Reply to the commentary: Should we, not could we? A commentary on “Pyloric valve transposition as substitute for a colostomy in humans: a preliminary report”

Am J Surg. 2012 Feb 4;

Authors: Chandra A

PMID: 22306431 [PubMed - as supplied by publisher]

Defining a new paradigm for surgical education.

Am J Surg. 2012 Feb 4;

Authors: Maa J

PMID: 22306432 [PubMed - as supplied by publisher]

Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: a multicenter study.

Dis Colon Rectum. 2012 Jan;55(1):42-50

Authors: McKay GD, Morgan MJ, Wong SK, Gatenby AH, Fulham SB, Ahmed KW, Toh JW, Hanna M, Hitos K,

Abstract

BACKGROUND: Evidence demonstrates short-term benefits of laparoscopic surgery for colon cancer. The situation for rectal cancer is less clear.

OBJECTIVES: This review assessed the use and short-term outcomes of elective open and laparoscopic colon and rectal cancer resections within an area health service.

DESIGN: This was a multicenter, retrospective review of a prospective database.

SETTINGS: All elective colon and rectal cancer resections in the western zone of Sydney South West Area Health Service from 2001 until 2008 were included.

PATIENTS: Included were 1721 patients who underwent either a laparoscopic colon (n = 434) or rectal (n = 157) resection or an open colon (n = 742) or rectal (n = 388) resection.

MAIN OUTCOME MEASURES: : Outcome measures included operating time, blood loss, adequacy of resection, conversion rate, intensive care unit admission, length of stay, and 26 acute postoperative complications.

RESULTS: Patients were matched for age, sex, ASA, BMI, and tumor stage. Laparoscopic surgery increased in frequency. Fewer patients experienced a complication in both the laparoscopic colon (28.8 vs 54.4%; p < 0.0001) and rectal (41.4 vs 60.3%; p < 0.0001) group irrespective of age. Laparoscopic operating time for colon and rectal cancer was 24.1 minutes (p < 0.0001) and 25.8 minutes (p < 0.0001) longer, with a low conversion-to-open rate (6.5% and 8.3%; p = 0.44). Laparoscopic surgery resulted in fewer transfusions (0.4 vs 0.7 units; p = 0.0028) and length of stay (7 vs 10 days; p = 0.0011) for colon cancers, and reduced intraoperative hemoglobin drop (20.5 vs 24.8; p = 0.029) and intensive care unit admissions (26.8 vs 36.3%; p = 0.032) for rectal cancers.

LIMITATIONS: : This was a nonrandomized study with rectal cancers more often resected with the open technique (71.2 vs 28.8%; p < 0.001).

CONCLUSIONS: Within an area health service, elective laparoscopic resection for colon and rectal cancer had improved short-term outcomes in comparison with open surgery.

PMID: 22156866 [PubMed - indexed for MEDLINE]

Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study.

Dis Colon Rectum. 2012 Jan;55(1):e3; author reply e3-4

Authors: Inusah S, Davis TD, Albright KC, McGwin G

PMID: 22156879 [PubMed - indexed for MEDLINE]

Effect of Roux-en-Y gastric bypass on testosterone and prostate-specific antigen.

Br J Surg. 2012 Feb 2;

Authors: Woodard G, Ahmed S, Podelski V, Hernandez-Boussard T, Presti J, Morton JM

Abstract

BACKGROUND: Obese men have lower serum levels of testosterone, dehydroepiandrosterone (DHEA) and prostate-specific antigen (PSA), but an increased risk of dying from prostate cancer. The aim of this study was to examine the effect of surgically induced weight loss on serum testosterone, DHEA and PSA levels in obese men. METHODS: Consecutive men undergoing Roux-en-$\font\ss=cmss10 scaled 1000 \hbox{Y}$ gastric bypass (RYGB) participated in a prospective, longitudinal study. Main outcomes were changes were body mass index (BMI), percentage excess weight loss, serum levels of testosterone, DHEA and PSA, PSA mass and plasma volume, measured before operation and 3, 6 and 12 months later. RESULTS: In 64 patients, mean BMI fell from 48·2 kg/m(2) before operation to 39·2, 35·6 and 32·4 kg/m(2) at 3, 6 and 12 months after RYGB. Testosterone levels rose significantly from 259 ng/dl to 386, 452 and 520 ng/dl respectively. Serum PSA levels increased significantly from 0·51 ng/ml to 0·67 ng/ml at 12 months. There were no significant changes in DHEA or PSA mass. CONCLUSION: RYGB normalizes the serum testosterone level. PSA levels increase with weight loss and may be inversely correlated with changes in plasma volume, indicating that PSA levels may be artificially low in obese men owing to haemodilution. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22302466 [PubMed - as supplied by publisher]

Endoscopic laser fragmentation and removal of a nonremovable metal esophageal stent for persistent dysphagia: a technical note.

Surg Endosc. 2012 Feb 1;

Authors: Coomber RS, Patel PH, Dhir A, Livingstone JI

Abstract

BACKGROUND: Self-expanding metal stents are widely used in the palliation of esophageal diseases (Todd, N Engl J Med 344(22):1681-1687, 2001). The majority are inserted for end-stage malignancy and are not designed to be removed. METHODS: We report the first recorded successful endoscopic removal of an “irremovable” stent by laser fragmentation after its placement became redundant. A 72-year-old man who had persistent dysphagia after esophageal stent insertion for Boerhaave’s syndrome had his stent removed by Nd-YAG laser fragmentation at staged endoscopies. RESULTS: The stent was removed in its entirety and the patients’ symptoms resolved. CONCLUSIONS: We describe a successful technique for the removal of a nonretrievable stent using laser fracture and endoscopic retrieval. This method of stent removal has not been previously reported.

PMID: 22302532 [PubMed - as supplied by publisher]

Randomized controlled trial of laparoscopic gastric ischemic conditioning prior to minimally invasive esophagectomy, the LOGIC trial.

Surg Endosc. 2012 Feb 1;

Authors: Veeramootoo D, Shore AC, Wajed SA

Abstract

INTRODUCTION: Minimally invasive esophagectomy (MIE) is a viable alternative to open resection for the management of esophagogastric cancer. However, the technique may relate to a higher incidence of ischemia-related gastric conduit complications. Laparoscopic ischemic conditioning (LIC) by ligating the left gastric vessels 2 weeks before MIE may have a protective role, possibly through an improvement of conduit perfusion. This project was designed to evaluate whether LIC influenced ultimate conduit perfusion. METHODS: A randomized controlled trial was designed to compare MIE with LIC (L) against MIE without (N). The project began in May 2009 and was offered to consecutive patients with the objective of recruiting 22 in each arm. Sample size calculations were based on data from previous clinical series. The main outcome measure was perfusion recorded by validated laser Doppler fluximetry, at the fundus (F) and greater curve (G); performed at routine staging laparoscopy and every stage of an MIE. A perfusion coefficient measured as ratio at stage of MIE over baseline was used for statistical analysis. RESULTS: Sixteen patients were recruited before an interim analysis of the trial data. At staging laparoscopy perfusion at F was higher than at G (p = 0.016). In the L cohort, an apparent rise in perfusion at G is observed post intervention (p = 0.176). At MIE, baseline perfusion is comparable for both arms; however, a significant drop is observed at both locations once the stomach is mobilized and exteriorized (p = 0.001). Once delivered at the neck, perfusion coefficient is approximately 38% of baseline levels. However, there was no discernible difference between the L (38.3 ± 12) and N (37.7 ± 16.8) cohorts (p = 0.798). CONCLUSIONS: LIC does not translate into an improved perfusion of the gastric conduit tip. The benefits reported from published clinical series suggest that the resistance of the conduit to ischemia occurs through alternative possibly microcellular mechanisms.

PMID: 22302533 [PubMed - as supplied by publisher]

The use of novel hemostatic sealant (Tisseel(®)) in laparoscopic myomectomy: a case-control study.

Surg Endosc. 2012 Feb 1;

Authors: Angioli R, Plotti F, Ricciardi R, Terranova C, Zullo MA, Damiani P, Montera R, Guzzo F, Scaletta G, Muzii L

Abstract

BACKGROUND: This is the first case-control study on the use of a fibrin sealant (Tisseel(®)) on uterine suture during laparoscopic myomectomy (LM), with the primary endpoint to evaluate the intraoperative bleeding and postoperative blood loss. In addition, we evaluated the time required to achieve hemostasis using Tisseel(®) and how much it can influence operative time. METHODS: From December 2009 to January 2011, consecutive patients older than 18 years with symptomatic isolate intramural myoma with maximal diameter ≤6 cm and ≥4 cm and with a sonographically diagnosed free myometrium margin ≥0.5 cm were included in the study. We selected from our institute’s database a group of consecutive patients with homogeneous features of the study group, who underwent laparoscopic myomectomy without Tisseel(®) application. RESULTS: Fifteen women with symptomatic myoma were enrolled in the study (group A). Regarding the control group (group B), we selected a homogenous group of 15 patients with the same preoperative characteristics of the study group. Mean operative time was 47.7 min and 62.1 min, for groups A and B respectively (p < 0.05). Mean time required to achieve complete haemostasis was 195.5 s in group A and 361.8 in control group B (p < 0.0001). Mean estimated blood loss was 111.3 mL and 230 mL in groups A and B, respectively (p < 0.05). Mean hemoglobin decrease was 1.36 g/dL and 2.04 g/dL in groups A and B, respectively (p < 0.05). CONCLUSIONS: The use of Tisseel(®) during LM may represent a valid alternative solution for obtaining hemostasis, reducing intra- and postoperative bleeding. Furthermore, it may help the surgeon to obtain a rapid healing of the injured surfaces, probably reducing the use of electrocoagulation and traumatisms.

PMID: 22302534 [PubMed - as supplied by publisher]

The optimal strategy for proximal mesh fixation during laparoscopic ventral rectopexy for rectal prolapse: an ex vivo study.

Surg Endosc. 2012 Feb 1;

Authors: Formijne Jonkers HA, van de Haar HJ, Draaisma WA, Heggelman BG, Consten EC, Broeders IA

Abstract

BACKGROUND: Laparoscopic ventral rectopexy (LVR) is an established technique for the treatment of rectal prolapse. Several techniques and devices can be used for proximal mesh fixation on the sacral promontory during this procedure. The aim of this study was to compare the fixation strength of a recently introduced screw for mesh fixation on the promontory during LVR with two other frequently used techniques. METHODS: An ex vivo experimental model using a porcine spinal column was designed to measure the strength of proximal mesh fixation. In a laparoscopic box trainer, a polypropylene mesh was anchored on the spinal column using three different fixation methods, i.e., the Protack 5-mm tacker device, Ethibond Excel 2-0 stitches, and the Karl Storz screw. Subsequently, increasing traction was applied to the mesh. This traction was applied at a standardized angle as determined by measuring the mean angle between the site of distal mesh fixation on the rectum and a line straight through the sacral promontory on 12 random dynamic MR scans of the pelvic floor after the LVR procedure. The applied force was measured at the moment that the fixation broke, using a calibrated electronic Newton meter. All fixation methods were tested ten times. RESULTS: The mean angle, as measured on the MR scans, was 100°. The mean disruption force, which led to a break of the proximal mesh fixation, was 58 N for the three Protack tacks, 55 N for the two stitches, and 70 N for the new screw. The use of a screw therefore led to a significantly stronger fixation compared to the use of stitches (p ≤ 0.05). No significant difference was determined between the tacks and the screw fixation and between the tacks and the stitches fixation. CONCLUSION: The new screw for proximal mesh fixation during LVR procedures offers similar fixation strength when compared to tacks. The use of one screw for proximal mesh fixation is therefore a reasonable alternative to the use of several tacks or sutures.

PMID: 22302535 [PubMed - as supplied by publisher]

The burden of endoscopic retrograde cholangiopancreatography (ERCP) performed with the patient under conscious sedation.

Surg Endosc. 2012 Feb 1;

Authors: Jeurnink SM, Steyerberg EW, Kuipers EJ, Siersema PD

Abstract

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that proves burdensome to patients. Nevertheless, very little data are available on patient tolerance of this procedure that may improve practice guidelines and could aid in decreasing the burden of ERCP. This study therefore investigated the burden of ERCP performed with the patient under conscious sedation. METHODS: Consecutive patients receiving ERCP under conscious sedation between November 2007 and December 2008 at the University Medical Center Utrecht and Erasmus MC Rotterdam (The Netherlands) were asked to participate in this study. The patients completed questionnaires on demographics, medical history, burden of ERCP (mental health, discomfort, and pain), symptoms and the EuroQol-5D (EQ-5D), including the EQ-VAS (lower EQ-5D scores and higher EQ-VAS scores represent a better quality of life). The paired t-test, the Kruskal-Wallis test, Pearson correlation, and logistic regression were used to evaluate the results. RESULTS: The questionnaire was returned by 149 (54%) of 276 eligible patients, 139 of whom completed the entire questionnaire (54% males; mean age, 60 ± 14 years). Throat ache (p < 0.001) was the only symptom higher than baseline value 1 day after the ERCP. On day 1, about one-tenth of the patients experienced moderate to severe mental health problems, which were associated with a higher EQ-5D score before ERCP (p = 0.01). Slightly fewer than half of the patients experienced pain and discomfort during and immediately after ERCP. More discomfort was experienced by patients who underwent therapeutic ERCP (p < 0.05) and those with a higher EQ-5D score (p < 0.001) or lower VAS (p < 0.01). Pain was associated with younger age (p < 0.01), higher EQ-5D score (p < 0.001), and lower VAS (p < 0.01). CONCLUSION: One-third to one-half of patients experience pain and discomfort during and immediately after ERCP when it is performed with conscious sedation for the patient. Other sedation strategies, such as the use of general anesthesia or propofol, may well reduce the burden of ERCP, particularly for patients with a higher EQ-5D score, younger age, or therapeutic ERCP treatment. However, randomized trials are warranted.

PMID: 22302536 [PubMed - as supplied by publisher]

Comparable early changes in gastrointestinal hormones after sleeve gastrectomy and Roux-En-Y gastric bypass surgery for morbidly obese type 2 diabetic subjects.

Surg Endosc. 2012 Feb 1;

Authors: Romero F, Nicolau J, Flores L, Casamitjana R, Ibarzabal A, Lacy A, Vidal J

Abstract

BACKGROUND: Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) are associated with similar type 2 diabetes mellitus (T2DM) resolution rates for morbidly obese subjects. However, the mechanisms underlying the resolution of T2DM after SG have not been clarified to date. This study aimed to compare the early changes in gastrointestinal hormones involved in insulin and glucagon secretion in morbidly obese T2DM subjects undergoing SG or RYGBP. METHODS: This prospective study investigated 12 subjects with T2DM who had undergone SG (n = 6) or RYGBP (n = 6). Five body mass index (BMI)-matched obese non-diabetic subjects and five BMI-matched obese diabetic subjects served as control subjects. Glucose, insulin, glucagon, glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and GLP-2 were determined after a standardized mixed liquid meal before surgery and 6 weeks afterward. RESULTS: After 6 weeks, five of the six subjects in each surgical group presented with T2DM remission, although the area under the curve (AUC)(0-120) of glucose was greater than that of the non-diabetic control subjects (P < 0.01). Postsurgically, the indices of insulin and glucagon secretion were comparable between the two surgical groups. The AUC(0-120) of GLP-1 (P < 0.05) and GLP-2 (P < 0.05) was significantly and comparably enlarged after SG and RYGB. The postsurgical GIP response was significantly associated with the glucagon response throughout the meal test (ρ = 0.747; P < 0.01). CONCLUSIONS: The data show that in a cohort of morbidly obese T2DM subjects, SG and RYGBP are associated with an early improvement in glucose tolerance, similar changes in insulin and glucagon secretion, and a similar GLP-1, GIP, and GLP-2 response to a standardized mixed liquid meal.

PMID: 22302537 [PubMed - as supplied by publisher]

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

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

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

Abstract

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

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

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

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

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

PMID: 22104564 [PubMed - indexed for MEDLINE]

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

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

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

Abstract

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

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

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

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

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

PMID: 22183034 [PubMed - indexed for MEDLINE]

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

Ann Surg. 2012 Jan 31;

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

Abstract

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

PMID: 22301608 [PubMed - as supplied by publisher]

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

Ann Surg. 2012 Jan 31;

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

Abstract

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

PMID: 22301609 [PubMed - as supplied by publisher]

Letter to the Editor.

Ann Surg. 2012 Jan 31;

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

PMID: 22301610 [PubMed - as supplied by publisher]

Diagnosis and management of the solitary pulmonary nodule.

BMJ. 2011;343:d4866

Authors: Weir G, Kos S, Burrill J, Salat P, Ho S, Liu D

PMID: 22167792 [PubMed - indexed for MEDLINE]

What is the most effective way to maintain weight loss in adults?

BMJ. 2011;343:d8042

Authors: Simpson SA, Shaw C, McNamara R

PMID: 22205707 [PubMed - indexed for MEDLINE]

The challenge of developing quality measures for breast cancer surgery.

JAMA. 2012 Feb 1;307(5):509-10

Authors: Morrow M, Katz SJ

PMID: 22298680 [PubMed - in process]

Current Strategies and Future Perspectives for Intraperitoneal Adhesion Prevention.

J Gastrointest Surg. 2012 Feb 2;

Authors: Brochhausen C, Schmitt VH, Planck CN, Rajab TK, Hollemann D, Tapprich C, Krämer B, Wallwiener C, Hierlemann H, Zehbe R, Planck H, Kirkpatrick CJ

Abstract

INTRODUCTION: The formation of peritoneal adhesions still is a relevant clinical problem after abdominal surgery. Until today, the most important clinical strategies for adhesion prevention are accurate surgical technique and the physical separation of traumatized serosal areas. Despite a variety of barriers which are available in clinical use, the optimal material has not yet been found. DISCUSSION: Mesothelial cells play a crucial physiological role in frictionless gliding of the serosa and the maintenance of an antiadhesive surface. The formation of postoperative adhesions results from a cascade of events and is regulated by various cellular and humoral factors. Therefore, optimization or functionalization of barrier materials by developments interacting with this cascade on a structural or pharmacological level could give an innovative input for future strategies in peritoneal adhesion prevention. For this purpose, the proper understanding of the formal pathogenesis of adhesion formation is essential. Based on the physiology of the serosa and the pathophysiology of adhesion formation, the available barriers in current clinical practice as well as new innovations are discussed in the present review.

PMID: 22297658 [PubMed - as supplied by publisher]

Neoadjuvant chemotherapy and bevacizumab for HER2-negative breast cancer.

N Engl J Med. 2012 Jan 26;366(4):299-309

Authors: von Minckwitz G, Eidtmann H, Rezai M, Fasching PA, Tesch H, Eggemann H, Schrader I, Kittel K, Hanusch C, Kreienberg R, Solbach C, Gerber B, Jackisch C, Kunz G, Blohmer JU, Huober J, Hauschild M, Fehm T, Müller BM, Denkert C, Loibl S, Nekljudova V, Untch M, ,

Abstract

BACKGROUND: Bevacizumab, a monoclonal antibody against vascular endothelial growth factor A, has shown clinical efficacy in patients with human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer. We evaluated the efficacy, measured according to the rate of pathological complete response (absence of invasive and intraductal disease in the breast and the axillary lymph nodes), and the safety of adding bevacizumab to neoadjuvant chemotherapy in patients with early-stage breast cancer.

METHODS: We randomly assigned 1948 patients with a median tumor size of 40 mm on palpation to receive neoadjuvant epirubicin and cyclophosphamide followed by docetaxel, with or without concomitant bevacizumab. Patients with untreated HER2-negative breast cancer were eligible if they had large tumors, hormone-receptor-negative disease, or hormone-receptor-positive disease with palpable nodes or positive findings on sentinel-node biopsy, and no increased cardiovascular or bleeding risk.

RESULTS: Overall, the rates of pathological complete response were 14.9% with epirubicin and cyclophosphamide followed by docetaxel and 18.4% with epirubicin and cyclophosphamide followed by docetaxel plus bevacizumab (odds ratio with addition of bevacizumab, 1.29; 95% confidence interval, 1.02 to 1.65; P=0.04); the corresponding rates of pathological complete response were 27.9% and 39.3% among 663 patients with triple-negative tumors (P=0.003) and 7.8% and 7.7% among 1262 patients with hormone-receptor-positive tumors (P=1.00). Breast-conserving surgery was possible in 66.6% of the patients in both groups. The addition of bevacizumab, as compared with neoadjuvant therapy alone, was associated with a higher incidence of grade 3 or 4 toxic effects (febrile neutropenia, mucositis, the hand-foot syndrome, infection, and hypertension) but with a similar incidence of surgical complications.

CONCLUSIONS: The addition of bevacizumab to neoadjuvant chemotherapy significantly increased the rate of pathological complete response among patients with HER2-negative early-stage breast cancer. Efficacy was restricted primarily to patients with triple-negative tumors, in whom the pathological complete response is considered to be a reliable predictor of long-term outcome. (Funded by Sanofi-Aventis and Roche, Germany; ClinicalTrials.gov number, NCT00567554.).

PMID: 22276820 [PubMed - indexed for MEDLINE]

Bevacizumab added to neoadjuvant chemotherapy for breast cancer.

N Engl J Med. 2012 Jan 26;366(4):310-20

Authors: Bear HD, Tang G, Rastogi P, Geyer CE, Robidoux A, Atkins JN, Baez-Diaz L, Brufsky AM, Mehta RS, Fehrenbacher L, Young JA, Senecal FM, Gaur R, Margolese RG, Adams PT, Gross HM, Costantino JP, Swain SM, Mamounas EP, Wolmark N

Abstract

BACKGROUND: Bevacizumab and the antimetabolites capecitabine and gemcitabine have been shown to improve outcomes when added to taxanes in patients with metastatic breast cancer. The primary aims of this trial were to determine whether the addition of capecitabine or gemcitabine to neoadjuvant chemotherapy with docetaxel, followed by doxorubicin plus cyclophosphamide, would increase the rates of pathological complete response in the breast in women with operable, human epidermal growth factor receptor 2 (HER2)-negative breast cancer and whether adding bevacizumab to these chemotherapy regimens would increase the rates of pathological complete response.

METHODS: We randomly assigned 1206 patients to receive neoadjuvant therapy consisting of docetaxel (100 mg per square meter of body-surface area on day 1), docetaxel (75 mg per square meter on day 1) plus capecitabine (825 mg per square meter twice a day on days 1 to 14), or docetaxel (75 mg per square meter on day 1) plus gemcitabine (1000 mg per square meter on days 1 and 8) for four cycles, with all regimens followed by treatment with doxorubicin-cyclophosphamide for four cycles. Patients were also randomly assigned to receive or not to receive bevacizumab (15 mg per kilogram of body weight) for the first six cycles of chemotherapy.

RESULTS: The addition of capecitabine or gemcitabine to docetaxel therapy, as compared with docetaxel therapy alone, did not significantly increase the rate of pathological complete response (29.7% and 31.8%, respectively, vs. 32.7%; P=0.69). Both capecitabine and gemcitabine were associated with increased toxic effects–specifically, the hand-foot syndrome, mucositis, and neutropenia. The addition of bevacizumab significantly increased the rate of pathological complete response (28.2% without bevacizumab vs. 34.5% with bevacizumab, P=0.02). The effect of bevacizumab on the rate of pathological complete response was not the same in the hormone-receptor-positive and hormone-receptor-negative subgroups. The addition of bevacizumab increased the rates of hypertension, left ventricular systolic dysfunction, the hand-foot syndrome, and mucositis.

CONCLUSIONS: The addition of bevacizumab to neoadjuvant chemotherapy significantly increased the rate of pathological complete response, which was the primary end point of this study. (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT00408408.).

PMID: 22276821 [PubMed - indexed for MEDLINE]

Accuracy of BRCA1/2 Mutation Prediction Models for Different Ethnicities and Genders: Experience in a Southern Chinese Cohort.

World J Surg. 2012 Jan 31;

Authors: Kwong A, Wong CH, Suen DT, Co M, Kurian AW, West DW, Ford JM

Abstract

BACKGROUND: BRCA1/2 mutation prediction models (BRCAPRO, Myriad II, Couch, Shattuck-Eidens, BOADICEA) are well established in western cohorts to estimate the probability of BRCA1/2 mutations. Results are conflicting in Asian populations. Most studies did not account for gender-specific prediction. We evaluated the performance of these models in a Chinese cohort, including males, before BRCA1/2 mutation testing. METHODS: The five risk models were used to calculate the probability of BRCA mutations in probands with breast and ovarian cancers; 267 were non-BRCA mutation carriers (247 females and 20 males) and 43 were BRCA mutation carriers (38 females and 5 males). RESULTS: Mean BRCA prediction scores for all models were statistically better for carriers than noncarriers for females but not for males. BRCAPRO overestimated the numbers of female BRCA1/2 mutation carriers at thresholds ≥20% but underestimated if <20%. BRCAPRO and BOADICEA underestimated the number of male BRCA1/2 mutation carriers whilst Myriad II underestimated the number of both male and female carriers. In females, BRCAPRO showed similar discrimination, as measured by the area under the receiver operator characteristic curve (AUC) for BRCA1/2 combined mutation prediction to BOADICEA, but performed better than BOADICEA in BRCA1 mutation prediction (AUC 93% vs. 87%). BOADICEA had the best discrimination for BRCA1/2 combined mutation prediction (AUC 87%) in males. CONCLUSIONS: The variation in model performance underscores the need for research on larger Asian cohorts as prediction models, and the possible need for customizing these models for different ethnic groups and genders.

PMID: 22290208 [PubMed - as supplied by publisher]

Slit Versus Non-Slit Mesh Placement in Total Extraperitoneal Inguinal Hernia Repair.

World J Surg. 2012 Jan 31;

Authors: Koeckerling F, Jacob DA, Lomanto D, Chowbey P, Bittner R

PMID: 22290209 [PubMed - as supplied by publisher]

Patient Readmission and Mortality after Colorectal Surgery for Colon Cancer: Impact of Length of Stay Relative to Other Clinical Factors.

J Am Coll Surg. 2012 Jan 28;

Authors: Schneider EB, Hyder O, Brooke BS, Efron J, Cameron JL, Edil BH, Schulick RD, Choti MA, Wolfgang CL, Pawlik TM

Abstract

BACKGROUND: Data on readmission as well as the potential impact of length of stay (LOS) after colectomy for colon cancer remain poorly defined. The objective of the current study was to evaluate risk factors associated with readmission among a nationwide cohort of patients after colorectal surgery. STUDY DESIGN: We identified 149,622 unique individuals from the Surveillance, Epidemiology, and End Results-Medicare dataset with a diagnosis of primary colorectal cancer who underwent colectomy between 1986 and 2005. In-hospital morbidity, mortality, LOS, and 30-day readmission were examined using univariate and multivariate logistic regression models. RESULTS: Primary surgical treatment consisted of right (37.4%), transverse (4.9%), left (10.5%), sigmoid (22.8%), abdominoperineal resection (7.3%), low anterior resection (5.6%), total colectomy (1.2%), or other/unspecified (10.3%). Mean patient age was 76.5 years and more patients were female (52.9%). The number of patients with multiple preoperative comorbidities increased over time (Charlson comorbidity score ≥3: 1986 to 1990, 52.5% vs 2001 to 2005, 63.1%; p < 0.001). Mean LOS was 11.7 days and morbidity and mortality were 36.5% and 4.2%, respectively. LOS decreased over time (1986 to 1990, 14.0 days; 1991 to 1995, 12.0 days; 1996 to 2000, 10.4 days; 2001 to 2005, 10.6 days; p < 0.001). In contrast, 30-day readmission rates increased (1986 to 1990, 10.2%; 1991 to 1995, 10.9%; 1996 to 2000, 12.4%; 2001 to 2005, 13.7%; p < 0.001). Factors associated with increased risk of readmission included LOS (odds ratio = 1.02), Charlson comorbidities ≥3 (odds ratio = 1.27), and postoperative complications (odds ratio = 1.17) (all p < 0.01). CONCLUSIONS: Readmission rates after colectomies have increased during the past 2 decades and mean LOS after this operation has declined. More research is needed to understand the balance and possible trade off between these hospital performance measures for all surgical procedures.

PMID: 22289517 [PubMed - as supplied by publisher]

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers.

Surg Endosc. 2012 Feb 1;

Authors: Maas KW, Biere SS, Scheepers JJ, Gisbertz SS, Turrado Rodriguez V, van der Peet DL, Cuesta MA

Abstract

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis. METHODS: The PubMed electronic database was used for comprehensive literature search by two independent reviewers. RESULTS: Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%. CONCLUSIONS: This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

PMID: 22294057 [PubMed - as supplied by publisher]

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.

Br J Surg. 2012 Jan 30;

Authors: Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K,

Abstract

BACKGROUND: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up. METHODS: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. RESULTS: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881). CONCLUSION: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis. Registration number: NCT01008488 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22290281 [PubMed - as supplied by publisher]

Self-collection of vaginal specimens for human papillomavirus testing in cervical cancer prevention (MARCH): a community-based randomised controlled trial.

Lancet. 2011 Nov 26;378(9806):1868-73

Authors: Lazcano-Ponce E, Lorincz AT, Cruz-Valdez A, Salmerón J, Uribe P, Velasco-Mondragón E, Nevarez PH, Acosta RD, Hernández-Avila M

Abstract

BACKGROUND: Vaginal self-sampling for human papillomavirus (HPV) DNA testing could increase rates of screening participation. In clinic-based settings, vaginal HPV testing is at least as sensitive as cytology for detecting cervical intraepithelial neoplasia (CIN) grade 2 or worse; however, effectiveness in home settings is unknown. We aimed to establish the relative sensitivity and positive predictive value for HPV screening of vaginal samples self-collected at home as compared with clinic-based cervical cytology.

METHODS: We did a community-based, randomised equivalence trial in Mexican women of low socioeconomic status aged 25-65 years. Participants came from 540 medically underserved, predominantly rural communities in Morelos, Guerrero, and the state of Mexico. Our primary endpoint was CIN 2 or worse, detected by colposcopy. We used a computer-generated randomisation sequence to randomly allocate patients to HPV screening or cervical cytology. Eight community nurses who were masked to patient allocation received daily lists of the women’s names and addresses, and did the assigned home visits. We referred women with positive results in either test to colposcopy. We did per-protocol and intention-to-screen analyses. This trial was registered with the Instituto Nacional de Salud Pública, Mexico, INSP number 590.

FINDINGS: 12,330 women were randomly allocated to HPV screening and 12,731 to cervical cytology; 9202 women in the HPV screening group adhered to the protocol, as did 11,054 in the cervical cytology group. HPV prevalence was 9·8% (95% CI 9·1-10·4) and abnormal cytology rate was 0·38% (0·23-0·45). HPV testing identified 117·4 women with CIN 2 or worse per 10,000 (95·2-139·5) compared with 34·4 women with CIN 2 or worse per 10,000 (23·4-45·3) identified by cytology; the relative sensitivity of HPV testing was 3·4 times greater (2·4-4·9). Similarly, HPV testing detected 4·2 times (1·9-9·2) more invasive cancers than did cytology (30·4 per 10,000 [19·1-41·7] vs 7·2 per 10,000 [2·2-12·3]). The positive predictive value of HPV testing for CIN 2 or worse was 12·2% (9·9-14·5) compared with 90·5% (61·7-100) for cytology.

INTERPRETATION: Despite the much lower positive predictive value for HPV testing of self-collected vaginal specimens compared with cytology, such testing might be preferred for detecting CIN 2 or worse in low-resource settings where restricted infrastructure reduces the effectiveness of cytology screening programmes. Because women at these sites will be screened only a few times in their lives, the high sensitivity of a HPV screen is of paramount importance.

FUNDING: Instituto Nacional de Salud Pública, the Health Ministry of Mexico, QiAGEN Corp.

PMID: 22051739 [PubMed - indexed for MEDLINE]

Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial.

BMJ. 2011;343:d7157

Authors: Andersson O, Hellström-Westas L, Andersson D, Domellöf M

Abstract

OBJECTIVE: To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on infant iron status at 4 months of age in a European setting.

DESIGN: Randomised controlled trial.

SETTING: Swedish county hospital.

PARTICIPANTS: 400 full term infants born after a low risk pregnancy.

INTERVENTION: Infants were randomised to delayed umbilical cord clamping (≥ 180 seconds after delivery) or early clamping (≤ 10 seconds after delivery).

MAIN OUTCOME MEASURES: Haemoglobin and iron status at 4 months of age with the power estimate based on serum ferritin levels. Secondary outcomes included neonatal anaemia, early respiratory symptoms, polycythaemia, and need for phototherapy.

RESULTS: At 4 months of age, infants showed no significant differences in haemoglobin concentration between the groups, but infants subjected to delayed cord clamping had 45% (95% confidence interval 23% to 71%) higher mean ferritin concentration (117 μg/L v 81 μg/L, P < 0.001) and a lower prevalence of iron deficiency (1 (0.6%) v 10 (5.7%), P = 0.01, relative risk reduction 0.90; number needed to treat = 20 (17 to 67)). As for secondary outcomes, the delayed cord clamping group had lower prevalence of neonatal anaemia at 2 days of age (2 (1.2%) v 10 (6.3%), P = 0.02, relative risk reduction 0.80, number needed to treat 20 (15 to 111)). There were no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy.

CONCLUSIONS: Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants even in regions with a relatively low prevalence of iron deficiency anaemia. Trial registration Clinical Trials NCT01245296.

PMID: 22089242 [PubMed - indexed for MEDLINE]

Gastroschisis.

BMJ. 2011;343:d7124

Authors: Nichol PF

PMID: 22089733 [PubMed - indexed for MEDLINE]

Denosumab and bone-metastasis-free survival in men with castration-resistant prostate cancer: results of a phase 3, randomised, placebo-controlled trial.

Lancet. 2012 Jan 7;379(9810):39-46

Authors: Smith MR, Saad F, Coleman R, Shore N, Fizazi K, Tombal B, Miller K, Sieber P, Karsh L, Damião R, Tammela TL, Egerdie B, Van Poppel H, Chin J, Morote J, Gómez-Veiga F, Borkowski T, Ye Z, Kupic A, Dansey R, Goessl C

Abstract

BACKGROUND: Bone metastases are a major cause of morbidity and mortality in men with prostate cancer. Preclinical studies suggest that osteoclast inhibition might prevent bone metastases. We assessed denosumab, a fully human anti-RANKL monoclonal antibody, for prevention of bone metastasis or death in non-metastatic castration-resistant prostate cancer.

METHODS: In this phase 3, double-blind, randomised, placebo-controlled study, men with non-metastatic castration-resistant prostate cancer at high risk of bone metastasis (prostate-specific antigen [PSA] ≥8·0 μg/L or PSA doubling time ≤10·0 months, or both) were enrolled at 319 centres from 30 countries. Patients were randomly assigned (1:1) via an interactive voice response system to receive subcutaneous denosumab 120 mg or subcutaneous placebo every 4 weeks. Randomisation was stratified by PSA eligibility criteria and previous or ongoing chemotherapy for prostate cancer. Patients, investigators, and all people involved in study conduct were masked to treatment allocation. The primary endpoint was bone-metastasis-free survival, a composite endpoint determined by time to first occurrence of bone metastasis (symptomatic or asymptomatic) or death from any cause. Efficacy analysis was by intention to treat. The masked treatment phase of the trial has been completed. This trial was registered at ClinicalTrials.gov, number NCT00286091.

FINDINGS: 1432 patients were randomly assigned to treatment groups (716 denosumab, 716 placebo). Denosumab significantly increased bone-metastasis-free survival by a median of 4·2 months compared with placebo (median 29·5 [95% CI 25·4-33·3] vs 25·2 [22·2-29·5] months; hazard ratio [HR] 0·85, 95% CI 0·73-0·98, p=0·028). Denosumab also significantly delayed time to first bone metastasis (33·2 [95% CI 29·5-38·0] vs 29·5 [22·4-33·1] months; HR 0·84, 95% CI 0·71-0·98, p=0·032). Overall survival did not differ between groups (denosumab, 43·9 [95% CI 40·1-not estimable] months vs placebo, 44·8 [40·1-not estimable] months; HR 1·01, 95% CI 0·85-1·20, p=0·91). Rates of adverse events and serious adverse events were similar in both groups, except for osteonecrosis of the jaw and hypocalcaemia. 33 (5%) patients on denosumab developed osteonecrosis of the jaw versus none on placebo. Hypocalcaemia occurred in 12 (2%) patients on denosumab and two (<1%) on placebo.

INTERPRETATION: This large randomised study shows that targeting of the bone microenvironment can delay bone metastasis in men with prostate cancer.

FUNDING: Amgen Inc.

PMID: 22093187 [PubMed - indexed for MEDLINE]

Urinary incontinence after treatment for prostate cancer.

BMJ. 2011;343:d6298

Authors: Doherty R, Almallah Z

PMID: 22102146 [PubMed - indexed for MEDLINE]

Problems in pregnancy.

BMJ. 2011;343:d7239

Authors: Nicholson T, Zehnder D, Short A, Ferraro A

PMID: 22106362 [PubMed - indexed for MEDLINE]

Comparative assessment of implantable hip devices with different bearing surfaces: systematic appraisal of evidence.

BMJ. 2011;343:d7434

Authors: Sedrakyan A, Normand SL, Dabic S, Jacobs S, Graves S, Marinac-Dabic D

Abstract

OBJECTIVE: To determine comparative safety and effectiveness of combinations of bearing surfaces of hip implants.

DESIGN: Systematic review of clinical trials, observational studies, and registries.

DATA SOURCES: Medline, Embase, Cochrane Controlled Trials Register, reference lists of articles, annual reports of major registries, summaries of safety and effectiveness for pre-market application and mandated post-market studies at the United States Food and Drug Administration.

STUDY SELECTION: Criteria for inclusion were comparative studies in adults reporting information for various combinations of bearings (such as metal on metal and ceramic on ceramic). Data search, abstraction, and analyses were independently performed and confirmed by at least two authors. Qualitative data syntheses were performed.

RESULTS: There were 3139 patients and 3404 hips enrolled in 18 comparative studies and over 830 000 operations in national registries. The mean age range in the trials was 42-71, and 26-88% were women. Disease specific functional outcomes and general quality of life scores were no different or they favoured patients receiving metal on polyethylene rather than metal on metal in the trials. While one clinical study reported fewer dislocations associated with metal on metal implants, in the three largest national registries there was evidence of higher rates of implant revision associated with metal on metal implants compared with metal on polyethylene. One trial reported fewer revisions with ceramic on ceramic compared with metal on polyethylene implants, but data from national registries did not support this finding.

CONCLUSIONS: There is limited evidence regarding comparative effectiveness of various hip implant bearings. Results do not indicate any advantage for metal on metal or ceramic on ceramic implants compared with traditional metal on polyethylene or ceramic on polyethylene bearings.

PMID: 22127517 [PubMed - indexed for MEDLINE]

Diagnosing and investigating adverse reactions in metal on metal hip implants.

BMJ. 2011;343:d7441

Authors: Fary C, Thomas GE, Taylor A, Beard D, Carr A, Glyn-Jones S

PMID: 22127518 [PubMed - indexed for MEDLINE]

Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial.

Lancet. 2012 Jan 7;379(9810):31-8

Authors: Enden T, Haig Y, Kløw NE, Slagsvold CE, Sandvik L, Ghanima W, Hafsahl G, Holme PA, Holmen LO, Njaastad AM, Sandbæk G, Sandset PM,

Abstract

BACKGROUND: Conventional anticoagulant treatment for acute deep vein thrombosis (DVT) effectively prevents thrombus extension and recurrence, but does not dissolve the clot, and many patients develop post-thrombotic syndrome (PTS). We aimed to examine whether additional treatment with catheter-directed thrombolysis (CDT) using alteplase reduced development of PTS.

METHODS: Participants in this open-label, randomised controlled trial were recruited from 20 hospitals in the Norwegian southeastern health region. Patients aged 18-75 years with a first-time iliofemoral DVT were included within 21 days from symptom onset. Patients were randomly assigned (1:1) by picking lowest number of sealed envelopes to conventional treatment alone or additional CDT. Randomisation was stratified for involvement of the pelvic veins with blocks of six. We assessed two co-primary outcomes: frequency of PTS as assessed by Villalta score at 24 months, and iliofemoral patency after 6 months. Analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00251771.

FINDINGS: 209 patients were randomly assigned to treatment groups (108 control, 101 CDT). At completion of 24 months’ follow-up, data for clinical status were available for 189 patients (90%; 99 control, 90 CDT). At 24 months, 37 (41·1%, 95% CI 31·5-51·4) patients allocated additional CDT presented with PTS compared with 55 (55·6%, 95% CI 45·7-65·0) in the control group (p=0·047). The difference in PTS corresponds to an absolute risk reduction of 14·4% (95% CI 0·2-27·9), and the number needed to treat was 7 (95% CI 4-502). Iliofemoral patency after 6 months was reported in 58 patients (65·9%, 95% CI 55·5-75·0) on CDT versus 45 (47·4%, 37·6-57·3) on control (p=0·012). 20 bleeding complications related to CDT included three major and five clinically relevant bleeds.

INTERPRETATION: Additional CDT should be considered in patients with a high proximal DVT and low risk of bleeding.

FUNDING: South-Eastern Norway Regional Health Authority; Research Council of Norway; University of Oslo; Oslo University Hospital.

PMID: 22172244 [PubMed - indexed for MEDLINE]

Recurrent aspiration and upper lobe cavitation.

Lancet. 2012 Jan 7;379(9810):92

Authors: Czapran A, Doherty M, Haddon A, Labib M

PMID: 22196831 [PubMed - indexed for MEDLINE]

Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial.

JAMA. 2012 Jan 18;307(3):265-74

Authors: Angiolillo DJ, Firstenberg MS, Price MJ, Tummala PE, Hutyra M, Welsby IJ, Voeltz MD, Chandna H, Ramaiah C, Brtko M, Cannon L, Dyke C, Liu T, Montalescot G, Manoukian SV, Prats J, Topol EJ,

Abstract

CONTEXT: Thienopyridines are among the most widely prescribed medications, but their use can be complicated by the unanticipated need for surgery. Despite increased risk of thrombosis, guidelines recommend discontinuing thienopyridines 5 to 7 days prior to surgery to minimize bleeding.

OBJECTIVE: To evaluate the use of cangrelor, an intravenous, reversible P2Y(12) platelet inhibitor for bridging thienopyridine-treated patients to coronary artery bypass grafting (CABG) surgery.

DESIGN, SETTING, AND PATIENTS: Prospective, randomized, double-blind, placebo-controlled, multicenter trial, involving 210 patients with an acute coronary syndrome (ACS) or treated with a coronary stent and receiving a thienopyridine awaiting CABG surgery to receive either cangrelor or placebo after an initial open-label, dose-finding phase (n = 11) conducted between January 2009 and April 2011. Interventions Thienopyridines were stopped and patients were administered cangrelor or placebo for at least 48 hours, which was discontinued 1 to 6 hours before CABG surgery.

MAIN OUTCOME MEASURES: The primary efficacy end point was platelet reactivity (measured in P2Y(12) reaction units [PRUs]), assessed daily. The main safety end point was excessive CABG surgery-related bleeding.

RESULTS: The dose of cangrelor determined in 10 patients in the open-label stage was 0.75 μg/kg per minute. In the randomized phase, a greater proportion of patients treated with cangrelor had low levels of platelet reactivity throughout the entire treatment period compared with placebo (primary end point, PRU <240; 98.8% (83 of 84) vs 19.0% (16 of 84); relative risk [RR], 5.2 [95% CI, 3.3-8.1] P < .001). Excessive CABG surgery-related bleeding occurred in 11.8% (12 of 102) vs 10.4% (10 of 96) in the cangrelor and placebo groups, respectively (RR, 1.1 [95% CI, 0.5-2.5] P = .763). There were no significant differences in major bleeding prior to CABG surgery, although minor bleeding episodes were numerically higher with cangrelor.

CONCLUSIONS: Among patients who discontinue thienopyridine therapy prior to cardiac surgery, the use of cangrelor compared with placebo resulted in a higher rate of maintenance of platelet inhibition.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00767507.

PMID: 22253393 [PubMed - indexed for MEDLINE]

Complete immunosuppression withdrawal and subsequent allograft function among pediatric recipients of parental living donor liver transplants.

JAMA. 2012 Jan 18;307(3):283-93

Authors: Feng S, Ekong UD, Lobritto SJ, Demetris AJ, Roberts JP, Rosenthal P, Alonso EM, Philogene MC, Ikle D, Poole KM, Bridges ND, Turka LA, Tchao NK

Abstract

CONTEXT: Although life-saving, liver transplantation burdens children with lifelong immunosuppression and substantial potential for morbidity and mortality.

OBJECTIVE: To establish the feasibility of immunosuppression withdrawal in pediatric living donor liver transplant recipients.

DESIGN, SETTING, AND PATIENTS: Prospective, multicenter, open-label, single-group pilot trial conducted in 20 stable pediatric recipients (11 male; 55%) of parental living donor liver transplants for diseases other than viral hepatitis or an autoimmune disease who underwent immunosuppression withdrawal. Their median age was 6.9 months (interquartile range [IQR], 5.5-9.1 months) at transplant and 8 years 6 months (IQR, 6 years 5 months to 10 years 9 months) at study enrollment. Additional entry requirements included stable allograft function while taking a single immunosuppressive drug and no evidence of acute or chronic rejection or significant fibrosis on liver biopsy. Gradual immunosuppression withdrawal over a minimum of 36 weeks was instituted at 1 of 3 transplant centers between June 5, 2006, and November 18, 2009. Recipients were followed up for a median of 32.9 months (IQR, 1.0-49.9 months).

MAIN OUTCOME MEASURES: The primary end point was the proportion of operationally tolerant patients, defined as patients who remained off immunosuppression therapy for at least 1 year with normal graft function. Secondary clinical end points included the durability of operational tolerance, and the incidence, timing, severity, and reversibility of rejection.

RESULTS: Of 20 pediatric patients, 12 (60%; 95% CI, 36.1%-80.9%) met the primary end point, maintaining normal allograft function for a median of 35.7 months (IQR, 28.1-39.7 months) after discontinuing immunosuppression therapy. Follow-up biopsies obtained more than 2 years after completing withdrawal showed no significant change compared with baseline biopsies. Eight patients did not meet the primary end point secondary to an exclusion criteria violation (n = 1), acute rejection (n = 2), or indeterminate rejection (n = 5). Seven patients were treated with increased or reinitiation of immunosuppression therapy; all returned to baseline allograft function. Patients with operational tolerance compared with patients without operational tolerance initiated immunosuppression withdrawal later after transplantation (median of 100.6 months [IQR, 71.8-123.5] vs 73.0 months [IQR, 57.6-74.9], respectively; P = .03), had less portal inflammation (91.7% [95% CI, 61.5%-99.8%] vs 42.9% [95% CI, 9.9%-81.6%] with no inflammation; P = .04), and had lower total C4d scores on the screening liver biopsy (median of 6.1 [IQR, 5.1-9.3] vs 12.5 [IQR, 9.3-16.8]; P = .03).

CONCLUSION: In this pilot study, 60% of pediatric recipients of parental living donor liver transplants remained off immunosuppression therapy for at least 1 year with normal graft function and stable allograft histology.

PMID: 22253395 [PubMed - indexed for MEDLINE]

Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review.

JAMA. 2012 Jan 18;307(3):294-303

Authors: Januel JM, Chen G, Ruffieux C, Quan H, Douketis JD, Crowther MA, Colin C, Ghali WA, Burnand B,

Abstract

CONTEXT: Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined.

OBJECTIVE: To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA.

DATA SOURCES: Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles.

STUDY SELECTION: Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa.

DATA EXTRACTION AND SYNTHESIS: Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models.

RESULTS: The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies.

CONCLUSION: Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.

PMID: 22253396 [PubMed - indexed for MEDLINE]

Estimating the incidence of symptomatic postoperative venous thromboembolism: the importance of perspective.

JAMA. 2012 Jan 18;307(3):306-7

Authors: Heit JA

PMID: 22253398 [PubMed - indexed for MEDLINE]

Global surgery–the final frontier?

Lancet. 2012 Jan 21;379(9812):194

Authors:

PMID: 22265618 [PubMed - in process]

Caregiving burden, stress, and health effects among family caregivers of adult cancer patients.

JAMA. 2012 Jan 25;307(4):398-403

Authors: Bevans M, Sternberg EM

Abstract

Unlike professional caregivers such as physicians and nurses, informal caregivers, typically family members or friends, provide care to individuals with a variety of conditions including advanced age, dementia, and cancer. This experience is commonly perceived as a chronic stressor, and caregivers often experience negative psychological, behavioral, and physiological effects on their daily lives and health. In this report, we describe the experience of a 53-year-old woman who is the sole caregiver for her husband, who has acute myelogenous leukemia and was undergoing allogeneic hematopoietic stem cell transplantation. During his intense and unpredictable course, the caregiver’s burden is complex and complicated by multiple competing priorities. Because caregivers are often faced with multiple concurrent stressful events and extended, unrelenting stress, they may experience negative health effects, mediated in part by immune and autonomic dysregulation. Physicians and their interdisciplinary teams are presented daily with individuals providing such care and have opportunity to intervene. This report describes a case that exemplifies caregiving burden and discusses the importance of identifying caregivers at risk of negative health outcomes and intervening to attenuate the stress associated with the caregiving experience.

PMID: 22274687 [PubMed - indexed for MEDLINE]

Papules, plaques, and nodules in an immunocompromised patient.

JAMA. 2012 Jan 25;307(4):404-5

Authors: Man XY, Zheng M

PMID: 22274688 [PubMed - indexed for MEDLINE]

Surgical Genomics: Using New Technology to Answer Age-old Questions.

Dis Colon Rectum. 2012 Feb;55(2):113-4

Authors: Kennedy GD

PMID: 22228151 [PubMed - in process]

Mutations in IRGM Are Associated With More Frequent Need for Surgery in Patients With Ileocolonic Crohn’s Disease.

Dis Colon Rectum. 2012 Feb;55(2):115-21

Authors: Sehgal R, Berg A, Polinski JI, Hegarty JP, Lin Z, McKenna KJ, Stewart DB, Poritz LS, Koltun WA

Abstract

BACKGROUND: : There are no clear criteria for judging the severity of disease in patients with Crohn’s disease. Yet classification of patients into low- and high-risk severity groups would benefit both medical and surgical management. At the time of this study, approximately 80 single-nucleotide polymorphisms within 55 genes had been associated with IBD.

OBJECTIVE: : The aim of this study was to identify genetic determinants (single-nucleotide polymorphisms) that could be markers of Crohn’s disease severity by the use of frequency of ileocolic surgery as a surrogate for disease severity.

DESIGN: : Sixty-six patients (30 male) with ileocolonic Crohn’s disease who previously underwent ileocolectomy were retrospectively studied. The severity of Crohn’s disease was quantified by dividing the total number of ileocolectomy procedures by the time between IBD diagnosis and the patient’s last clinic visit, the rationale being that more severe disease would be associated with a more frequent need for surgery. Genotyping for the 83 single-nucleotide polymorphisms associated with IBD was done on a customized Illumina Veracode genotyping platform. Three genetic models (general, additive, and dominant) were used to statistically quantify the genetic association of the studied single-nucleotide polymorphisms to the frequency of surgery after adjusting for covariates (age, smoking, family history, disease location, and disease behavior).

RESULTS: : For the entire group the average number of ileocolectomies per patient was 1.7 (range, 1-5) with an average duration of disease of 14.7 years. Single-nucleotide polymorphism rs4958847 in the IRGM gene (immunity-related GTPase family, M) was the most significant single-nucleotide polymorphism in all 3 models tested (p = 0.007) as being associated with ileocolectomy, and it remained significant even after a Benjamini-Hochberg false-discovery correction for multiple observations. Patients carrying the “at-risk” allele for this single-nucleotide polymorphism (n = 20) had an average of 1 surgery every 6.87 ± 1.33 years in comparison with patients carrying the wild-type genotype (n = 46) who averaged 1 surgery in 11.43 ± 1.21 years (p = 0.007, Mann-Whitney U test).

CONCLUSIONS: : Single-nucleotide polymorphism rs4958847 in the IRGM gene correlated very significantly with frequency of surgery in patients with ileocolonic Crohn’s disease. IRGM is a mediator of innate immune responses and is involved in autophagy. The presence of this IRGM SNP may be a marker for disease severity and/or early recurrence after ileocolectomy and may assist in surgical and medical decision making.

PMID: 22228152 [PubMed - in process]

Rate of residual disease after complete endoscopic resection of malignant colonic polyp.

Dis Colon Rectum. 2012 Feb;55(2):122-7

Authors: Butte JM, Tang P, Gonen M, Shia J, Schattner M, Nash GM, Temple LK, Weiser MR

Abstract

BACKGROUND: : Following polypectomy, colectomy is performed selectively to ensure complete clearance of neoplasia.

OBJECTIVE: : This study aimed to determine the risk factors associated with residual disease at colectomy following malignant polypectomy.

DESIGN: : This is a retrospective study.

SETTING: : This investigation took place at a tertiary teaching cancer center.

PATIENTS: : Consecutive patients undergoing polypectomy followed by colectomy from 1990 to 2007 were identified from a prospective database.

MAIN OUTCOME MEASURES: : Factors associated with residual disease at colectomy were associated with clinicopathologic features.

RESULTS: : Colectomy following polypectomy was performed in 143 patients: 127 with clear invasion of polyp submucosa (invasive disease), and 16 suspicious for submucosal invasion. Residual disease after colectomy was diagnosed in 27 (19%) of 143 patients. Disease was present in the colonic wall in 19 patients (13%): invasive in 16 (11%), and noninvasive in 3 (2.1%). Of the 16 patients with residual invasive disease at colectomy, 15 had clearly invasive disease at polypectomy and 1 was suspicious for invasive disease at polypectomy. Lymph node metastasis was noted in 10 (7.0%) patients. When analyzing patients with clearly invasive disease at polypectomy by margin status, residual invasive disease in the colon wall was noted in 8 of 50 (16%) with <1 mm (positive) polypectomy margin, 7 of 33 (21%) with indeterminate polypectomy margin, and 0 of 44 with ≥1 mm (negative) polypectomy margin (p = 0.009). Nodal metastasis was associated with the presence of lymphovascular invasion (p = 0.01).

LIMITATIONS: : This study is limited by its retrospective nature and selection bias.

CONCLUSIONS: : Following malignant polypectomy, colectomy should be considered in medically fit patients if the polypectomy margin is positive (≤1 mm) or unknown, or if lymphovascular invasion is present.

PMID: 22228153 [PubMed - in process]

BRAF Mutations in Colorectal Cancer Are Associated With Distinct Clinical Characteristics and Worse Prognosis.

Dis Colon Rectum. 2012 Feb;55(2):128-33

Authors: Kalady MF, Dejulius KL, Sanchez JA, Jarrar A, Liu X, Manilich E, Skacel M, Church JM

Abstract

BACKGROUND: : Colorectal cancer is a heterogeneous disease with multiple underlying genetic mutations causing different clinical phenotypes. Mutation in the BRAF oncogene is a key step in malignant transformation within the methylator pathway to colorectal cancer. However, there is a paucity of information about BRAF mutant colorectal tumors.

OBJECTIVE: : This study defines the clinical characteristics and oncologic outcome associated with colorectal cancer BRAF mutations.

DESIGN: : Colorectal adenocarcinomas from a single-institution frozen-tumor biobank were studied. Genomic DNA was isolated and analyzed for mutations in the BRAF oncogene by polymerase chain reaction amplification followed by direct sequencing. A sample was classified as mutant if any of the tested loci were mutated. Patient and tumor characteristics were recorded including patient age, sex, tumor location, tumor differentiation, and microsatellite instability.

MAIN OUTCOME MEASURES: : Statistical associations with BRAF mutant tumors were determined by the Fisher exact probability test, χ test, or Wilcoxon analysis. Kaplan-Meier estimates and multivariate Cox regression analysis were performed for overall survival.

RESULTS: : Four hundred seventy-five colorectal adenocarcinomas were included in the study population; 56 samples harbored a BRAF mutation (12%). There were significant differences between BRAF wild-type and mutant tumors in age (66 vs 75 years, p = 0.004), female sex (44% vs 71%, p < 0.001), proximal tumor location (44% vs 95%, p < 0.001), and frequency of microsatellite instability (16% vs 76%, p < 0.001). There was no difference in cancer stage between BRAF mutant and wild-type populations. Survival data were analyzed for 322 patients with stage I to III disease, and patients with a BRAF mutation had decreased overall survival than those without a mutation (p = 0.018). With the use of Cox regression analysis, BRAF mutation conferred a worse overall survival (HR 1.79, CI 1.05-3.05, p = 0.03) independent of microsatellite instability status.

CONCLUSIONS: : BRAF mutations in colorectal cancers are associated with distinct clinical characteristics and worse prognosis.

PMID: 22228154 [PubMed - in process]

Single-port laparoscopic right hemicolectomy: the first 100 resections.

Dis Colon Rectum. 2012 Feb;55(2):134-9

Authors: Waters JA, Rapp BM, Guzman MJ, Jester AL, Selzer DJ, Robb BW, Johansen BJ, Tsai BM, Maun DC, George VV

Abstract

BACKGROUND: : Single-port laparoscopy remains a novel technique in the field of colorectal surgery. Several small series have examined its safety for colon resection.

OBJECTIVE: : Our aim was to analyze our entire experience and short-term outcomes with single-port laparoscopic right hemicolectomy since its introduction at our institution. We assert that this approach is feasible and safe for the wide array of patients and indications encountered by a colorectal surgeon.

DESIGN: : This is a retrospective analysis of prospectively gathered data for all patients who underwent single-port laparoscopic right hemicolectomy with the use of standard laparoscopic instrumentation, for malignant or benign disease, between July 2009 and November 2010 in a high-volume, academic, colorectal surgery practice. MAIN OUTOME MEASURES:: Demographic, clinical, operative, and pathologic factors were reviewed and analyzed. All conversions to conventional laparoscopic or open operations were considered in this analysis.

RESULTS: : One hundred patients underwent single-port laparoscopic right hemicolectomy during the study period. Mean age was 63 years, and 61% of the patients were men. Forty-three percent had undergone previous abdominal surgery, and the median body mass index was 26 (range, 18-46). Median ASA classification was 3 (range, 1-4). Five percent of the operations were performed urgently, and 56% were performed for carcinoma, of which half were T3 or T4 tumor stage. Median operative duration was 105 (range, 64-270) minutes. Mean and median blood loss was 106 and 50 mL. Two percent required conversion to multiport laparoscopy, and 4% converted to the open approach. Median postoperative stay was 4 (range, 2-48) days. Median lymph node number was 18 (range, 11-42). There was one mortality in this series. Morbidity, including wound infection, was 13%.

CONCLUSIONS: : This represents the largest experience with single-port laparoscopic right hemicolectomy to date. This technique was used with acceptable morbidity and mortality and without compromise of conventional oncologic parameters by colorectal surgeons experienced in minimally invasive technique. These findings support the use of a single-port approach for patients requiring right hemicolectomy.

PMID: 22228155 [PubMed - in process]

Single-incision laparoscopic surgery for ileocolic resection in Crohn’s disease.

Dis Colon Rectum. 2012 Feb;55(2):140-6

Authors: Rijcken E, Mennigen R, Argyris I, Senninger N, Bruewer M

Abstract

BACKGROUND: : Single-incision laparoscopic surgery is a development in the field of minimally invasive surgery that is being increasingly used for colorectal procedures.

OBJECTIVE: : We report on the short-term results of single-port laparoscopic ileocolic resection in patients with ileocecal Crohn’s disease.

DESIGN: : This investigation is a retrospective matched-pair control study. Data were obtained from a prospectively maintained single-institution inflammatory bowel disease database.

SETTINGS: : This study was conducted at a tertiary care university hospital.

PATIENTS: : Twenty consecutive patients receiving elective single-port ileocolic resection between April 2010 and May 2011 were included (6 male, 14 female; age, 31.6 ± 10.8 years; BMI, 21.5 ± 2.6 kg/m). Their data were compared with the data of 20 individually matched patients who had undergone standard 3-trocar laparoscopic-assisted ileocolic resection between 2007 and 2010 (6 male, 14 female; age, 31.7 ± 10.7 years; BMI, 21.2 ± 2.5 kg/m). All patients had medically refractory stenosis of the terminal ileum in histologically confirmed Crohn’s disease.

INTERVENTIONS: : Single-port laparoscopic-assisted or standard laparoscopic-assisted ileocolic resection was performed.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the surgical details and early outcome.

RESULTS: : The mean length of the paraumbilical single-port incision was 3.8 cm (range, 2.5-5.0 cm). Conversion rates were similar in both groups (1/20 vs 2/20, p = 0.55). Additional strictureplasties or short-segment small-bowel resections were performed in both groups. The overall complication rate was 20% (4/20) in both groups. There were no observed differences in postoperative pain scores and hospital stay duration.

LIMITATIONS: : The limitations of this study were as follows: this study was a comparison of 2 different time points with possible selection bias, there was no prestudy power calculation, and the study might be underpowered.

CONCLUSIONS: : Single-port ileocolic resection is a safe procedure for the surgical treatment of stenotizing Crohn’s disease of the terminal ileum. Avoidance of additional trocars was the only identified benefit.

PMID: 22228156 [PubMed - in process]

Long-term Quality of Life and Sexual and Urinary Function After Abdominoperineal Resection for Distal Rectal Cancer.

Dis Colon Rectum. 2012 Feb;55(2):147-54

Authors: Kasparek MS, Hassan I, Cima RR, Larson DR, Gullerud RE, Wolff BG

Abstract

BACKGROUND: : Permanent colostomy, pelvic dissection, and radiotherapy after abdominoperineal resection can put quality of life and sexual and urinary function at risk; however, there are limited data using validated instruments on patients undergoing abdominoperineal resection regarding these outcome measures.

OBJECTIVE: : We evaluated the quality of life and the sexual and urinary function of patients undergoing abdominoperineal resection for rectal cancer and compared the outcomes of patients who received and did not receive pre- or postoperative pelvic radiotherapy.

METHODS: : European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR38, International Consultation on Incontinence Questionnaire, American Urological Association Symptom Index, Brief Sexual Function Inventory for men, and sexual function module of the Cancer Rehabilitation Evaluation System for women were mailed to 219 patients who underwent abdominoperineal resection between 1994 and 2004.

RESULTS: : One-hundred forty-three patients responded (response rate, 65%), of whom 55 (38%) were treated with surgery alone and 88 (62%) received pelvic radiotherapy. Generic and disease-specific quality of life and sexual and urinary function were similar between patients not receiving and receiving pelvic radiotherapy. However, a proportion of patients experienced adverse quality of life after surgery, and this was associated with a younger age, male sex, and sexual inactivity. In sexually active men, sexual function after abdominoperineal resection was diminished compared with population-based controls.

LIMITATIONS: : This study was limited by the lack of baseline data and cross-sectional nature of survey.

CONCLUSIONS: : Quality of life and sexual function can be impaired after abdominoperineal resection, although the impact of pelvic radiotherapy appears to be limited. Indication and timing of radiotherapy should be based on oncological indications, but quality of life and functional outcomes should be considered when counseling patients.

PMID: 22228157 [PubMed - in process]

T-pouch: results of the first 10 years with a nonintussuscepting continent ileostomy.

Dis Colon Rectum. 2012 Feb;55(2):155-62

Authors: Kaiser AM

Abstract

BACKGROUND: : Continent ileostomy is an alternative for patients who are either not candidates for an ileo-anal pullthrough or in whom an ileo-anal pullthrough failed. We previously described a new type of continent ileostomy (T-pouch) with a nonintussuscepting valve.

OBJECTIVE: : This study performed an outcomes analysis of the first 10 years with 40 patients.

DESIGN: : A prospective database of patients with a T-pouch from 2000 to 2010 was retrospectively analyzed.

MAIN OUTCOME MEASURES: : The primary outcomes measured were demographics and surgical recovery information and the functional data obtained via questionnaire: incontinence, difficulty of pouch intubation, restrictions (work, social, diet, and sexual), quality of health and life, and level of satisfaction with surgery, which were rated on a scale of 0 to 10.

RESULTS: : Twenty-three women and 17 men (mean age, 51.2) received a T-pouch. Median follow-up was 6.2 years (range, 0.8-11 years). Five patients (12.5%) experience a leak; 3 leaks were managed conservatively and/or with drain placement. Pouch intubations were done 4 times per day in a mean of 6.8 minutes; the insertion difficulty was rated as 2.5 of 10. Ninety-two percent achieved good continence. All quality-of-life and dysfunction/restriction scores showed significant improvement. Major abdominal surgeries for pouch-related reasons were needed in 30%; minor service operations of the skin-level stoma were needed in 25% of the patients. Of the patients, 87.5% would do the surgery again; 90% would recommend it to others with the same diagnosis.

LIMITATIONS: : This study was limited by the cohort size and the lack of long-term data.

CONCLUSION: : Ten years with 40 patients confirmed that creation of a T-pouch is complex but could be performed with an acceptable rate of complications. It dramatically improved functional outcomes; most notably, it improved fecal control and decreased social, sexual, and work restrictions.

PMID: 22228158 [PubMed - in process]

Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract?

Dis Colon Rectum. 2012 Feb;55(2):163-6

Authors: van Onkelen RS, Gosselink MP, Schouten WR

Abstract

BACKGROUND: : Transanal advancement flap repair is successful in 2 of every 3 patients with a cryptoglandular fistula passing through the middle or upper third of the external anal sphincter. It has been suggested that ongoing disease in the remaining fistula tract contributes to failure. Ligation of the intersphincteric fistula tract might be a useful tool to eradicate this ongoing disease.

OBJECTIVE: : The aim of the present study was to evaluate the effect of an additional ligation of the fistula tract on the outcome of transanal advancement flap repair.

DESIGN: : This investigation was designed as a prospective clinical study.

SETTINGS: : The study took place in a university hospital.

PATIENTS: : A consecutive series of 41 patients with a high transsphincteric fistula of cryptoglandular origin were included.

INTERVENTION: : Ligation of the intersphincteric fistula tract was performed in addition to flap repair.

MAIN OUTCOME MEASURES: : Early and late complications were recorded. Continence scores were determined with the use of the Fecal Incontinence Severity Index.

RESULTS: : Median duration of follow-up was 15 months. Primary healing was observed in 21 patients (51%). Of the 20 patients with a failure, the original transsphincteric fistula persisted in 12 patients. In 8 patients, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulectomy, which was successful in all of them. The overall healing rate was 71%.

LIMITATIONS: : This was a preliminary observational study with no control group.

CONCLUSIONS: : The ligation of the intersphincteric fistula tract procedure is prone to infection and does not enhance the outcome of flap repair.

PMID: 22228159 [PubMed - in process]

Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure.

Dis Colon Rectum. 2012 Feb;55(2):167-74

Authors: Chun LJ, Haigh PI, Tam MS, Abbas MA

Abstract

OBJECTIVE: : The aim of this study was to determine the morbidity of a defunctioning loop ileostomy and the subsequent closure rate, and to identify the predictors of complications and nonclosure of stoma.

DESIGN: : This study is a retrospective review of a single-institution experience.

PATIENTS: : All patients who underwent a planned temporary defunctioning loop ileostomy performed synchronously with a pelvic anastomosis during a 6-year period were included.

MAIN OUTCOME MEASURES: : The primary outcome measures were the ileostomy complication rate for the entire spectrum of care, readmission and reoperation rates to treat ileostomy complications, and subsequent closure rate. Patient and treatment factors were evaluated for their independent effect on complications and closure rate with the use of multivariable logistic regression.

RESULTS: : One hundred twenty-three patients were identified (median age, 51 years). Of these patients, 64.2% developed ≥1 minor or major ileostomy complications (13.8% during index hospitalization, 52.8% as outpatient, and 23.4% after closure). Readmitted for dehydration following ileostomy formation were 11.4% of patients. The ileostomy was closed in 76.4% of patients with 8.6% requiring a midline laparotomy. The overall ileostomy-related reoperation rate was 10.4% (2.4% during index hospitalization, 1.6% at readmission, and 6.4% following ileostomy closure). Obesity (BMI ≥30 kg/m) was associated with a higher overall ileostomy complication rate (OR 8.56, 95% CI 1.64-44.74) and outpatient complication rate (OR 7.69, 95% CI 2.48-23.81). Age >65 years (OR 53.34, 95% CI 4.21-676.14) and hypertension (OR 8.36, 95% CI 1.09-64.43) increased the risks of high ileostomy output and dehydration. Obesity (OR 4.61, 95% CI 1.14-18.54) and smoking (4.47, 95% CI 1.43-13.98) decreased the likelihood of ileostomy closure.

LIMITATION: : This study was limited by its retrospective nature.

CONCLUSIONS: : The morbidity of a defunctioning loop ileostomy remains significant. Obesity is an independent predictor of ileostomy complications. Older age and hypertension increase the risks of high-output stoma and dehydration. Almost one quarter of patients never have the ileostomy closed. Obesity and smoking are associated with less likelihood of a subsequent ileostomy closure.

PMID: 22228160 [PubMed - in process]

Dehydration is the most common indication for readmission after diverting ileostomy creation.

Dis Colon Rectum. 2012 Feb;55(2):175-80

Authors: Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, Poritz LS

Abstract

BACKGROUND: : Early readmission after discharge from the hospital is an undesirable outcome. Ileostomies are commonly used to prevent symptomatic anastomotic complications in colorectal resections.

OBJECTIVE: : The aim of this study was to identify factors predictive of readmission after colectomy/proctectomy and diverting loop ileostomy.

DESIGN: : This study is a retrospective review.

PATIENTS: : Patients were included who underwent colon and rectal resections with ileostomy at our institution. Sex, age, type of disease, comorbidities, elective vs urgent procedure, type of ileostomy, operative method, steroid use, ASA score, and the use of diuretics were evaluated as potential factors for readmission.

MAIN OUTCOME MEASURES: : The primary outcomes measured were the need for readmission and the presence of dehydration (ostomy output ≥1500 mL over 24 hours and a blood urea nitrogen/creatinine level ≥20, or physical findings of dehydration).

RESULTS: : Six hundred three loop ileostomies were created mostly in white (95.3%), male (55.6%) patients undergoing colon or rectal resections. IBD was the most common indication at 50.9%, with rectal cancer at 16.1%, and other at 31.0%. The 60-day readmission rate was 16.9% (n = 102) with the most common cause dehydration (n = 44, 43.1%). Regression analysis demonstrated that the laparoscopic approach (p = 0.02), lack of epidural anesthesia (p = 0.004), preoperative use of steroids (p = 0.04), and postoperative use of diuretics (p = 0.0001) were highly predictive for readmission. Furthermore, regression analysis for readmission for dehydration identified the use of postoperative diuretics as the sole risk factor (p = 0.0001).

LIMITATIONS: : This study is limited by the retrospective analysis of data, and it does not capture patients that were treated at home or in clinic.

CONCLUSION: : Readmission after colon or rectal resection with diverting loop ileostomy was high at 16.9%. Dehydration was the major cause for readmission. Patients receiving diuretics are at increased risk for readmission for dehydration. High-risk patients should be treated more cautiously as inpatients and closely monitored in the outpatient setting to help reduce dehydration and readmission.

PMID: 22228161 [PubMed - in process]

Clinicopathologic and molecular characteristics of synchronous colorectal cancers: heterogeneity of clinical outcome depending on microsatellite instability status of individual tumors.

Dis Colon Rectum. 2012 Feb;55(2):181-90

Authors: Bae JM, Cho NY, Kim TY, Kang GH

Abstract

BACKGROUND: : The contribution of chromosomal instability, microsatellite instability, and epigenetic instability to the development of synchronous colorectal carcinomas is controversial.

OBJECTIVE: : This study aimed to investigate the relative roles of microsatellite instability and epigenetic instability in the development of synchronous colorectal cancers.

DESIGN: : This was a retrospective study of medical records with histologic, immunohistochemical, and molecular examination of stored tissue samples.

SETTING: : The study took place at Seoul National University Hospital, Korea.

PATIENTS: : A total of 46 patients with synchronous colorectal cancers and 105 patients with solitary colorectal cancers were included.

MAIN OUTCOME MEASURES: : Clinicopathologic and molecular characteristics including microsatellite instability, mismatch repair gene expression, CpG island methylator phenotype, and mutation of KRAS and BRAF were analyzed.

RESULTS: : Patients with synchronous tumors were more likely to be men than those with solitary tumors and had a tendency toward colocalization of individual tumors in the left or right colon. MSI-deficient cancers were more frequent in synchronous than in solitary cancers. The frequencies of CpG island methylator phenotype-high and KRAS and BRAF mutations were not different between synchronous and solitary cancers. No differences between synchronous cancers and solitary cancers were observed in overall survival or progression-free survival. Within the synchronous cancer group, patients with individual tumors discordant for microsatellite instability status had the worst clinical outcome, whereas those with individual tumors concordant for microsatellite instability-deficient status had the best clinical outcome.

LIMITATIONS: : The study was limited by its retrospective nature. Molecular analysis was performed only on cancerous lesions.

CONCLUSIONS: : Our findings suggest that microsatellite instability plays a more important role than does epigenetic instability in the development of synchronous colorectal cancers, and that information regarding concordant or discordant microsatellite instability status between individual tumors might help to predict clinical outcome of synchronous colorectal cancers.

PMID: 22228162 [PubMed - in process]

Risk Factors for Rectal Stump Cancer in Inflammatory Bowel Disease.

Dis Colon Rectum. 2012 Feb;55(2):191-196

Authors: Lutgens MW, van Oijen MG, Vleggaar FP, Siersema PD, Broekman MM, Oldenburg B,

Abstract

BACKGROUND:: Patients with long-standing colitis carry an increased risk of colorectal cancer and are therefore enrolled in colonoscopic surveillance programs. It is presently not known if endoscopic surveillance of patients with colitis with a closed rectal stump after a subtotal colectomy is justified. Neither is it clear which of these patients might be at increased risk for rectal stump cancer. OBJECTIVE:: The aim of this study is to identify the risk factors for rectal stump cancer. DESIGN:: This investigation is a retrospective descriptive case-control study. SETTINGS:: This study was conducted at tertiary referral centers in the Netherlands. PATIENTS:: Colorectal cancer cases associated with inflammatory bowel disease diagnosed between 1990 and 2006 were selected in a nationwide pathology archive. Patients with rectal stump cancer were selected from this group. The pathology archive was also used to identify inflammatory bowel disease controls matched for referral center with a closed rectal stump after subtotal colectomy, but without neoplasia. Follow-up started at the date of subtotal colectomy with the formation of a rectal stump. Demographic and disease characteristics were collected at baseline. MAIN OUTCOME MEASUREMENTS:: Hazard ratios with 95% confidence intervals were calculated for factors associated with the development of rectal stump cancer with the use of univariate Cox regression analysis. End points were rectal stump cancer, end of follow-up, or death. RESULTS:: A total of 12 patients with rectal stump cancer and 18 matching controls without neoplasia were identified. Univariate analysis showed an association between rectal stump cancer and primary sclerosing cholangitis, and disease duration until subtotal colectomy. LIMITATIONS:: This study is limited by its retrospective design, and, despite being the largest series to date, it still has a limited number of cases. CONCLUSIONS:: Risk factors for rectal stump cancer in a closed rectal stump after subtotal colectomy were primary sclerosing cholangitis and disease duration until subtotal colectomy.

PMID: 22228163 [PubMed - as supplied by publisher]

Pathological evaluation of mesocolic resection quality and ex vivo methylene blue injection: what is the impact on lymph node harvest after colon resection for cancer?

Dis Colon Rectum. 2012 Feb;55(2):197-204

Authors: Frasson M, Faus C, Garcia-Granero A, Puga R, Flor-Lorente B, Cervantes A, Navarro S, Garcia-Granero E

Abstract

BACKGROUND: : Although the National Quality Forum has endorsed the harvest of ≥12 lymph nodes as a standard quality indicator for colon cancer surgery, this minimum quantity is not reached in many centers.

OBJECTIVE: : The aim of this study was to assess the impact of the implementation of a mesocolon evaluation pathological protocol and ex vivo arterial methylene blue injection on the number of nodes harvested after colon cancer resection.

DESIGN: : A prospective series was compared with a historical group.

SETTINGS: : This study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital.

PATIENTS: : From June 2009 to December 2009, all the specimens after colon resection for cancer were analyzed with the use of a “mesocolon quality pathological evaluation” protocol. Moreover, a consecutive series of specimens was analyzed after arterial ex vivo injection of methylene blue. We compared the study groups with our previous series (2005-2009).

INTERVENTIONS: : The “mesocolon quality pathological evaluation” protocol was used with or without arterial methylene blue ex vivo injection.

MAIN OUTCOME MEASURE: : The primary outcome measure was the number of lymph nodes harvested.

RESULTS: : The mean number (SD) of lymph nodes collected was 20.6 (10.5), 37.1 (12.8), and 47.6 (12.9) (p < 0.0001) in the control, protocol, and methylene blue groups. In the control group, the minimum number of 12 and 18 lymph nodes collected was not reached in 92 (15.9%) and 258 (44.6%) patients. In contrast, all patients in the protocol and methylene blue groups had more than 18 lymph nodes collected. The multivariate analysis confirmed the application of the “mesocolon quality pathological evaluation” protocol and the methylene blue ex vivo injection, along with the type of resection and the length of the specimen, to be independent factors determining the number of nodes collected.

LIMITATIONS: : The patients are not randomly selected and are compared with a retrospective series.

CONCLUSION: : The implementation of a “mesocolon quality pathological evaluation” protocol along with the arterial ex vivo injection of methylene blue can significantly increase the number of nodes isolated after colonic resection, reaching a 100% rate of specimens with more than 12 nodes.

PMID: 22228164 [PubMed - in process]

Perioperative use of statins in elective colectomy.

Dis Colon Rectum. 2012 Feb;55(2):205-10

Authors: Singh PP, Srinivasa S, Bambarawana S, Lemanu DP, Kahokehr AA, Zargar-Shoshtari K, Hill AG

Abstract

BACKGROUND: : Statins have many beneficial effects and may attenuate the proinflammatory and metabolic stress response to surgery and consequently reduce postoperative morbidity.

OBJECTIVE: : This study investigated whether perioperative use of statins improved short-term outcomes after elective colectomy.

DESIGN: : This study is a retrospective review of prospectively collected data. SETTINGS AND PATIENTS:: This study was conducted in consecutive patients undergoing elective colonic resection within an enhanced recovery program at a tertiary hospital (Manukau Surgery Centre, Middlemore Hospital, Auckland, New Zealand) from January 2005 to December 2010.

MAIN OUTCOME MEASURES: : Complications, hospital stay, and readmissions were recorded for 30 days postoperatively. Postoperative functional recovery was measured by the use of the validated Surgical Recovery Score. Serum proinflammatory cytokines were measured on postoperative day 1.

RESULTS: : There were 269 patients; 86 patients were on a statin perioperatively, whereas 183 patients had no statin. Members of the statin group were older (median age, 72 vs 69 years; p = 0.021), included more men (53% vs 40%; p = 0.049), and included a higher number of patients with an ASA score of 3 (55% vs 22%; p < 0.001). Patients on statin therapy had a significantly lower number of anastomotic leaks (1% vs 7%; p = 0.031). However, there was no significant difference in total complications or median hospital stay. The 2 groups had comparable functional recovery, and there was no significant difference in serum cytokine levels.

LIMITATIONS: : This retrospective study did not analyze type, duration, or dose of statins given perioperatively.

CONCLUSION: : Patients on perioperative statins had greater baseline perioperative risks compared with nonusers, but they achieved equivalent outcomes overall. Statin use was associated with reduced anastomotic leaks. Thus, perioperative statin use may reduce morbidity after elective colectomy, and this finding warrants further investigation.

PMID: 22228165 [PubMed - in process]

Viscoelastic assessment of anal canal function using acoustic reflectometry: a clinically useful technique.

Dis Colon Rectum. 2012 Feb;55(2):211-7

Authors: Mitchell PJ, Klarskov N, Telford KJ, Hosker GL, Lose G, Kiff ES

Abstract

BACKGROUND: : Anal acoustic reflectometry is a new reproducible technique that allows a viscoelastic assessment of anal canal function. Five new variables reflecting anal canal function are measured: the opening and closing pressure, opening and closing elastance, and hysteresis.

OBJECTIVE: : The aim of this study was to assess whether the parameters measured in anal acoustic reflectometry are clinically valid between continent and fecally incontinent subjects.

DESIGN: : This was an age- and sex-matched study of continent and incontinent women.

SETTING: : The study was conducted at a university teaching hospital.

PATIENTS: : One hundred women (50 with fecal incontinence and 50 with normal bowel control) were included in the study. Subjects were age matched to within 5 years.

MAIN OUTCOME MEASURES: : Parameters measured with anal acoustic reflectometry and manometry were compared between incontinent and continent groups using a paired t test. Diagnostic accuracy was assessed by the use of receiver operator characteristic curves.

RESULTS: : Four of the 5 anal acoustic reflectometry parameters at rest were significantly different between continent and incontinent women (eg, opening pressure in fecally incontinent subjects was 31.6 vs 51.5 cm H2O in continent subjects, p = 0.0001). Both anal acoustic reflectometry parameters of squeeze opening pressure and squeeze opening elastance were significantly reduced in the incontinent women compared with continent women (50 vs 99.1 cm H2O, p = 0.0001 and 1.48 vs 1.83 cm H2O/mm, p = 0.012). In terms of diagnostic accuracy, opening pressure at rest measured by reflectometry was significantly superior in discriminating between continent and incontinent women in comparison with resting pressure measured with manometry (p = 0.009).

CONCLUSIONS: : Anal acoustic reflectometry is a new, clinically valid technique in the assessment of continent and incontinent subjects. This technique, which assesses the response of the anal canal to distension and relaxation, provides a detailed viscoelastic assessment of anal canal function. This technique may not only aid the investigation of fecally incontinent subjects, but it may also improve our understanding of anal canal physiology during both the process of defecation and maintenance of continence.

PMID: 22228166 [PubMed - in process]

Transparent Cap-Assisted Colonoscopy Versus Standard Adult Colonoscopy: A Systematic Review and Meta-analysis.

Dis Colon Rectum. 2012 Feb;55(2):218-25

Authors: Westwood DA, Alexakis N, Connor SJ

Abstract

BACKGROUND: : Cap-assisted colonoscopy uses a transparent plastic hood attached to the tip of the colonoscope to flatten the semilunar folds and improve mucosal exposure. Several studies have examined the effect of cap-assisted colonoscopy on polyp detection, but the data are inconsistent.

OBJECTIVE: : This study aimed to evaluate whether cap-assisted colonoscopy improves the yield of colorectal neoplasia detected compared with standard colonoscopy.

DATA SOURCES: : A systematic search of the PubMed, MEDLINE, Embase, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction.

STUDY SELECTION: : Publications that compared cap-assisted colonoscopy vs standard colonoscopy in adults in a prospective randomized controlled study were selected for review.

MAIN OUTCOME MEASURES: : The primary outcomes used for meta-analysis were cecal intubation rate, cecal intubation time, and polyp detection rate. The analysis was performed using a fixed-effect model. Outcomes were calculated as odds ratios or standardized mean differences with 95% confidence intervals. The average polyp miss rate determined by tandem colonoscopy was also calculated.

RESULTS: : The outcomes of 6185 patients were studied. Cap-assisted colonoscopy detected significantly more patients with polyps (OR 1.13; p = 0.030) and had a lower average polyp miss rate (12.2% vs 28.6%) than standard colonoscopy. Cap-assisted colonoscopy had a significantly higher cecal intubation rate than standard colonoscopy (OR 1.36; p = 0.020), whereas the time to cecal intubation (standard mean difference, 0.04 min; p = 0.280) was similar for the 2 colonoscope types.

CONCLUSIONS: : Cap-assisted colonoscopy is associated with improved detection of colorectal neoplasia and higher cecal intubation rates than standard adult colonoscopy.

PMID: 22228167 [PubMed - in process]

CT Scans in Diagnosing Diverticulitis in the Emergency Department: Is the Radiation Exposure Warranted?

Dis Colon Rectum. 2012 Feb;55(2):226-7

Authors: Lutwak N, Dill C

PMID: 22228168 [PubMed - in process]

Reverse-hybrid robotic mesorectal excision for rectal cancer.

Dis Colon Rectum. 2012 Feb;55(2):228-33

Authors: Park IJ, You YN, Schlette E, Nguyen S, Skibber JM, Rodriguez-Bigas MA, Chang GJ

Abstract

PURPOSE: : The robotic system offers potential technical advantages over laparoscopy for total mesorectal excision with radical lymphadenectomy for rectal cancer. However, the requirement for fixed docking limits its utility when the working volume is large or patient repositioning is required. The purpose of this study was to evaluate short-term outcomes associated with a novel setup to perform total mesorectal excision and radical lymphadenectomy for rectal cancer by the use of a “reverse” hybrid robotic-laparoscopic approach.

METHODS: : This is a prospective consecutive cohort observational study of patients who underwent robotic rectal cancer resection from January 2009 to March 2011. During the study period, a technique of reverse-hybrid robotic-laparoscopic rectal resection with radical lymphadenectomy was developed. This technique involves reversal of the operative sequence with lymphovascular and rectal dissection to precede proximal colonic mobilization. This technique evolved from a conventional-hybrid resection with laparoscopic vascular control, colonic mobilization, and robotic pelvic dissection. Perioperative and short-term oncologic outcomes were analyzed.

RESULTS: : Thirty patients underwent reverse-hybrid resection. Median tumor location was 5 cm (interquartile range 3-9) from the anal verge. Median BMI was 27.6 (interquartile range 25.0-32.1 kg/m). Twenty (66.7%) received neoadjuvant chemoradiation. There were no conversions. Median blood loss was 100 mL (interquartile range 75-200). Total operation time was a median 369 (interquartile range 306-410) minutes. Median docking time was 6 (interquartile range 5-8) minutes, and console time was 98 (interquartile range 88-140) minutes. Resection was R0 in all patients; no patients had an incomplete mesorectal resection. Six patients (20%) underwent extended lymph node dissection or en bloc resection.

CONCLUSIONS: : Reverse-hybrid robotic surgery for rectal cancer maximizes the therapeutic applicability of the robotic and conventional laparoscopic techniques for optimized application in minimally invasive rectal surgery.

PMID: 22228169 [PubMed - in process]

Self-assessment quiz: answers, critiques, and references.

Dis Colon Rectum. 2012 Feb;55(2):e19-20

Authors:

PMID: 22228170 [PubMed - in process]

Residency programs in colon and rectal surgery.

Dis Colon Rectum. 2012 Feb;55(2):e28-30

Authors:

PMID: 22228171 [PubMed - in process]

Outcome of Surgery for Primary Hyperaldosteronism.

World J Surg. 2012 Jan 28;

Authors: Liao CH, Wu V, Jeff Chueh S, Sankari BR

PMID: 22286966 [PubMed - as supplied by publisher]

Evliya Celebi’s Description of the Removal of a Musket Ball From the Brain of a Habsburg Prince: An Interesting Excerpt From the “Seyahatname”

World J Surg. 2012 Jan 28;

Authors: Bilsel Y

Abstract

In the 17th century an Ottoman traveler, Evliya Celebi, was inspired by a dream to embark on a journey across the Ottoman Empire. He traveled far and wide across Europe and North Africa and wrote extensively about his adventures in the Seyahatname. The Seyahatname, or “Book of Travels,” is the longest and most detailed travel account in Islamic (if not world) literature. It is a vast panorama of the Ottoman world in the mid-17th century. This article is concerned with Celebi’s description of several surgeries that he claimed to have witnessed in Vienna during the year 1665. He describes several procedures, the first and most detailed of which is a fascinating brain operation that seems to be a highly unusual procedure for the time. His impressions of Central European medicine, as viewed by a Muslim from the East, offer an unexplored perspective. We examine what his description tells us about the perceptions and images of surgery and medicine.

PMID: 22286967 [PubMed - as supplied by publisher]

Surgical Management of Normocalcemic Primary Hyperparathyroidism.

World J Surg. 2012 Jan 28;

Authors: Wade TJ, Yen TW, Amin AL, Wang TS

Abstract

BACKGROUND: Primary hyperparathyroidism (pHPT), typically defined as elevated serum calcium levels associated with inappropriately elevated parathyroid hormone (PTH) levels, can occur also in patients with normal serum calcium levels. This study investigated the characteristics, workup, and surgical management of patients with normocalcemic pHPT. METHODS: A retrospective chart review of a prospectively collected, single-institution parathyroid database was performed on patients with sporadic pHPT who underwent parathyroidectomy between 12/99 and 12/08. RESULTS: In all, 93 of 771 (12%) pHPT patients had normal serum calcium levels 3 months prior to surgery. Ionized calcium (iCa) levels were available for 58 patients and were elevated in 50 (86%). Among those with elevated iCa levels 90% had single-gland disease (SGD), whereas 63% with normal iCa levels had SGD (p = 0.07). Preoperative imaging identified SGD in 60% of patients with normal iCa and in 66% with elevated iCa levels. Intraoperative PTH (IOPTH) monitoring identified cure in 51 of 58 (88%) patients including 6 (75%) with normal iCa. At a median follow-up of 358 days, postoperative calcium and PTH levels were similar in the groups. One (1%) patient had recurrent disease. CONCLUSIONS: Most patients with apparent normocalcemic pHPT have elevated ionized calcium levels. For patients with normocalcemic pHPT, we recommend measuring iCa levels preoperatively, performing localization studies, and utilizing IOPTH monitoring to guide a successful operation.

PMID: 22286968 [PubMed - as supplied by publisher]

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]

Advances in preoperative risk assessment and management.

Curr Probl Surg. 2012 Jan;49(1):11-40

Authors: Bader AM

PMID: 22137353 [PubMed - indexed for MEDLINE]

False-negative fine-needle aspiration of thyroid nodules cannot be attributed to sampling error alone.

Am J Surg. 2012 Jan 25;

Authors: Yu XM, Patel PN, Chen H, Sippel RS

Abstract

BACKGROUND: The goal of this study was to determine whether sampling error was the major cause for false-negative fine needle aspiration (FNA) results for thyroid nodules. METHODS: Patients who underwent preoperative FNA between 1994 and 2008 were identified, and the results were compared with surgical pathology findings. Other related variables including nodule number and size were also recorded. RESULTS: Excluding the microcarcinomas, the false-negative rate was 4% (19/479). Sampling errors occurred in only 4 (21%) cases in which the malignant nodule was not actually biopsied. Of the other 15 cases, 8 (53%) were solitary nodules, 8 (53%) were ≥4 cm in size, and 5 (33%) had underlying thyroiditis. Because of the missed diagnosis, 9 patients (47%) had lobectomy only as the initial surgery, which then required a completion thyroidectomy. CONCLUSIONS: Sampling error is a minor cause for false-negative FNAs, suggesting that there are some inherent limitations to cytological evaluation of the thyroid.

PMID: 22284047 [PubMed - as supplied by publisher]

Training in laparoscopic colorectal surgery: a new educational model using specially embalmed human anatomical specimen.

Surg Endosc. 2012 Jan 28;

Authors: Slieker JC, Theeuwes HP, van Rooijen GL, Lange JF, Kleinrensink GJ

Abstract

BACKGROUND: With an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training “before the job” on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed. METHODS: The new embalming method Anubifix(™) combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model. RESULTS: Eleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills. CONCLUSION: The new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of “training before the job.”

PMID: 22286275 [PubMed - as supplied by publisher]

Educational and training aspects of new surgical techniques: experience with the endoscopic-laparoscopic interdisciplinary training entity (ELITE) model in training for a natural orifice translumenal endoscopic surgery (NOTES) approach to appendectomy.

Surg Endosc. 2012 Jan 28;

Authors: Gillen S, Gröne J, Knödgen F, Wolf P, Meyer M, Friess H, Buhr HJ, Ritz JP, Feussner H, Lehmann KS

Abstract

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is a new surgical concept that requires training before it is introduced into clinical practice. The endoscopic-laparoscopic interdisciplinary training entity (ELITE) is a training model for NOTES interventions. The latest research has concentrated on new materials for organs with realistic optical and haptic characteristics and the possibility of high-frequency dissection. This study aimed to assess both the ELITE model in a surgical training course and the construct validity of a newly developed NOTES appendectomy scenario. METHODS: The 70 attendees of the 2010 Practical Course for Visceral Surgery (Warnemuende, Germany) took part in the study and performed a NOTES appendectomy via a transsigmoidal access. The primary end point was the total time required for the appendectomy, including retrieval of the appendix. Subjective evaluation of the model was performed using a questionnaire. Subgroups were analyzed according to laparoscopic and endoscopic experience. RESULTS: The participants with endoscopic or laparoscopic experience completed the task significantly faster than the inexperienced participants (p = 0.009 and 0.019, respectively). Endoscopic experience was the strongest influencing factor, whereas laparoscopic experience had limited impact on the participants with previous endoscopic experience. As shown by the findings, 87.3% of the participants stated that the ELITE model was suitable for the NOTES training scenario, and 88.7% found the newly developed model anatomically realistic. CONCLUSIONS: This study was able to establish face and construct validity for the ELITE model with a large group of surgeons. The ELITE model seems to be well suited for the training of NOTES as a new surgical technique in an established gastrointestinal surgery skills course.

PMID: 22286276 [PubMed - as supplied by publisher]

A model for rural trauma care.

Br J Surg. 2012 Mar;99(3):309-14

Authors: McSwain N, Rotondo M, Meade P, Duchesne J

Abstract

BACKGROUND: In the United States and many other countries, there has been limited attempt to develop a trauma system that addresses the unique trauma situations that occur in rural areas. Rather the planners have attempted to simply extend the urban based trauma system into rural communities. This extension does not address the needs of the majority of patients who are injured in rural communities.

METHODS: A review of the types of patients seen in the rural communities, the volume of these patients and the destination protocols used in the rural communities as taught by the ACS/ATLS and the implications of the CDC Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage were reviewed, assessed and compared to the needs in the rural areas for a rural trauma system. In addition, a quality assessment tool was used from a major trauma centre whereby the frequency of patients transported to the centre that were inappropriate for the trauma centre was indicated by the volume that were discharged in 6 h.

RESULTS: Most of the patients injured in the rural communities can be treated in the critical access and rural hospital (> 90 per cent) and can be provided with good care without the need for emergency medical service (EMS) transportation long distances to the trauma centre, inappropriate use of air EMS vehicles thus circumventing families having to travel long distances to see patients, incurring expense and inconvenience, and avoiding loss of revenue to the local hospitals and the overload of urban trauma centres. Rather triage criteria can be taught as per the EMS systems, training given to rural hospital personnel, hospital administrators instructed as to the benefit of such a system, citizens educated as to the advantage of keeping their loved ones closer to home and trauma system registries used to enhance the correct use of the trauma system.

CONCLUSION: Only 5-10 per cent of trauma injuries require the resources of a trauma centre. Proper triage and medical provider education can be used for the benefit of the patient, the EMS system, the rural and urban hospital, and proper quality assurance to assure that the ‘right patient is treated at the right hospital at the right time’, for the benefit of the patient. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287070 [PubMed - in process]

Use of models in identification and prediction of physiology in critically ill surgical patients.

Br J Surg. 2012 Jan 27;

Authors: Cohen MJ

Abstract

BACKGROUND: With higher-throughput data acquisition and processing, increasing computational power, and advancing computer and mathematical techniques, modelling of clinical and biological data is advancing rapidly. Although exciting, the goal of recreating or surpassing in silico the clinical insight of the experienced clinician remains difficult. Advances toward this goal and a brief overview of various modelling and statistical techniques constitute the purpose of this review. METHODS: A review of the literature and experience with models and physiological state representation and prediction after injury was undertaken. RESULTS: A brief overview of models and the thinking behind their use for surgeons new to the field is presented, including an introduction to visualization and modelling work in surgical care, discussion of state identification and prediction, discussion of causal inference statistical approaches, and a brief introduction to new vital signs and waveform analysis. CONCLUSION: Modelling in surgical critical care can provide a useful adjunct to traditional reductionist biological and clinical analysis. Ultimately the goal is to model computationally the clinical acumen of the experienced clinician. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287099 [PubMed - as supplied by publisher]

Tissue engineering and the road to whole organs.

Br J Surg. 2012 Jan 30;

Authors: Vacanti JP

PMID: 22287115 [PubMed - as supplied by publisher]

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves’ disease with a 5-year follow-up.

Br J Surg. 2012 Jan 27;

Authors: Barczyński M, Konturek A, Hubalewska-Dydejczyk A, Gołkowski F, Nowak W

Abstract

BACKGROUND: The extent of thyroid resection in Graves’ disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves’ disease and mild active ophthalmopathy. METHODS: Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves’ ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism. RESULTS: Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves’ ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury. CONCLUSION: TT for Graves’ disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287122 [PubMed - as supplied by publisher]

Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer.

Br J Surg. 2012 Jan 27;

Authors: Segelman J, Granath F, Holm T, Machado M, Mahteme H, Martling A

Abstract

BACKGROUND: This was a population-based cohort study to determine the incidence, prevalence and risk factors for peritoneal carcinomatosis (PC) from colorectal cancer. METHODS: Prospectively collected data were obtained from the Regional Quality Registry. The Cox proportional hazards regression model was used for multivariable analysis of clinicopathological factors to determine independent predictors of PC. RESULTS: All 11 124 patients with colorectal cancer in Stockholm County during 1995-2007 were included and followed until 2010. In total, 924 patients (8·3 per cent) had synchronous or metachronous PC. PC was the first and only localization of metastases in 535 patients (4·8 per cent). The prevalence of synchronous PC was 4·3 per cent (477 of 11 124). The cumulative incidence of metachronous PC was 4·2 per cent (447 of 10 646). Independent predictors for metachronous PC were colonic cancer (hazard ratio (HR) 1·77, 95 per cent confidence interval 1·31 to 2·39; P = 0·002 for right-sided colonic cancer), advanced tumour (T) status (HR 9·98, 3·10 to 32·11; P < 0·001 for T4), advanced node (N) status (HR 7·41, 4·78 to 11·51; P < 0·001 for N2 with fewer than 12 lymph nodes examined), emergency surgery (HR 2·11, 1·66 to 2·69; P < 0·001) and non-radical resection of the primary tumour (HR 2·75, 2·10 to 3·61; P < 0·001 for R2 resection). Patients aged > 70 years had a decreased risk of metachronous PC (HR 0·69, 0·55 to 0·87; P = 0·003). CONCLUSION: PC is common in patients with colorectal cancer and is associated with identifiable risk factors. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287157 [PubMed - as supplied by publisher]

Reoperative surgery for bilateral multinodular goitre in the era of total thyroidectomy.

Br J Surg. 2012 Jan 30;

Authors: Vasica G, O’Neill CJ, Sidhu SB, Sywak MS, Reeve TS, Delbridge LW

Abstract

BACKGROUND: Total thyroidectomy, rather than bilateral subtotal thyroidectomy, is now accepted as the preferred management for bilateral benign multinodular goitre (BMNG) in order to reduce the need for reoperative surgery. The aim of this study was to examine whether this approach has had an impact on presentation for bilateral reoperative thyroid surgery. METHODS: This was a retrospective cohort study. The study group comprised patients presenting with recurrent BMNG who underwent bilateral reoperative thyroid surgery following previous bilateral subtotal or partial thyroidectomy. They were compared with patients undergoing unilateral reoperative thyroid surgery following previous lobectomy, and those undergoing primary total thyroidectomy for BMNG. RESULTS: Between 1 January 1987 and 31 December 2009, 12 354 consecutive thyroid procedures were undertaken. Among those with BMNG, primary total thyroidectomy was undertaken in 3298 patients, unilateral reoperative thyroidectomy in 337 and bilateral reoperative thyroidectomy in 191. Presentations of patients with recurrent BMNG declined gradually over the study period following the change in policy from subtotal to total thyroidectomy; only five patients (representing less than 0·5 per cent of all thyroid surgery) underwent bilateral reoperative surgery for BMNG in the last year of the study. Four of these patients had their initial operation before 1987 and in another unit, whereas the remaining patient initially had surgery overseas. CONCLUSION: The introduction of a policy of initial total thyroidectomy for bilateral BMNG has essentially eliminated the need for bilateral reoperative surgery for recurrent goitre. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287186 [PubMed - as supplied by publisher]

How to Manage Thyroid Nodules With Two Consecutive Non-Diagnostic Results on Ultrasonography-Guided Fine-Needle Aspiration.

World J Surg. 2012 Jan 7;

Authors: Moon HJ, Kwak JY, Choi YS, Kim EK

Abstract

BACKGROUND: The aim of this study was to investigate the factors for considering surgery on thyroid nodules that had non-diagnostic results on two consecutive cytology examinations. METHODS: A total of 104 thyroid nodules with two consecutive non-diagnostic cytology examinations in 104 patients were investigated. Nodules with one or more suspicious ultrasonography (US) features of marked hypoechogenicity, a not well defined margin, microcalcifications, or a taller-than-wide shape were assessed as sonographically suspicious. Those without any suspicious features were assessed as sonographically benign. The clinicopathologic characteristics of patients and US features of the nodules were compared according to malignancy and benignity. The odds ratio for predicting malignancy was calculated. RESULTS: Altogether, 12 nodules were malignant, and 92 were benign. Age, sex, nodule size, and solidness were not associated with malignancy (P = 0.73, 0.92, 0.48, and 0.73, respectively). The malignancy rate of sonographically suspicious nodules was 25.7%, higher than the 4.3% of sonographically benign nodules (P = 0.002). The odds ratio of sonographically suspicious nodules for predicting malignancy was 16.01 (95% confidence interval 2.36-108.54, P = 0.005). CONCLUSIONS: Based on sonographic features, surgery can be performed selectively on nodules with two consecutive non-diagnostic cytology results.

PMID: 22228400 [PubMed - as supplied by publisher]

The Life of John Wishart (1850-1926): Study of an Academic Surgical Career Prior to the Flexner Report.

World J Surg. 2012 Jan 20;

Authors: Claydon E, McAlister VC

Abstract

BACKGROUND: The 1910 Flexner Report on Medical Education in the United States and Canada is often taken as the point when medical schools in North America took on their modern form. However, many fundamental advances in surgery, such as anesthesia and asepsis, predated the report by decades. To understand the contribution of educators in this earlier period, we investigated the forgotten career of John Wishart, founding Professor of Surgery at Western University, London Ontario. METHODS: Archives at the University of Western Ontario, University of Toronto, London City Library, and Wellington County Museum were searched for material about Wishart and his times. RESULTS: A fragmented biography can be assembled from family notes and obituaries with the help of contemporary documents compiled by early 20th century medical school historians. Wishart assisted Abraham Groves in the first reported operation for which aseptic technique was used (1874). He was considered locally to perform pioneering surgery, including an appendectomy in 1886. Wishart was a founding member of the medical faculty at Western University in 1881, initially as Demonstrator of Anatomy and subsequently as its first Professor of Clinical Surgery, which post he held until 1910. Comprehensive notes from his undergraduate lectures demonstrate his teaching style, which mixed organized didacticism with practical advice. The role of the Flexner review in the termination of his professorship is hinted at in minutes of Faculty of Medicine meetings. Wishart was a foundation fellow of the American College of Surgeons and a founding physician of London’s Catholic hospital, St. Joseph’s, despite his own Protestant background. CONCLUSIONS: Wishart’s career comprised all the elements of modern academic surgery, including pioneering service, research, and teaching. Surgery at Western owes as much to Wishart as it does to university reorganization in response to the Flexner report.

PMID: 22270978 [PubMed - as supplied by publisher]

Morbidity and Mortality Results From a Prospective Randomized Controlled Trial Comparing Billroth I and Roux-en-Y Reconstructive Procedures After Distal Gastrectomy for Gastric Cancer.

World J Surg. 2012 Jan 20;

Authors: Imamura H, Takiguchi S, Yamamoto K, Hirao M, Fujita J, Miyashiro I, Kurokawa Y, Fujiwara Y, Mori M, Doki Y

Abstract

BACKGROUND: Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed after distal gastrectomy. Which reconstruction procedure is superior remains controversial. We conducted a randomized controlled trial to compare the clinical efficacy of B-I and R-Y. METHODS: Between August 2005 and December 2008, a total of 332 patients with potentially curable gastric cancer enrolled from 18 institutions were intraoperatively randomized to either the B-I group or the R-Y group. Postoperative morbidity and hospital mortality were recorded prospectively in a fixed format and were compared between these two groups. RESULTS: The operating time was significantly longer in the R-Y group than in the B-I group (214 vs. 180 minutes, P < 0.0001). Regarding clinical symptoms during the postoperative hospital stay, the incidence of nausea, vomiting, and discontinuance of food intake was significantly higher in the R-Y group than in the B-I group (12.4% vs. 3.7%, P = 0.0027; 8.9% vs. 3.1%, P = 0.022; and 12.4% vs. 4.3%, P = 0.0064, respectively). There was no significant difference in the overall operative morbidity rate between the R-Y and B-I groups (13.6% vs. 8.6%, respectively, P = 0.14). Anastomotic leakage occurred in two patients (1.2%) in the B-I group and in none in the R-Y group; the difference did not reach statistical significance (P = 0.09). Postoperative hospital stay was significantly longer in the R-Y group than in the B-I group (16.4 vs. 14.1 days, P = 0.019). CONCLUSIONS: We concluded that B-I reconstruction was superior to R-Y reconstruction in terms of perioperative complications.

PMID: 22270979 [PubMed - as supplied by publisher]

Partial Pathologic Response and Nodal Status as Most Significant Prognostic Factors for Advanced Rectal Cancer Treated With Preoperative Chemoradiotherapy.

World J Surg. 2012 Jan 20;

Authors: Huebner M, Wolff BG, Smyrk TC, Aakre J, Larson DW

Abstract

BACKGROUND: This study evaluated the impact of tumor regression grading (TRG) and other pathologic variates in a cohort of rectal carcinoma patients treated with neoadjuvant chemoradiotherapy (CRT). The value of a grading less than pCR for predicting survival is unknown. Tumor budding has not been systematically studied in rectal cancer after neoadjuvant therapy. METHODS: Pathologic risk factors for survival were evaluated on surgical specimens of 237 patients with stages I, II, and III rectal cancer treated between 1996 and 2006. All patients underwent preoperative CRT followed by surgical resection 6-8 weeks later. TRG, tumor grade, budding, venous invasion, radial margin, and nodal status were evaluated. The prognostic value of TRG categories was calculated with Cox regression models and validated with resampling methods. RESULTS: TRG of <25% occurred in 61 (25.7%) and a complete response in 39 (16.4%) of the resected specimens. TRG of <25% was shown to be a statistically significant predictor for cancer-specific survival (CSS) and recurrence-free survival (RFS) compared to TRG ≥25% (P = 0.013). Tumor budding was present in 24 (10.1%) of the patients and was negatively associated with CSS (P = 0.013). Lymph node involvement was observed in 83 (35.0%) patients. TRG and nodal status (P < 0.001) were the most significant predictors associated with outcome. CONCLUSION: Partial pathologic response ≥25% was a superior predictor compared to pCR for improved survival after preoperative CRT. CSS and RFS were adversely affected by the presence of lymph node metastases.

PMID: 22270980 [PubMed - as supplied by publisher]

Pediatric Non-Wilms’ Renal Tumors: A Third World Experience.

World J Surg. 2012 Jan 20;

Authors: Saula PW, Hadley GP

Abstract

BACKGROUND: Pediatric non-Wilms’ renal tumors (NWRT) are poorly understood owing to their heterogeneity and relative rarity. This study aimed at auditing the outcome of the management of NWRT in a tertiary hospital in the Third World. METHODS: Records of all patients (n = 68) treated for NWRT over a 32-year period (1978-2010) were reviewed retrospectively. RESULTS: The major histological groups included clear cell sarcoma of the kidney (CCSK) (33.8%), mesoblastic nephroma (17.6%), cystic partially differentiated nephroblastoma (CPDN) (17.6%), intrarenal neuroblastoma (8.8%), malignant rhabdoid tumor (MRT) (7.4%), and renal cell carcinoma (RCC) (5.9%). Sixteen (69.7%) patients with CCSK and 11 (91.7%) with CPDN were aged 1-4 years. Ten (83.3%) patients with mesoblastic nephroma were aged <1 year and three (60.0%) with RCC were aged 10-14 years. Ten (43.5%) patients with CCSK and four (80.0%) with RCC had metastases at diagnosis. The sensitivity of a pretreatment Tru-Cut biopsy was 100% for MRT. All the patients with CCSK, mesoblastic nephroma, CPDN, and RCC had radical nephrectomy. Only eight (34.8%) patients with CCSK received radiotherapy. The overall 1-10-year survival rates were 52.2%, 91.7%, 75.0%, 40.0% and 0.0% for CCSK, mesoblastic nephroma, CPDN, RCC, and MRT, respectively. The overall 1-10-year survival for the entire cohort was 51.5%. CONCLUSIONS: The demography and clinical presentation of pediatric NWRT, which comprises 13.6% of pediatric renal tumors in the Third World, were similar to those in the Developed World. The overall 1-10-year survival for pediatric NWRT was low.

PMID: 22270981 [PubMed - as supplied by publisher]

Validation of the “Perrier” Parathyroid Adenoma Location Nomenclature.

World J Surg. 2012 Jan 21;

Authors: Mazeh H, Stoll SJ, Robbins JB, Sippel RS, Chen H

Abstract

BACKGROUND: In 2009, the “Perrier” nomenclature was introduced to enhance communications among surgeons and specialists regarding the location of parathyroid adenomas. The purpose of this study was to validate the utility of the nomenclature in a prospective manner at a different institution. METHODS: A prospective database was created from June 2010 through January 2011 evaluating 108 consecutive patients. In each case, the location of the parathyroid adenoma according to the nomenclature was predicted individually by an attending physician and a resident based on preoperative imaging studies. A radiologist interpreted the images retrospectively. These predictions were compared to the operative findings. RESULTS: The mean age of the patients was 61 ± 1 years, and 82% were women. The distribution using the nomenclature was as follows: A (adherent to posterior thyroid capsule) 20%; B (tracheoesophageal groove) 27%; C (tracheoesophageal groove but close to the clavicle) 12%; D (directly over the recurrent laryngeal nerve) 2%; E (easy to identify, inferior thyroid pole) 35%; F (fallen into the thymus) 4%. The overall predicting accuracy was significantly higher for the attending physicians than for the residents or the radiologist (78% vs. 64% vs. 25%, P < 0.001). It was 73-92%, 55-77%, and 12-46%, respectively, for locations with more than four patients. The accuracy was not affected by parathyroid hormone or and calcium levels, or the gland weight. CONCLUSIONS: The “Perrier” nomenclature is reproducible. The most common adenoma locations were B and E in our study, similar to the initial studies. Nevertheless, there is a wide range of preoperative predicting accuracy based on the imaging studies obtained and the interpreter’s experience.

PMID: 22270982 [PubMed - as supplied by publisher]

Invasion of the Hepatic Artery is a Crucial Predictor of Poor Outcomes in Gallbladder Carcinoma.

World J Surg. 2012 Jan 20;

Authors: Kobayashi A, Oda T, Fukunaga K, Sasaki R, Ohkohchi N

Abstract

BACKGROUND: In the present study we undertook a retrospective analysis of gallbladder carcinoma to assess whether histologically determined hepatic artery (HA) invasion and portal vein (PV) invasion can be considered prognostic factors. METHODS: Seventy-one patients who had undergone radical resection for gallbladder carcinoma between 1995 and 2008 at University of Tsukuba were selected from the database for analysis. Patients who required extended surgery for para-aortic lymph node metastasis were also included. Correlation between invasion of the HA and the PV and prognosis and other clinicopathologic factors were analyzed. RESULTS: There were two postoperative deaths among the 71 patients. Pathological invasion of the HA was confirmed in 16 (22.5%) cases and PV invasion was confirmed in 15 patients. Patients with invasion of the HA had a significantly poorer prognosis than those without HA invasion (P < 0.0001). Additionally, in univariate analysis, gender (male), positive para-aortic lymph node metastasis, PV invasion, and HA invasion were identified as significant poor prognostic factors. In multivariate analysis, only HA invasion was an independent prognostic factor (Odds Ratio 0.323; P = 0.029). CONCLUSIONS: Invasion of the HA is a crucial prognostic factor in patients with gallbladder carcinoma.

PMID: 22270983 [PubMed - as supplied by publisher]

Log Odds of Positive Lymph Nodes in Colon Cancer: A Meaningful Ratio-based Lymph Node Classification System.

World J Surg. 2012 Jan 20;

Authors: Persiani R, Cananzi FC, Biondi A, Paliani G, Tufo A, Ferrara F, Vigorita V, D’Ugo D

Abstract

BACKGROUND: The log odds of positive lymph nodes (LODDS), defined as the log of the ratio between the numbers of positive and negative lymph nodes, has recently been proposed as a new prognostic index in surgical oncology. The aim of the present study was to investigate whether the LODDS system of lymph node classification was a more accurate prognostic tool than the tumor node metastasis (TNM) and lymph node ratio (LNR) classifications in colon cancer patients. MATERIALS AND METHODS: Clinicopathologic data from 258 colon cancer patients who had undergone surgical resection were reviewed. Lymph node parameters were categorized according to the Internation Union Against Cancer/American Joint Cancer Commission (UICC/AJCC) TNM staging system, the LNR (LNR0 with ratio ≤ 0.05, LNR1 with 0.05 < ratio ≤ 0.20, LNR2 with ratio > 0.20), and the log odds ratio (LODDS0 ≤ -1.36, -1.36 < LODDS1 ≤ -0.53, and LODDS2 > -0.53). RESULTS: The LODDS was able to identify patients who would have been included in different prognostic categories, according to both the TNM and LNR. In addition, LODDS was significantly related to the number of positive and negative lymph nodes, as well as the number of examined lymph nodes. In multivariate analysis, LODDS classification (LODDS0: HR 1; LODDS1: HR 3.687, p = 0.003; LODDS2: HR 9.440, p < 0.001) was identified as an independent prognostic factor. DISCUSSION: The LODDS system is a highly reliable staging system with strong predictive ability for patient outcome. Compared with other nodal staging systems, the prognostic power of LODDS is less influenced by the number of lymph nodes dissected and examined.

PMID: 22270984 [PubMed - as supplied by publisher]

Comparison of Outcomes of Laparoscopic Versus Open Appendectomy in Children: Data from The Nationwide Inpatient Sample (NIS), 2006-2008.

World J Surg. 2012 Jan 20;

Authors: Masoomi H, Mills S, Dolich MO, Ketana N, Carmichael JC, Nguyen NT, Stamos MJ

Abstract

BACKGROUND: The benefits of laparoscopic appendectomy (LA) remain undefined as compared to open appendectomy (OA) in children, particularly in cases of perforated appendicitis. The purpose of the present study was to evaluate the outcomes of LA versus OA in perforated and nonperforated appendicitis in children. METHODS: Using the Nationwide Inpatient Sample database, we evaluated the clinical data of children (<18 years old) who underwent LA and OA from 2006 to 2008. Incidental and elective appendectomies were excluded. RESULTS: A total of 212,958 children underwent urgent appendectomy in the United States during these years. The overall rate of perforated appendicitis was 27.7, and 56.9% of all cases were performed laparoscopically. In nonperforated cases, LA was associated with comparable overall complication rate (LA: 2.56 vs. OA: 2.66%; p = 0.26), shorter length of hospital stay (LOS, LA: 1.6 vs. OA: 2.0 days; p < 0.01), comparable mortality (LA: 0.01 vs. OA: 0.02%; p = 0.25); and higher hospital charges (LA: $20,328 vs. OA: $16,830; p < 0.01) compared to OA. In perforated cases, LA had a lower overall complication rate (LA: 16.03 vs. OA: 18.07%; p < 0.01), shorter LOS (LA: 5.1 vs. OA: 5.8 days; p < 0.01), lower mortality (LA: 0.0% versus OA: 0.06%; p < 0.01), and similar hospital charges (LA: $33,361 versus OA: $33, 662; p = 0.71) compared to OA. CONCLUSIONS: LA is safe in children with acute perforated and nonperforated appendicitis, and is associated with shorter hospital stay than OA. The laparoscopic approach is associated with lower morbidity and mortality in perforated cases. However, in nonperforated cases, these benefits are modest and are associated with higher hospital charges.

PMID: 22270985 [PubMed - as supplied by publisher]

Long-term Results with the Modified Sugiura Procedure for the Management of Variceal Bleeding: Standing the Test of Time in the Treatment of Bleeding Esophageal Varices.

World J Surg. 2012 Jan 21;

Authors: Voros D, Polydorou A, Polymeneas G, Vassiliou I, Melemeni A, Chondrogiannis K, Arapoglou V, Fragulidis GP

Abstract

BACKGROUND: The surgical approaches to the treatment of bleeding esophageal varices in cirrhotic patients have been reduced since the clinical development of endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. However, when acute sclerotherapy fails, and in cases where no further treatment is accessible, emergency surgery may be life saving. In the present study we retrospectively analyzed the results of the modified Sugiura procedure, performed as emergency and semi-elective treatment in the patient with bleeding esophageal varices. METHODS: Ninety patients with cirrhosis and portal hypertension were managed in our department for variceal esophageal bleeding between January 1985 and December 1992. The modified Sugiura procedure was performed in 46 patients on an emergency (25 patients) or semi-elective (21 patients) basis. Liver cirrhosis stage according to Child classification was A in 4 patients, B in 16 patients, and C in 26 patients. RESULTS: Acute bleeding was controlled in all patients. Postoperative mortality was 23.9% (11 of 46 patients). The mortality rate was 34.6% in Child class C patients (9 of 26 patients), and 12.5% in Child class B patients (2 of 16 patients). Twenty-four patients had long-term follow-up extending from 14 months to 22 years (mean 83.1 months). Ten of 24 patients (41.6%) did not develop rebleeding for 5-22 years (mean 10.3 years). Overall 5-year survival in these 24 patients was 62.5%. CONCLUSIONS: The modified Sugiura procedure remains an effective rescue therapy for patients with bleeding esophageal varices when alternative treatments fail or are not indicated. Moreover, it can be a life-saving procedure in patients with anatomy unsuitable for shunt surgery or for patients treated in nonspecialized centers where surgical expertise for a shunt operation is not available.

PMID: 22270986 [PubMed - as supplied by publisher]

Trauma and Burn Education: A Global Survey.

World J Surg. 2012 Jan 20;

Authors: Zonies D, Maier RV, Civil I, Eid A, Geisler BP, Guerrero A, Mock C

Abstract

BACKGROUND: The World Health Assembly recently adopted a resolution to urge improved competency in the provision of injury care through medical education. This survey sought to investigate trauma education experience and competency among final year medical students worldwide. METHODS: An Internet survey was distributed to medical students and conducted from March 2008 to January 2009. Demographic data and questions pertaining to both instruction and attainment of specific skills in burn and trauma care were assessed. RESULTS: There were 776 responses from final year medical students in 77 countries, with at least 10 countries from each economic stratum. Over 93% of final year students reported receiving some form of trauma or burn training, with 79% reporting a minimum compulsory requirement. Students received theoretical instruction without practical exposure. Few felt prepared to undertake basic procedures, such as laceration repair (19%), vascular access (8%), or endotracheal intubation (21%). Over 99% agreed that trauma education should be mandatory, but only half felt prepared to provide basic care. Those from low income and low middle income countries felt better prepared to provide trauma care than students from high middle and high income countries. CONCLUSIONS: Trauma education and experience varies among medical students in different countries. Many critical concepts are not formally taught and practical experience with many basic procedures is often lacking. The present study confirms that the trauma care training received by medical students needs to be strengthened in countries at all economic levels.

PMID: 22270987 [PubMed - as supplied by publisher]

Metastasis-associated Protein 1 Nuclear Expression is Closely Associated with Tumor Progression and Angiogenesis in Patients with Esophageal Squamous Cell Cancer.

World J Surg. 2012 Jan 21;

Authors: Li SH, Tian H, Yue WM, Li L, Gao C, Li WJ, Hu WS, Hao B

Abstract

BACKGROUND: The purposes of the present study were to detect the expression of metastasis-associated protein 1 (MTA1) in patients with esophageal squamous cell cancer (ESCC), and to evaluate the relevance of MTA1 protein expression to the tumor progression, angiogenesis, and prognosis. METHODS: Both MTA1 protein and intratumoral microvessels were examined by immunohistochemical staining in 131 ESCC patients who successfully underwent subtotal esophagectomy and esophagogastric anastomosis at Qilu Hospital between Jan 2004 and Dec 2005. Intratumoral microvessel density (MVD) was recorded by counting CD-34 positive immunostained endothelial cells. All statistical analyses were performed with SPSS 13.0 statistical software. RESULTS: High expression of MTA1 protein was detected in 57 cases and significantly correlated with tumor invasion depth (P = 0.041), lymph node metastasis (P = 0.021), pathologic stage (P = 0.003), and MVD (P = 0.044). Survival analysis showed that patients with MTA1 protein high expression had significantly poor overall 5-year survival (P = 0.002), and the factor found on multivariate analysis to significantly affect overall survival was only pathologic stage (P = 0.040). Further stratified survival analysis split by pathologic stage demonstrated that MTA1 protein high expression significantly predicted unfavorable prognosis among patients with pathologic stage II disease (P = 0.006). CONCLUSIONS: High expression of the MTA1 protein is common in ESCC, and is closely associated with tumor progression, increased tumor angiogenesis, and poor survival. These findings indicate that MTA1 protein has clinical potentials as a useful indicator of progressive phenotype, a promising prognostic predictor to identify patients with poor prognosis, and a potential novel therapeutic target of antiangiogenesis for patients with ESCC.

PMID: 22270988 [PubMed - as supplied by publisher]

Trainees, Trainers, and Training; Where Does Their Destiny Lie ?

World J Surg. 2012 Jan 20;

Authors: Brand M, Thomas W

PMID: 22270989 [PubMed - as supplied by publisher]

Prognostic Factors for Recurrence of Papillary Thyroid Carcinoma in the Lymph Nodes, Lung, and Bone: Analysis of 5,768 Patients with Average 10-year Follow-up.

World J Surg. 2012 Jan 20;

Authors: Ito Y, Kudo T, Kobayashi K, Miya A, Ichihara K, Miyauchi A

Abstract

BACKGROUND: Papillary thyroid carcinoma (PTC) frequently recurs to the lymph nodes, which may not be fatal immediately but is a stressor for physicians and patients. Recurrence to the distant organs, although less frequent, is often life-threatening, and the lung and bone are organs to which PTC is likely to recur. In the present study we investigated factors predicting recurrence of PTC to the lymph nodes, lung, and bone in a large number of patients undergoing long-term follow-up. METHODS: A total of 5,768 PTC patients (608 males and 5,159 females) without distant metastasis at diagnosis who underwent initial surgery between 1987 and 2004 in Kuma Hospital were enrolled in this study. The postoperative follow-up ranged from 12 to 280 months, and was 129 months (10.8 years) on average. RESULTS: To date, node, lung, and bone recurrences have been detected in 389 (7%), 118 (2%), and 33 patients (0.6%), respectively, and 57 patients (1%) have died of PTC. We examined the prognostic significance of the tumor size (T), extrathyroid extension (Ex), age 55 years or older (Age), male gender (Gender), clinical node metastasis (N), and extranodal tumor extension (LN-Ex) for each outcome on multivariate analysis. Age, Gender, T > 2 cm, N, and Ex were independent predictors of lymph node recurrence. Age, Ex, T > 2 cm, and N were independent prognostic factors for lung recurrence. Ex, T > 4 cm, and N independently predicted bone recurrence. Of these, N ≥ 3 cm had the strongest prognostic value for lymph node, lung, and bone recurrences. In contrast, Age was the strongest predictor for carcinoma death. LN-Ex also had a prognostic value for carcinoma death, although it was not a predictor of carcinoma recurrence. Ex, N ≥ 3 cm, and T > 2 cm also had a prognostic impact on carcinoma death. CONCLUSIONS: Large lymph node metastasis showed a strong prognostic impact on carcinoma recurrence not only to the lymph nodes but also to the lung and bone, and carcinoma death. Extrathyroid extension also independently predicted these recurrences and carcinoma death, although hazard ratios were lower than for large node metastasis. Age 55 years or older, in contrast, was the strongest predictor of carcinoma death. Extranodal tumor extension did not independently affect recurrence, but it had prognostic significance for carcinoma death. These findings suggest that recurring PTC lesions of older patients and/or extranodal tumor extensions are difficult to control and very progressive.

PMID: 22270990 [PubMed - as supplied by publisher]

No Impact of Perioperative Blood Transfusion on Recurrence of Hepatocellular Carcinoma after Hepatectomy.

World J Surg. 2012 Jan 20;

Authors: Kuroda S, Tashiro H, Kobayashi T, Oshita A, Amano H, Ohdan H

Abstract

BACKGROUND: Although several studies have shown that perioperative blood transfusion is a poor prognostic factor of outcome after hepatectomy for hepatocellular carcinoma (HCC), the impact of perioperative blood transfusion on the prognosis of HCC remains unknown. METHODS: Data from 835 patients (76 transfused patients and 759 nontransfused patients) who underwent curative hepatectomy for HCC were retrospectively collected and analyzed. To overcome bias due to the different distribution of covariates for the two groups, a one-to-one match was created using propensity score analysis. After matching, patient outcomes were analyzed. RESULTS: After one-to-one matching, 60 transfused patients and 60 nontransfused patients had the same preoperative and operative characteristics (excluding operative blood loss). Although the morbidity rate of hepatectomy was significantly higher in the transfused group than in the nontransfused group (P = 0.016), there was no significant difference in mortality rate (P = 0.242). Additionally, the overall survival rate of transfused patients was similar to that of nontransfused patients (P = 0.466), and the difference in disease-free survival rate between the two groups was insignificant (P = 0.621). CONCLUSIONS: Perioperative blood transfusion did not influence the overall and disease-free survival rate in the HCC patients studied. Perioperative blood transfusion may not be considered a poor prognostic factor for patients with HCC.

PMID: 22270991 [PubMed - as supplied by publisher]

Early Data from the First Population-Wide Breast Cancer-Specific Registry in Hong Kong.

World J Surg. 2012 Jan 20;

Authors: Cheung P, Hung WK, Cheung C, Chan A, Wong TT, Li L, Chan SW, Chan KW, Choi P, Kwan WH, Yau CC, Chan EY, Law SC, Kwan D

Abstract

BACKGROUND: Current measures for breast cancer prevention and options for treatment adopted in Hong Kong are mainly based on research data and clinical evidence from overseas. It is essential to establish a cancer-specific registry to monitor the status of breast cancer in Hong Kong. OBJECTIVES: We summarized the current status of breast cancer in Hong Kong based on the data collected from Hong Kong Breast Cancer Registry (HKBCR). METHODS: Prevalent and newly diagnosed breast cancers (including in situ and invasive breast cancers) were registered in the HKBCR. Information on patient demographics, risk factors, medical information, and survival were analyzed and reported in this study. RESULTS: Data of 2,330 breast cancer patients were analyzed. We observed an earlier median age at diagnosis in Hong Kong than those reported in other countries. Distribution of cancer stage was: stage 0 (11.4%), stage I (31.4%), stage II (41%), stage III (12.5%), stage IV (0.8%), and unclassified (2.9%). The percentages of patients who received surgery, chemotherapy, radiation therapy, and endocrine therapy were 98.7, 67.9, 64.8, and 64.1%, respectively. At a median follow-up of 1.2 years, locoregional recurrence was recorded at 2%, distant recurrence at 2.8%, and breast-cancer-related mortality at 0.3%. CONCLUSIONS: The HKBCR serves as a surveillance program to monitor disease and treatment patterns. It is pivotal to support research for more effective breast cancer prevention and treatment strategies in Hong Kong.

PMID: 22270992 [PubMed - as supplied by publisher]

Not the Number but the Location of Lymph Nodes Matters for Recurrence Rate and Disease-Free Survival in Patients with Differentiated Thyroid Cancer.

World J Surg. 2012 Jan 20;

Authors: de Meer SG, Dauwan M, de Keizer B, Valk GD, Borel Rinkes IH, Vriens MR

Abstract

BACKGROUND: Several Japanese studies have focused on identifying prognostic factors in patients with positive lymph nodes to predict recurrence rate and disease-free survival (DFS). However, different treatment protocol is followed in Japan compared with the European and American approach. This study was designed to investigate whether the number and/or location of lymph nodes predicts prognosis in patients with DTC treated with total thyroidectomy, lymph node dissection, and postoperative radioactive iodine ablation. METHODS: All 402 patients who were treated at the Department of Nuclear Medicine between 1998 and 2010 for DTC were reviewed. Patients were treated with (near) total thyroidectomy, lymph node dissection on indication, and postoperative I-131 ablation. Median follow-up was 49 (range, 10-240) months. Outcome measures were recurrence rate, disease-free survival, and mean time to recurrence. RESULTS: Ninety-seven patients had proven lymph node metastases. Recurrence rate was significantly higher in patients with positive lymph nodes in the lateral compartment vs. patients with lymph node metastasis in the central compartment (60 vs. 30%, p = 0.007). Disease-free survival and mean time to recurrence also were significantly shorter (30 vs. 52 months, p = 0.035 and 7 vs. 44 months, p = 0.004, respectively). The number of lymph nodes and extranodal growth were not significantly associated with the outcome measures used. CONCLUSIONS: The location of positive lymph nodes was significantly correlated with the risk of recurrence and a shorter DFS. Hence, the TNM criteria are useful in subdividing patients based on risk of recurrence and DFS.

PMID: 22270993 [PubMed - as supplied by publisher]