroid carcinomas (P < .0001). The level of eIF4E expression also correlated with tumor stage (P = .002). Using Western blot analysis, p-rpS6, p-4EBP1, 4EBP1, and eIF4E were detected at higher levels in aggressive PTC and MTC cells. Treatment of MTC cells with increasing concentrations of rapamycin resulted in significant cell death and in decreased cell growth associated with deactivation of the mTOR pathway.

CONCLUSION: mTOR signaling, which controls protein synthesis through regulation of translation initiation, is activated in aggressive PTC and MTC and represents a promising target for investigational therapies in these patients.

PMID: 22136849 [PubMed - in process]

Surgical completeness of bilateral axillo-breast approach robotic thyroidectomy: Comparison with conventional open thyroidectomy after propensity score matching.

Surgery. 2011 Dec;150(6):1266-74

Authors: Lee KE, Koo do H, Im HJ, Park SK, Choi JY, Paeng JC, Chung JK, Oh SK, Youn YK

Abstract

BACKGROUND: Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) has good postoperative and excellent cosmetic outcomes. To assess the surgical completeness of BABA RoT, it was compared to open thyroidectomy (OT) after propensity score matching of the cohorts.

METHODS: Between 2008 and 2010, 760 patients who underwent total thyroidectomy with central node dissection (CND) caused by papillary thyroid carcinoma (PTC) in Seoul National University Hospital were enrolled; 327 BABA robotic and 423 open method operations were performed. We selected 174 robotic and 237 open thyroidectomy patients who received radioactive iodine (RAI) ablation. Propensity score matching using 3 demographic and 5 pathologic factors was used to generate 2 matched cohorts, each composed of 108 patients.

RESULTS: The matched BABA RoT and OT cohorts were not different with regard to the RAI uptake ratio, stimulated thyroglobulin (Tg) levels, or proportion of patients with stimulated Tg levels <1.0 ng/mL on the first ablation. The number of RAI ablation sessions and RAI doses needed to achieve a complete ablation also did not differ significantly.

CONCLUSION: The surgical completeness of BABA RoT did not differ from OT. BABA RoT may be suitable for patients with PTC who prefer scarless neck surgery.

PMID: 22136850 [PubMed - in process]

Does the presence of thyroid cancer increase the risk of venous thromboembolism in patients undergoing thyroidectomy?

Surgery. 2011 Dec;150(6):1275-85

Authors: Reinke CE, Hadler RA, Karakousis GC, Fraker DL, Kelz RR

Abstract

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of postoperative morbidity and mortality in cancer patients. We evaluate the association between thyroid cancer (TCA) and VTE in thyroidectomy patients and assess the impact of TCA status on risk level using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Best Practices guideline.

METHODS: A retrospective cohort study of thyroidectomy patients using the ACS NSQIP database (2005-2008) was performed. Patients were stratified by the presence (TCA) or absence (non-TCA) of TCA. The incidence of 30-day postoperative VTE and VTE risk factors were compared between groups. Risk factor scores (RFS) for VTE were computed with and without TCA as a factor.

RESULTS: Fifteen VTE events were documented in 19,640 patients. The incidence of VTE was 0.08% in the TCA and 0.07% in non-TCA groups (P = .783). TCA patients were younger, had a lower body mass index, and had longer operations than non-TCA patients. TCA patients had slightly higher RFS before inclusion of TCA (mean of 4.26 vs 4.16; P < .001). After adjustment for the RFS, TCA was not associated with an increased risk of VTE.

CONCLUSION: TCA does not seem to be independently associated with VTE in patients undergoing thyroidectomy. The decision for anticoagulation should therefore be determined by individual patient risk factors.

PMID: 22136851 [PubMed - in process]

Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism.

Surgery. 2011 Dec;150(6):1286-94

Authors: Wang TS, Cheung K, Farrokhyar F, Roman SA, Sosa JA

Abstract

BACKGROUND: Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative localization. This study examines the cost-utility of sestamibi in combination with single photon emission computed tomography (sestamibi-SPECT); ultrasound; and 4-dimensional computed tomography (4D-CT).

METHODS: A decision tree was constructed for patients undergoing initial parathyroidectomy. Patients were randomized to 1 of 5 preoperative localization protocols: (1) ultrasound; (2) sestamibi-SPECT; (3) 4D-CT; (4) sestamibi-SPECT and ultrasound; and (5) sestamibi-SPECT and ultrasound and 4D-CT, if discordant (sestamibi-SPECT and ultrasound ±4D-CT). From a societal perspective, all relevant costs were included. Input data were obtained from literature and Medicare. The incremental cost-utility ratio was determined in dollars per quality-adjusted life years ($/QALY). Sensitivity analyses were performed.

RESULTS: In the base-case, ultrasound was least expensive, with a cost of $6666, compared to $6773 (4-D CT); $7214 (sestamibi-SPECT and ultrasound ±4D-CT); $7330 (sestamibi-SPECT); and $7371(sestamibi-SPECT and ultrasound). Sestamibi-SPECT and ultrasound ±4D-CT were most cost-effective because improved localization resulted in fewer bilateral explorations. QALY were comparable across modalities. Compared to sestamibi-SPECT, ultrasound, 4D- CT, and sestamibi-SPECT and ultrasound ±4D-CT resulted a win-win situation-costing less and accruing more utility. Sensitivity analyses demonstrated that the model was sensitive to surgery cost and diagnostic accuracy of imaging.

CONCLUSION: In our model, sestamibi-SPECT and ultrasound ±4D-CT were the most cost-effective methods, followed by 4D-CT and ultrasound. Sestamibi-SPECT alone was least cost-effective. Cost-utilities were dependent on the sensitivities of ultrasound and 4D-CT and may vary by institution.

PMID: 22136852 [PubMed - in process]

Thyroid-specific knockout of the tumor suppressor mitogen-inducible gene 6 activates epidermal growth factor receptor signaling pathways and suppresses nuclear factor-κB activity.

Surgery. 2011 Dec;150(6):1295-302

Authors: Lin CI, Barletta JA, Nehs MA, Morris ZS, Donner DB, Whang EE, Jeong JW, Kimura S, Moore FD, Ruan DT

Abstract

BACKGROUND: Mitogen-inducible gene 6 (Mig-6) is a putative tumor suppressor gene and prognostic biomarker in papillary thyroid cancer. We hypothesized that Mig-6 knockout would activate pro-oncogenic signaling in mouse thyrocytes.

METHODS: We performed a thyroid-specific knockout using the Cre/loxP recombinase system.

RESULTS: Four knockout and 4 control mouse thyroids were harvested at 2 months of age. Immunoblotting confirmed Mig-6 ablation in knockout mice thyrocytes. Epidermal growth factor receptor (EGFR) and extracellular signal-regulated kinase (ERK) phosphorylation levels were increased in Mig-6 knockout compared to wild-type mice. Total EGFR levels were similar in knockout and wild-type mice. However, EGFR was absent in the caveolae-containing membrane fraction of knockout mice, indicating that Mig-6 depletion is associated with a change in the membrane distribution of EGFR. Although p65 localized to the nucleus in wild-type mice, it was distributed in both cytoplasm and nucleus in knockouts, suggesting that Mig-6 loss decreases p65 activity.

CONCLUSION: Our results confirm the feasibility of targeted, thyroid-specific gene knockout as a strategy for studying the relevance of specific genes in thyroid oncogenesis. We suggest that the loss of Mig-6 alters the membrane distribution of EGFR, which may limit receptor degradation and activate this oncogenic signaling pathway.

PMID: 22136853 [PubMed - in process]

The founding of the American Association of Endocrine Surgeons: The time was right.

Surgery. 2011 Dec;150(6):1303-7

Authors: Thompson NW

PMID: 22136854 [PubMed - in process]

Comparison of intraoperative time use and perioperative outcomes for robotic versus laparoscopic adrenalectomy.

Surgery. 2011 Dec 3;

Authors: Karabulut K, Agcaoglu O, Aliyev S, Siperstein A, Berber E

Abstract

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

PMID: 22142558 [PubMed - as supplied by publisher]

Creating a learning healthcare system in surgery: Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) at 5 years.

Surgery. 2011 Nov 29;

Authors: , Kwon S, Florence M, Grigas P, Horton M, Horvath K, Johnson M, Jurkovich G, Klamp W, Peterson K, Quigley T, Raum W, Rogers T, Thirlby R, Farrokhi ET, Flum DR

Abstract

There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a “perfect” operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.

PMID: 22129638 [PubMed - as supplied by publisher]

Surrogate decision making: a woman in fulminant liver failure after an acetaminophen overdose.

Surgery. 2011 Nov;150(5):1006-10

Authors: O’Connor ES, Schwarze ML, Kodner IJ, Keune JD

PMID: 22132422 [PubMed - in process]

Surgery in the early middle ages: Evidence of cauterisation from Pisa.

Surgery. 2011 Nov 16;

Authors: Fornaciari A, Giuffra V

PMID: 22099185 [PubMed - as supplied by publisher]

Is celiac axis resection justified for T4 pancreatic body cancer?

Surgery. 2011 Nov 14;

Authors: Yamamoto Y, Sakamoto Y, Ban D, Shimada K, Esaki M, Nara S, Kosuge T

Abstract

BACKGROUND: The clinical impact of the distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer remains unclear. METHODS: We reviewed the records of 13 patients who underwent distal pancreatectomy-celiac axis resection between 1991 and 2009, 58 patients who underwent distal pancreatectomy for pancreatic body cancer involving major vessels, the extrapancreatic neural plexus or other organs (T4 according to the Japanese stage classification) between 1991 and 2009, and 24 patients with unresectable locally advanced pancreatic cancer without distant metastases (unresectable group) between 2001 and 2009. The clinicopathologic factors and overall survival among the 3 groups were compared. RESULTS: The distal pancreatectomy-celiac axis resection group was associated with a significantly higher incidence of morbidity (92% vs 60%, P = .03) and positive surgical margins (69% vs 26%, P = .003) than the distal pancreatectomy group; however, no survival difference was found between the 2 groups. No survivor has lived more than 3 years after operation in the distal pancreatectomy-celiac axis resection group. The distal pancreatectomy-celiac axis resection group had a significantly better prognosis than the unresectable group (median survival time, 20.8 vs 9.8 months; P = .01). CONCLUSION: Aggressive resection for T4 pancreatic body cancer by distal pancreatectomy-celiac axis resection can be justified for otherwise unresectable tumors. The surgical indication should be evaluated carefully because of the higher incidence of morbidity and lower incidence of curability compared with distal pancreatectomy, as well as because there have been no long-term survivors so far.

PMID: 22088810 [PubMed - as supplied by publisher]

Error training: Missing link in surgical education.

Surgery. 2011 Nov 15;

Authors: Darosa DA, Pugh CM

PMID: 22088811 [PubMed - as supplied by publisher]

Forging successful interdisciplinary research collaborations: A nationwide survey of departments of surgery.

Surgery. 2011 Nov 15;

Authors: Heller CA, Michelassi F

Abstract

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

PMID: 22088812 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Justinger C, Slotta JE, Schilling MK

Abstract

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

PMID: 22088813 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Guan Q, Li S, Yip G, Gleave ME, Nguan CY, Du C

Abstract

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

PMID: 22088814 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Luo Y, Wang Y, Poynter JA, Manukyan MC, Herrmann JL, Abarbanell AM, Weil BR, Meldrum DR

Abstract

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

PMID: 22088815 [PubMed - as supplied by publisher]

Accidental discovery: The polytetrafluoroethylene graft.

Surgery. 2011 Nov 15;

Authors: Yao JS, Eskandari MK

PMID: 22088816 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Gaujoux S, Tang L, Klimstra D, Gonen M, Brennan MF, D’Angelica M, Dematteo R, Fong Y, Jarnagin W, Allen PJ

Abstract

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

PMID: 22088817 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Upton D, Mason V, Doran B, Solowiej K, Shiralkar U, Shiralkar S

Abstract

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

PMID: 22088818 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Grützmann R, Rückert F, Hippe-Davies N, Distler M, Saeger HD

Abstract

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

PMID: 22088819 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Shen YM, Sun WB, Chen J, Liu SJ, Wang MG

Abstract

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

PMID: 22088820 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 15;

Authors: Monte SV, Caruana JA, Ghanim H, Sia CL, Korzeniewski K, Schentag JJ, Dandona P

Abstract

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

PMID: 22088821 [PubMed - as supplied by publisher]

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

Surgery. 2011 Nov 1;

Authors: Zeng L, Zhang AQ, Gu W, Chen KH, Jiang DP, Zhang LY, Du DY, Hu P, Huang SN, Wang HY, Jiang JX

Abstract

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

PMID: 22047946 [PubMed - as supplied by publisher]

Quality of care in surgery: The health services research perspective.

Surgery. 2011 Nov;150(5):881-6

Authors: Etzioni DA

PMID: 22018283 [PubMed - in process]

MicroRNA-10b is overexpressed in pancreatic cancer, promotes its invasiveness, and correlates with a poor prognosis.

Surgery. 2011 Nov;150(5):916-22

Authors: Nakata K, Ohuchida K, Mizumoto K, Kayashima T, Ikenaga N, Sakai H, Lin C, Fujita H, Otsuka T, Aishima S, Nagai E, Oda Y, Tanaka M

Abstract

BACKGROUND: MicroRNAs (miRNAs) have been gaining attention as new, key molecules that contribute to carcinogenesis. In pancreatic cancer, previous profiling analyses of miRNA expression have shown that several miRNAs are differently expressed in normal and cancerous tissues. Several pancreatic cancer-specific miRNAs differed, however, in each analysis.

METHODS: We investigated the miRNA expression profiles of the pancreatic cancer cell lines CAPAN-1 and CFPAC1 and an immortalized human normal pancreatic ductal epithelial cell line (HPDE) using a high-throughput, TaqMan, qRT-PCR array analysis. We also analyzed the expression levels of this miRNA in microdissected (n = 15) and formalin-fixed, paraffin-embedded (FFPE) (n = 115) samples from pancreatic cancers by quantitative RT-PCR. Finally, we investigated the effects of this miRNA on the invasiveness of pancreatic cancer cells.

RESULTS: Based on the microarray analysis, miR-372, miR-146a, miR-204, miR-10a, and miR-10b showed particularly large differences (>10-fold changes) between both pancreatic cell lines and HPDE cells. Thirteen of the 15 pancreatic cancer cell lines showed 2.1- to 36.4-fold (median, 15.3-fold) greater levels of miR-10b than HPDE cells. Microdissection analysis revealed that miR-10b exhibited greater expression levels in pancreatic cancer cells (n = 5) than in normal pancreatic ductal cells (n = 10) (P < .020). Analysis of FFPE samples showed that high miR-10b expression was associated with a lesser overall survival (P = .014). Furthermore, miR-10b correlated with the invasiveness of pancreatic cancer cells (P < .01).

CONCLUSION: miR-10b is overexpressed in pancreatic cancer and may be involved in the invasiveness in pancreatic cancer cells, thereby leading to a poor prognosis.

PMID: 22018284 [PubMed - in process]

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

Surgery. 2011 Oct 21;

Authors: Palter VN, Graafland M, Schijven MP, Grantcharov TP

Abstract

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

PMID: 22019340 [PubMed - as supplied by publisher]

MicroRNAs: New helpers for surgeons?

Surgery. 2011 Oct 21;

Authors: Billeter AT, Druen D, Kanaan ZM, Polk HC

PMID: 22019341 [PubMed - as supplied by publisher]

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

Surgery. 2011 Oct 22;

Authors: Nasr AO, Dillon MF, Conlon S, Downey P, Chen G, Ireland A, Leen E, Bouchier-Hayes D, Walsh TN

Abstract

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

PMID: 22019500 [PubMed - as supplied by publisher]

Immunosuppressants accelerate microvascular thrombus formation in vivo: Role of endothelial cell activation.

Surgery. 2011 Oct 22;

Authors: Püschel A, Lindenblatt N, Katzfuß J, Vollmar B, Klar E

Abstract

BACKGROUND: In the early postoperative period after pancreas-kidney transplantation, pancreatic venous thrombosis is a major complication that leads to allograft dysfunction and graft loss. Beside ischemia and reperfusion injury, immunosuppressive drugs have been accused of supporting thrombogenicity. The aim of this study was to evaluate the effect of commonly applied immunosuppressants on microvascular thrombus formation in normal and postischemic tissue in vivo. METHODS: In the skin fold chambers of tacrolimus-, cyclosporine A-, antithymocyte globulin-, rapamycine-, or saline-treated mice, light/dye-induced microvascular thrombus formation was studied. Additional mice underwent ischemia and reperfusion of the skin fold chamber tissue and received tacrolimus, antithymocyte globulin, or saline before reperfusion. Additionally, the effect of prednisolone was tested in animals with ischemia and reperfusion. Concentrations of sP-selectin, soluble vascular cell adhesion molecule-1, and asymmetric dimethylarginine were assessed by enzyme-linked immunosorbent assay. Immunohistochemistry of the skin fold chamber tissue served for analysis of vascular endothelial nitric oxide synthase and inducible nitric oxide synthase expression. RESULTS: In normal tissue, tacrolimus, cyclosporine A, antithymocyte globulin, and rapamycine accelerated microvascular thrombus formation significantly when compared with saline. Whereas ischemia and reperfusion in saline-treated mice enhanced thrombus formation, thrombogenicity was not further increased by ischemia and reperfusion in tacrolimus – or antithymocyte globulin-treated animals. Application of prednisolone reversed the tacrolimus- and antithymocyte globulin-induced prothrombotic effect. Antithymocyte globulin increased sP-selectin and soluble vascular cell adhesion molecule-1, whereas tacrolimus induced asymmetric dimethylarginine production significantly. While tacrolimus and antithymocyte globulin additionally induced endothelial nitric oxide synthase and inducible nitric oxide synthase expression, cyclosporine A influenced only endothelial inducible nitric oxide synthase expression. CONCLUSION: Immunosuppressants enhance thrombus formation in vivo. Although antithymocyte globulin activates the microvascular endothelium, we show for the first time that tacrolimus increases asymmetric dimethylarginine plasma levels. Thus, impaired nitric oxide availability might be the underlying mechanism for the tacrolimus-associated increased thrombogenicity. The efficacy of prednisolone to reverse the tacrolimus-associated and antithymocyte globulin-associated acceleration of thrombus formation underlines the application of this anti-inflammatory drug prior to reperfusion in immunosuppressive regimens.

PMID: 22019501 [PubMed - as supplied by publisher]

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

Surgery. 2011 Oct 25;

Authors: Chen G, Wang H, Fan Y, Zhang L, Ding J, Cai L, Xu T, Lin H, Bie P

Abstract

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

PMID: 22033169 [PubMed - as supplied by publisher]

The gavel box.

Surgery. 2011 Oct;150(4):575-89

Authors: Nussbaum MS

PMID: 22000168 [PubMed - in process]

Reconstruction after major chest wall resection: Can rigid fixation be avoided?

Surgery. 2011 Oct;150(4):590-7

Authors: Hanna WC, Ferri LE, McKendy KM, Turcotte R, Sirois C, Mulder DS

Abstract

BACKGROUND: Rigid fixation is advocated as the best method to achieve good respiratory outcomes after chest wall resection at the expense of a high complication rate. The following study aims to examine the role of myocutaneous pedicled flaps, with or without soft prosthesis, in the reconstruction of small and large chest wall defects.

METHODS: All patients who underwent resection of chest wall tumors between 2003-2010 were identified from a prospectively entered database. Operative and postoperative outcomes were documented. Patients were stratified into 2 separate groups based on the size of the residual chest wall defect; the Small Defect (SD) group (<60 cm(2)) and the Large Defect (LD) group (>60 cm(2)).

RESULTS: Thirty-seven patients were identified over a 7-year period: 9 in the SD group and 28 in the LD group. Primary sarcoma was the most common indication for resection (57%). The mean size of the chest wall defect was 50.8 cm(2) in the SD group and 149.4 cm(2) in the LD group (P = .001). All patients underwent reconstruction with autologous tissue, nonrigid prosthesis, or a combination of the two. Prosthesis was used in 11% of patients in the SD group and 61% of patients in the LD group (P = .018). The rate of immediate postoperative extubation was 100% in the SD group and 89% in the LD group (P = .42). The rate of postoperative pneumonia was 7% in the LD group vs 0% in the SD group. The rate of surgical site infection was 7% in the LD group and 0% in the SD group. A subgroup analysis of the LD group demonstrated no statistical differences in any of the measured outcomes between patients in whom mesh prosthesis was used and patients in whom a myocutaneous flap alone was used. However, there was a clinical suggestion of prolonged ventilation in the subgroup where mesh was not used and of higher infection rates in the subgroup where mesh was used.

CONCLUSION: Small chest wall defects can be reconstructed with pedicled myocutaneous flaps alone without compromising respiratory outcomes. In carefully selected patients with moderate size defects larger than 60cm(2), reconstruction with pedicled myocutaneous flap alone offers similar postoperative outcomes as reconstruction with nonrigid prosthesis, at the expense of a possible need for a short period of mechanical ventilation.

PMID: 22000169 [PubMed - in process]

The protective role of laparoscopic antireflux surgery against aspiration of pepsin after lung transplantation.

Surgery. 2011 Oct;150(4):598-606

Authors: Fisichella PM, Davis CS, Lundberg PW, Lowery E, Burnham EL, Alex CG, Ramirez L, Pelletiere K, Love RB, Kuo PC, Kovacs EJ

Abstract

BACKGROUND: The goal of this study was to determine, in lung transplant patients, if laparoscopic antireflux surgery (LARS) is an effective means to prevent aspiration as defined by the presence of pepsin in the bronchoalveolar lavage fluid (BALF).

METHODS: Between September 2009 and November 2010, we collected BALF from 64 lung transplant patients at multiple routine surveillance assessments for acute cellular rejection, or when clinically indicated for diagnostic purposes. The BALF was tested for pepsin by enzyme-linked immunosorbent assay (ELISA). We then compared pepsin concentrations in the BALF of healthy controls (n = 11) and lung transplant patients with and without gastroesophageal reflux disease (GERD) on pH-monitoring (n = 8 and n = 12, respectively), and after treatment of GERD by LARS (n = 19). Time to the development of bronchiolitis obliterans syndrome was contrasted between groups based on GERD status or the presence of pepsin in the BALF.

RESULTS: We found that lung transplant patients with GERD had more pepsin in their BALF than lung transplant patients who underwent LARS (P = .029), and that pepsin was undetectable in the BALF of controls. Moreover, those with more pepsin had quicker progression to BOS and more acute rejection episodes.

CONCLUSION: This study compared pepsin in the BALF from lung transplant patients with and without LARS. Our data show that: (1) the detection of pepsin in the BALF proves aspiration because it is not present in healthy volunteers, and (2) LARS appears effective as a measure to prevent the aspiration of gastroesophageal refluxate in the lung transplant population. We believe that these findings provide a mechanism for those studies suggesting that LARS may prevent nonallogenic injury to the transplanted lungs from aspiration of gastroesophageal contents.

PMID: 22000170 [PubMed - in process]

Does the interval from imaging to operation affect the rate of unanticipated metastasis encountered during operation for pancreatic adenocarcinoma?

Surgery. 2011 Oct;150(4):607-16

Authors: Glant JA, Waters JA, House MG, Zyromski NJ, Nakeeb A, Pitt HA, Lillemoe KD, Schmidt CM

Abstract

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with a propensity for early metastasis that is often encountered unexpectedly at operation. Our objective was to examine the effect of the time interval between preoperative imaging and attempted resection and the venue in which imaging was performed on the frequency of unanticipated metastasis (UM) encountered at operation. We hypothesize that imaging obtained locally at our hospital and within 4 weeks of operation will result in a lesser frequency of UM encountered at operation.

METHODS: Between January 2004 and December 2009, records of patients undergoing planned pancreatic resection for PDAC at a high volume pancreatic surgery center were compiled. Exclusion criteria included neoadjuvant therapy, prior pancreatic resection, or evidence of metastasis on imaging. Review and analysis of clinical, radiographic, operative, and pathologic data were undertaken. Frequency of UM and outcome of resection was compared with the interval between most recent cross-sectional imaging (dual-phase contrast-enhanced CT or MRI) and operation defined as imaging-to-operation interval (IOI).

RESULTS: Four-hundred eighty-seven patients met eligibility requirements for the study: 431 (88%) proximal and 56 (12%) distal PDAC. 202 (41%) patients had their most recent imaging performed at an outside institution, and no difference in the rates of UM was observed whether imaging was conducted at our institution or at an outside institution (P > .05). Of 329 with complete imaging information for analysis, UM were discovered in 60 (18%): 52 (18%) of 293 proximal PDAC and 8 (22%) of 36 distal PDAC. In proximal PDAC, there was a linear relationship in the frequency of UM as a function of the weekly IOI (R(2) = .99; P = .006). For distal PDAC, no significant difference in the frequency of UM as a function of IOI was observed.

CONCLUSION: For proximally located PDAC, the frequency of UM increases with greater imaging-to-operation interval. Performing imaging at a high volume, pancreatic surgery center compared with elsewhere was not associated with a decrease in the rate of UM. Obtaining timely diagnostic imaging for proximal PDAC may improve the accuracy of preoperative staging, and thereby reduce the number of operations not producing oncologic benefit.

PMID: 22000171 [PubMed - in process]

A comparison of future recruitment needs in urban and rural hospitals: The rural imperative.

Surgery. 2011 Oct;150(4):617-25

Authors: Williams TE, Satiani B, Ellison EC

Abstract

BACKGROUND: The potential impact of shortages of the surgical workforce on both urban and rural hospitals is undefined. There is a predicted shortage of 30,000 surgeons by 2030 and the need to train and hire more than 100,000 surgeons. The aim of this study is to estimate the average recruitment needs in our nation’s hospitals for 7 surgical specialties to ensure adequate access to surgical care as the U.S. population grows to 364 million by 2030.

METHODS: We used the census figure of 309 million in 2010 for U.S. population. Currently there are estimated to be 3,012 urban hospitals and 1,998 rural hospitals in the U.S. (American Hospital Association’s Trend Watch report, 2009). At 253 million people (82 % of the population of 309 million in 2010) receive healthcare in urban hospitals; 56 million people receive healthcare in rural hospitals (18%). We assumed a work force model based on our previous publications, equal population growth in all geographic areas, recruitment by rural hospitals limited to Ob-Gyn, General Surgery, and Orthopedics, and that the percentage of the population receiving care at urban and rural hospitals will stay constant.

RESULTS: Rural hospitals will have to recruit an average of 3.4 OBGYN’s, and an average of 1.6 Orthos, and 2.0 GS for a total of 7 full-time equivalents in the period from 2011 to 2030. Urban hospitals which have to recruit surgical specialists will have to recruit ten Ob-Gyns, about 5 Orthos, 6 GS’s, 5 ear, nose, and throat surgeons (ENT’s), an average of 2.5 urologists, a neurosurgeon, and a thoracic surgeon to meet the recruiting goals for the surgical services for their hospitals.

CONCLUSION: Rural hospitals will be in competition with urban hospitals for hiring from a limited pool of surgeons. As urban hospitals have a socioeconomic advantage in hiring, surgical care in rural areas may be at risk. It is imperative that each rural hospital analyze local future healthcare needs and devise strategies that will enhance hiring and retention to optimize access to surgical care.

PMID: 22000172 [PubMed - in process]

Albumin is a better predictor of outcomes than body mass index following coronary artery bypass grafting.

Surgery. 2011 Oct;150(4):626-34

Authors: Bhamidipati CM, Lapar DJ, Mehta GS, Kern JA, Upchurch GR, Kron IL, Ailawadi G

Abstract

OBJECTIVE: Body mass index (BMI) influences risk in coronary artery bypass grafting (CABG) patients, but albumin level is not collected by the Society of Thoracic Surgeons database. We postulate that preoperative albumin is a better predictor of mortality than BMI following CABG.

METHODS: BMI from patients with serum albumin level within 6 months of isolated CABG during 1995-2010 from our institutional databases were identified. Patients were stratified by National Heart, Lung, and Blood Institute (NHLBI) BMI class, and by preoperative albumin. Regression models were used to assess predictors of morbidity and mortality.

RESULTS: We analyzed 2,794 isolated CABG patients at our institution. Unadjusted mortality was highest with lowest BMI (P ≤ .05), and in patients with 2-3 g/dL albumin (P = .02). Ejection fraction (EF) and intra-aortic balloon pump (IABP) use were similar despite BMI; however, EF was lowest and IABP use highest in the 2-3 g/dL albumin group (P < .001, respectively). Unlike BMI groups, increasing albumin was associated with lower major complication rates (P = .001). Similarly, adjusted mortality was not influenced by BMI (AOR 0.97, 95% CI 0.93-1.02), but increasing albumin levels reduced the adjusted odds of death (AOR 0.61, 95% CI 0.42-0.90).

CONCLUSION: Albumin, more than body mass index, is associated with mortality and morbidity in isolated CABG recipients and may be a better indicator for outcomes.

PMID: 22000173 [PubMed - in process]

Improving breast cancer care through a regional quality collaborative.

Surgery. 2011 Oct;150(4):635-42

Authors: Breslin TM, Caughran J, Pettinga J, Wesen C, Mehringer A, Yin H, Share D, Silver SM

Abstract

BACKGROUND: Regional collaborative organizations provide an effective structure for improving the quality of surgical care. With low complication rates and a long latency between surgical care and outcomes such as survival and local recurrence, quality measurement in breast cancer surgery is ideally suited to process measures. Diagnostic biopsy technique for breast cancer diagnosis is measurable and amenable to change at the provider level. We present initial results from our analysis of institutional variation in surgical and core needle biopsy use within a regional breast cancer quality collaborative.

METHODS: Established in 2006, the Michigan Breast Oncology Quality Initiative (MiBOQI) consists of 18 hospitals collecting data on breast cancer care using the National Comprehensive Cancer Centers Network (NCCN) Oncology Outcomes Database Project platform to analyze and compare breast cancer practices and outcomes amongst member institutions. Institutional review board approval is obtained at each site. Data are submitted electronically to the NCCN and analyzed for concordance with practice guidelines. Aggregate and blinded data are shared with project directors and institutions at collaborative meetings, and ongoing practice patterns are observed for change. We analyzed variation in breast biopsy technique for initial cancer diagnosis over time and between institutions. Diagnostic biopsies were categorized as core needle, surgical excisional, surgical incisional, and other surgical biopsy.

RESULTS: Procedural data for 8,066 patients treated for breast cancer between November 1, 2006 and December 31, 2009 were analyzed. The mean patient age was 59.5 years (range, 25.4-90.0 years). Within MiBOQI, 21% of patients underwent surgical biopsy for initial diagnosis. The percentage of patients undergoing surgical biopsy ranged from 8% to 37%, and the majority of surgical biopsies were classified as excisional biopsies. Patients with ductal carcinoma in situ were more likely to undergo surgical biopsy compared to those with invasive cancer (30.4% vs 17.8%; P < .001). There was no association between biopsy type and patient age, race, or comorbidity. Data on biopsy technique were shared with site project directors and a target surgical biopsy rate of <15% was chosen by consensus. Site project directors disseminated the data to their institutions and developed action plans for provider and patient education. Over the study period, the percentage of cases undergoing surgical biopsy for the entire MiBOQI collaborative decreased from 21% to 15% (P < .001).

CONCLUSION: The regional quality collaborative model can be used to collect, analyze, and disseminate surgical breast care quality data to organizations and treating physicians. These data can be used to describe patterns of care and make comparisons over time and between organizations. These data can also be used to set regional quality standards and provide an avenue for physician-led quality improvement.

PMID: 22000174 [PubMed - in process]

Predictive value of response to steroid therapy on response to splenectomy in children with immune thrombocytopenic purpura.

Surgery. 2011 Oct;150(4):643-8

Authors: Hollander LL, Leys CM, Weil BR, Rescorla FJ

Abstract

BACKGROUND: Many but not all studies suggest that a favorable response to preoperative steroid therapy predicts a successful outcome after splenectomy in children with immune thrombocytopenic purpura (ITP). The purpose of this study is to further examine the relationship between steroid response and outcome after splenectomy in children.

METHODS: After institutional review board approval, records of children undergoing splenectomy for ITP were reviewed. Patients’ responses were determined by platelet counts and grouped by complete response (CR; ≥150,000/μL), partial response (PR; 149,999- ≥50,000/μL), or no response (NR; <50,000/μL).

RESULTS: Thirty-seven children were identified. After steroid therapy, 20 patients (54%) had CR, 9 (24%) had PR, and 8 (22%) had NR. After splenectomy, 31 patients (84%) had CR, 6 (16%) had PR, and 0 had NR. Of the 20 patients that had a CR to steroid therapy, 18 (80%) had CR and 2 (20%) had PR to splenectomy. Of the 9 patients that had PR to steroids, 7 (78%) had CR to splenectomy and 2 (22%) had PR. Of the 8 patients that had NR to steroids, 6 (75%) had CR and 2 (25%) had PR to splenectomy. Response to splenectomy was not associated with response to steroids (P = .59).

CONCLUSION: These data suggest that response to splenectomy in children with ITP is unrelated to previous response to steroids.

PMID: 22000175 [PubMed - in process]

Tumor volume and percent positive lymph nodes as a predictor of 5-year survival in colorectal cancer.

Surgery. 2011 Oct;150(4):649-55

Authors: Poritz LS, Sehgal R, Hartnett K, Berg A, Koltun WA

Abstract

BACKGROUND: Survival with stage III colorectal cancer (CRC) is variable and difficult to predict. Tumor size is not part of the staging system for CRC and in itself is not a predictor of survival. We hypothesize, however, that tumor size is important in determining disease free survival.

METHODS: Patients with stage III CRC were identified and divided into 2 categories: those who developed metastatic disease within 5 years after surgery and those who were alive and disease free at 5 years. A ratio of tumor volume to percent positive nodes was calculated for each patient (TN ratio).

RESULTS: Sixty-three patients were identified. 35 (55%) were alive and tumor free at 5 years. The TN ratio was significantly higher in patients who were disease free. Compared to number of positive nodes, percent positive nodes, and tumor volume, the TN ratio was the most significant predictor of disease free survival at 5 years.

CONCLUSION: Patients who survive 5 years after CRC surgery have a statistically significantly higher TN ratio than those patients who have metastatic disease within 5 years. Patients with small tumors and positive nodes have a lower TN ratio and a statistically decreased 5-year survival.

PMID: 22000176 [PubMed - in process]

Lower extremity vascular injuries: Increased mortality for minorities and the uninsured?

Surgery. 2011 Oct;150(4):656-64

Authors: Crandall M, Sharp D, Brasel K, Carnethon M, Haider A, Esposito T

Abstract

BACKGROUND: There is increasing evidence to suggest that racial disparities exist in outcomes for trauma. Minorities and the uninsured have been found to have higher mortality rates for blunt and penetrating trauma. However, mechanisms for these disparities are incompletely understood. Limiting the inquiry to a homogenous group, those with lower extremity vascular injuries (LEVIs), may clarify these disparities.

METHODS: The National Trauma Data Bank (NTDB; version 7.0, American College of Surgeons) was used for this study. LEVIs were identified using codes from the International Classification of Diseases, 9th revision. Univariate and multivariate analyses were performed using Stata software (version 11; StataCorp, LP, College Station, TX).

RESULTS: Records were reviewed for 4,928 LEVI patients. The mechanism of injury was blunt in 2,452 (49.8%), penetrating in 2,452 (49.8%), and unknown in 24 cases (0.5%). Mortality was similar by mechanism (7.6% overall). Regression analysis using mechanism as a covariate revealed a significantly worse mortality for people of color (POC; odds ratio [OR], 1.45; 95% confidence interval [CI], 1.03-2.02; P = .03) and the uninsured (UN; OR, 1.62; 95% CI, 1.15-2.23; P = .006). However, when separate analyses were performed stratifying by mechanism, no significant mortality disparities were found for blunt trauma (POC OR, 1.28; 95% CI, 0.85-1.96; P = .23; UN OR, 1.33; 95% CI, 0.78-2.22; P = .29), but disparities remained for penetrating trauma (POC OR, 1.81; 95% CI, 0.93-3.57; P = .08; UN OR, 1.85; 95% CI, 1.18-2.94; P = .009).

CONCLUSION: For patients with LEVI, mortality disparities based on race or insurance status were only observed for penetrating trauma. It is possible that injury heterogeneity or patient cohort differences may partly explain mortality disparities that have been observed between racial and socioeconomic groups.

PMID: 22000177 [PubMed - in process]

Pneumonia in the surgical intensive care unit: Is every one preventable?

Surgery. 2011 Oct;150(4):665-72

Authors: Wahl WL, Zalewski C, Hemmila MR

Abstract

BACKGROUND: Pneumonia is a major complication for hospitalized patients and has come under the scrutiny of health care regulating bodies, which propose that hospital-acquired pneumonia should not be reimbursed and potentially be a “never event.” We hypothesized that many of our acutely injured patients develop pneumonia at the time of their initial traumatic event despite aggressive measures to prevent pneumonia during hospitalization.

METHODS: This retrospective review included all mechanically ventilated patients admitted to a mixed surgical intensive care units (ICU; trauma, general surgery, and burns) who developed pneumonia from 2006 to 2008. All pneumonia diagnosed by culture were obtained from bronchoalveolar lavage (BAL) specimens with ≥10(4) colony forming united (CFU)/mL considered a positive result. Criteria for ventilator-associated pneumonia (VAP) applied only to those patients ventilated mechanically for >48 hours at the time of a positive BAL culture. Aspiration organisms included Streptococcus species, methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, and oral flora. This was an institutional review board-approved study.

RESULTS: There were 208 mechanically ventilated who patients underwent BAL, half of which were performed in the first 48 hours after admission for fever, infiltrate on chest radiograph, or increasing white blood cell count (early BAL group). Of these patients, 58% had positive BAL cultures (pneumonia) but did not have VAP. Only 10% of patients studied with early BAL had no growth on culture. Although the predominant organisms in the early BAL group were aspiration-type organisms, 17% had resistant pathogens, and 16% had other Gram-negative rods (GNR). This percentage was compared with the VAP group in whom 33% of patients had resistant organisms (P = .04) and 8% other GNR (P = NS). Twenty-five patients with ≤10(4) CFU/mL on early BAL underwent repeat BAL, and 16 (64%) were later diagnosed with VAP.

CONCLUSION: Many intubated patients in the surgical ICU had evidence of early pneumonia or bacterial growth within 48 hours after arrival, suggesting early infection or colonization occurred before ICU admission. In addition, 33% with early bacterial growth on early BAL had resistant organisms or GNR on BAL culture, which suggests a patient-derived rather than environmentally acquired source.

PMID: 22000178 [PubMed - in process]

Use of antibiotics alone for treatment of uncomplicated acute appendicitis: A systematic review and meta-analysis.

Surgery. 2011 Oct;150(4):673-83

Authors: Liu K, Fogg L

Abstract

BACKGROUND: The use of antibiotics alone in the treatment of uncomplicated acute appendicitis has been controversial. The present report is based on a systematic review and meta-analysis of existing studies that compared antibiotics treatment to appendectomy in patients with uncomplicated acute appendicitis.

METHODS: A Medline search was performed for studies published between 1970 and 2009. Studies were selected based on specific inclusion and exclusion criteria. Six reports comprised of 1,201 patients were analyzed.

RESULTS: In patients treated with antibiotics alone, 6.9 ± 4.4% failed to respond and required appendectomy, and acute appendicitis recurred in 14.2 ± 10.6%. One appendectomy patient had a recurrence. A normal appendix was found in 7.3 ± 5.1% of patients at appendectomy. Complications were considerably less likely to occur with antibiotic treatment than with appendectomy. Major surgical complications included enterocutaneous fistula and reoperation.

CONCLUSION: In some cases, antibiotic treatment may fail, and there is a risk of recurrence. However, surgically treated patients, including those with the potential for spontaneous resolution and those with a normal appendix, are subjected to the risks of operative morbidity and mortality. Antibiotic therapy incurs significantly fewer complications. Prospective randomized studies are urgently needed to conclusively define the roles of appendectomy and antibiotic treatment in the management of uncomplicated acute appendicitis.

PMID: 22000179 [PubMed - in process]

Comparative effectiveness of bariatric surgery and nonsurgical therapy in adults with type 2 diabetes mellitus and body mass index <35 kg/m(2).

Surgery. 2011 Oct;150(4):684-91

Authors: Serrot FJ, Dorman RB, Miller CJ, Slusarek B, Sampson B, Sick BT, Leslie DB, Buchwald H, Ikramuddin S

Abstract

BACKGROUND: Outcomes of bariatric surgery in patients with a body mass index (BMI) <35 kg/m(2) have been an active area of investigation. We examined the comparative effectiveness of Roux-en-Y gastric bypass (RYGB) to routine medical management (nonsurgical controls; NSCs) in achieving appropriate targets defined by the American Diabetes Association for type 2 diabetes mellitus (T2DM) in patients with class I obesity (BMI 30.0-34.9 kg/m(2)) T2DM at 1 year.

METHODS: We identified patients undergoing RYGB (N = 17) with both class I obesity and T2DM and compared them to similar NSC (N = 17) treated in the Primary Care Center. Data were collected at baseline and 1 year for systolic blood pressure (SBP), as well as blood levels for low-density lipoprotein (LDL) cholesterol and hemoglobin A1c (HbA1c).

RESULTS: After RYGB, BMI decreased from 34.6 ± 0.8 kg/m(2) to 25.8 ± 2.5 kg/m(2) (P < .001) and HbA1c decreased from 8.2 ± 2.0% to 6.1 ± 2.7% (P < .001). The NSC cohort had no significant change in either BMI or HbA1c. SBP and LDL did not significantly change in either group. The RYGB group had a decrease in medication use compared to the NSC group (P < .001). The RYGB group ceased the use of antihypertensive and antihyperlipidemia medications by 1 year despite abnormal values.

CONCLUSION: RYGB can be performed in patients with both a BMI <35 kg/m(2) and T2DM with better weight loss, glycemic control, and fewer antihyperglycemic medications than NSC. Inappropriate cessation of medications may partially explain the persistent increase in both SBP and LDL after RYGB.

PMID: 22000180 [PubMed - in process]

Donation after cardiac death: A 29-year experience.

Surgery. 2011 Oct;150(4):692-702

Authors: Bellingham JM, Santhanakrishnan C, Neidlinger N, Wai P, Kim J, Niederhaus S, Leverson GE, Fernandez LA, Foley DP, Mezrich JD, Odorico JS, Love RB, De Oliveira N, Sollinger HW, D’Alessandro AM

Abstract

OBJECTIVE: To report the long-term outcomes of 1218 organs transplanted from donation after cardiac death (DCD) donors from January 1980 through December 2008.

METHODS: One-thousand two-hundred-eighteen organs were transplanted into 1137 recipients from 577 DCD donors. This includes 1038 kidneys (RTX), 87 livers (LTX), 72 pancreas (PTX), and 21 DCD lungs. The outcomes were compared with 3470 RTX, 1157 LTX, 903 PTX, and 409 lung transplants from donors after brain death (DBD).

RESULTS: Both patient and graft survival is comparable between DBD and DCD transplant recipients for kidney, pancreas, and lung after 1, 3, and 10 years. Our findings reveal a significant difference for patient and graft survival of DCD livers at each of these time points. In contrast to the overall kidney transplant experience, the most recent 16-year period (n = 396 DCD and 1,937 DBD) revealed no difference in patient and graft survival, rejection rates, or surgical complications but delayed graft function was higher (44.7% vs 22.0%; P < .001). In DCD LTX, biliary complications (51% vs 33.4%; P < .01) and retransplantation for ischemic cholangiopathy (13.9% vs 0.2%; P < .01) were increased. PTX recipients had no difference in surgical complications, rejection, and hemoglobin A1c levels. Surgical complications were equivalent between DCD and DBD lung recipients.

CONCLUSION: This series represents the largest single center experience with more than 1000 DCD transplants and given the critical demand for organs, demonstrates successful kidney, pancreas, liver, and lung allografts from DCD donors.

PMID: 22000181 [PubMed - in process]

Risk stratification for the development of a subsequent pneumonia after a nondiagnostic bronchoalveolar lavage.

Surgery. 2011 Oct;150(4):703-10

Authors: Qureshi I, Kerwin AJ, McCarter YS, Tepas JJ

Abstract

BACKGROUND: Broncho-alveolar lavage (BAL) is an invasive bedside procedure to define type and concentration of pathologic organisms causing ventilator associated pneumonia (VAP). We evaluated if the absence of pathogens on final results represented a lavage aspect of the BAL as a therapeutic procedure to eliminate organisms.

METHODS: BAL results collected from 2008 to 2009 were stratified as positive (POS) ≥100,000 cfu), indeterminate (INT)≤100,000 cfu pathologic organisms, or negative defined as mixed flora (MF) or sterile (STR). The INT, MF, and STR results were assessed by incidence of a subsequent POS sample.

RESULTS: Nine-hundred forty-nine BALs performed on 490 SICU patients were interpreted as POS in 227 patients (46%). 237 non- POS patients needed a subsequent BAL. Any pathogen on the first BAL (INT group) indicates a high likelihood for subsequent BAL which will be POS. Monthly cumulative sum analysis (CUSUM) of yield was unable to identify any specific period in which BAL performance varied from trend.

CONCLUSION: MF and STR represent adequate sampling of secretions that are clinically benign. Any pathogen, regardless of concentration, should be considered a biomarker for future pneumonia. CUSUM analysis suggest better training in timing and indication may decrease unnecessary procedures yielding negative results.

PMID: 22000182 [PubMed - in process]

The addition of a nurse practitioner to an inpatient surgical team results in improved use of resources.

Surgery. 2011 Oct;150(4):711-7

Authors: Robles L, Slogoff M, Ladwig-Scott E, Zank D, Larson MK, Aranha G, Shoup M

Abstract

BACKGROUND: Resident work hour restrictions and changes in reimbursement may lead to an adverse effect on the continuity of care of a patient after discharge. This study analyzes whether adding a nurse practitioner (NP) to a busy inpatient surgery service would improve patient care after discharge.

METHODS: In 2007, a NP joined a team of 3 surgery attendings. She coordinated the discharge plan and communicated with patients after discharge. We reviewed the records of patients 1 year before (N = 415) and 1 year after (N = 411) the NP joined the team. The discharge courses of the patients were reviewed, and an unnecessary emergency room (ER) visit was defined as an ER visit that did not result in an inpatient admission.

RESULTS: The 2 groups were statistically similar with regard to age, race, acuity of the operation, duration of hospital stay, and hospital readmissions. Telephone communication between nurses and discharged patients was 846 calls before the NP and 1,319 calls after the NP, representing an increase of 64% (P < .0001). Visiting nurse, physical therapy, or occupational therapy services were rendered to only 25% of patients before the NP compared to 39% after (P < .0001). There were more unnecessary ER visits before the NP (103/415; 25%) compared to after (54/411; 13%) (P = .001).

CONCLUSION: Adding a NP to our inpatient surgery service led to an overall improvement in the use of resources and a 50% reduction in unnecessary ER visits. This study shows that the addition of a NP not only improves continuity of care on discharge but also has the potential to yield financial benefits for the hospital.

PMID: 22000183 [PubMed - in process]

In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury.

Surgery. 2011 Oct;150(4):718-26

Authors: Claridge JA, Carter JW, McCoy AM, Malangoni MA

Abstract

BACKGROUND: There continues to be controversy over the added value of direct supervision of residents, particularly its effect on patient outcomes. The purpose of this study was to compare direct and indirect resident supervision for the management of blunt spleen injuries and to evaluate differences in patient care.

METHODS: All patients with blunt splenic injury admitted off hours over a 6.5-year period to a regional level I trauma center were analyzed. Data analyzed included patient demographics, injury characteristics, hospital course, and treatment modality. Direct supervision was defined as the presence of a surgical attending on call in the hospital. Indirect supervision was defined as the surgical attending taking the call from home. Primary analysis consisted of a comparison of outcomes and compliance with a protocol for nonoperative management (NOM) between these groups.

RESULTS: There were 506 total cases, of which 274 (54%) were directly supervised, 157 (31%) had indirect supervision, and 75 (15%) presented when a fellow was the most senior person in house. The mean injury severity score was 21, patients averaged 34 years of age. The splenic salvage rate was 89.7% and the mortality rate was 8.5%. The primary comparison revealed a significantly higher percentage of patients going to operation with direct supervision. Direct supervision was associated with significantly greater protocol compliance for NOM (82% vs 95%; P < .001). Indirect supervision was associated with a greater use of intensive care unit (ICU) resources and protocol noncompliance with the use of splenic artery embolization. The overall success of NOM was 98.6%. Failure of NOM was associated with lack of protocol compliance. Failure of NOM was 9.6% in patients with protocol deviation and 0.3% with protocol adherence. There were no differences in mortality or splenectomy rates between the groups.

CONCLUSION: This study shows that there were significant differences in the management of blunt splenic injury depending on the type of supervision. Indirect supervision was associated with less compliance with a management protocol, fewer patients undergoing initial operation, more ICU use, increased hospital charges, and a greater use of splenic artery embolization without indication. These results emphasize the value of direct supervision in the management of a select group of trauma patients.

PMID: 22000184 [PubMed - in process]