Pain management in the pediatric surgical patient.

Surg Clin North Am. 2012 Jun;92(3):471-85

Authors: Sohn VY, Zenger D, Steele SR

Abstract

Surgeons performing painful, invasive procedures in pediatric patients must be cognizant of both the potential short- and long-term detrimental effects of inadequate analgesia. This article reviews the available tools, sedation procedures, the management of intraoperative, postoperative, and postprocedural pain, and the issues surrounding neonatal addiction.

PMID: 22595704 [PubMed - in process]

Pyloric stenosis in pediatric surgery: an evidence-based review.

Surg Clin North Am. 2012 Jun;92(3):527-39

Authors: Pandya S, Heiss K

Abstract

Pyloric stenosis is a common pediatric surgical problem that requires a combination of both medical and surgical attention. This article reviews the classical elements necessary to care for the patient in a safe and effective manner. A well-tested management approach that can be applied to the general surgical environment is described. Perioperative management of the patient is discussed and the currently used techniques are reviewed. Current recommendations include the routine use of ultrasonography for diagnosis, attention to the preoperative correction of electrolytes, and the use of minimally invasive techniques for treatment.

PMID: 22595707 [PubMed - in process]

Pediatric gastroesophageal reflux disease.

Surg Clin North Am. 2012 Jun;92(3):541-58

Authors: Blanco FC, Davenport KP, Kane TD

Abstract

This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.

PMID: 22595708 [PubMed - in process]

Pediatric Chest II: Benign Tumors and Cysts.

Surg Clin North Am. 2012 Jun;92(3):645-58

Authors: Petroze R, McGahren ED

Abstract

Thoracic tumors are rare in children, and metastatic or malignant conditions must be excluded during the diagnostic evaluation. The majority of primary pulmonary neoplasms in children are malignant; this article primarily addresses benign tumors. Surgical resection is the standard treatment for benign thoracic tumors in children. Thoracotomy is a traditional approach, but the thoracoscopic technique for diagnosis and treatment of thoracic tumors is well established. The term benign tumors can be a misnomer in that although their histology is not malignant, these tumors can be locally aggressive with significant associated morbidity and potential for mortality.

PMID: 22595713 [PubMed - in process]

Congenital diaphragmatic hernia and protective ventilation strategies in pediatric surgery.

Surg Clin North Am. 2012 Jun;92(3):659-68

Authors: Garcia A, Stolar CJ

Abstract

Infants affected with congenital diaphragmatic hernias (CDH) suffer from some degree of respiratory insufficiency arising from a combination of pulmonary hypoplasia and pulmonary hypertension. Respiratory care strategies to optimize blood gasses lead to significant barotrauma, increased morbidity, and overuse of extracorporeal membrane oxygenation (ECMO). Newer permissive hypercapnia/spontaneous ventilation protocols geared to accept moderate hypercapnia at lower peak airway pressures have led to improved outcomes. High-frequency oscillatory ventilation can be used in infants who continue to have persistent respiratory distress despite conventional ventilation. ECMO can be used successfully as a resuscitative strategy to minimize further barotrauma in carefully selected patients.

PMID: 22595714 [PubMed - in process]

Chest wall deformities in pediatric surgery.

Surg Clin North Am. 2012 Jun;92(3):669-84

Authors: Obermeyer RJ, Goretsky MJ

Abstract

Chest wall deformities can be divided into 2 main categories, congenital and acquired. Congenital chest wall deformities may present any time between birth and early adolescence. Acquired chest wall deformities typically follow prior chest surgery or a posterolateral diaphragmatic hernia repair (Bochdalek). The most common chest wall deformities are congenital pectus excavatum (88%) and pectus carinatum (5%). This article addresses the etiology, pathophysiology, clinical evaluation, diagnosis, and management of these deformities.

PMID: 22595715 [PubMed - in process]

Neonatal bowel obstruction.

Surg Clin North Am. 2012 Jun;92(3):685-711

Authors: Juang D, Snyder CL

Abstract

Newborn intestinal obstructions are a common reason for admission to neonatal ICUs. The incidence is estimated to be approximately 1 in 2000 live births. There are 4 cardinal signs of intestinal obstruction in newborns: (1) maternal polyhydramnios, (2) bilious emesis, (3) failure to pass meconium in the first day of life, and (4) abdominal distention. The presentation may vary from subtle and easily overlooked findings on physical examination to massive abdominal distention with respiratory distress and cardiovascular collapse. A careful history and physical examination often identify the diagnosis. Concomitant resuscitation (volume, gastric decompression, and ventilatory support) may be necessary.

PMID: 22595716 [PubMed - in process]

Congenital abdominal wall defects and reconstruction in pediatric surgery: gastroschisis and omphalocele.

Surg Clin North Am. 2012 Jun;92(3):713-27

Authors: Ledbetter DJ

Abstract

The embryology, epidemiology, associated anomalies, prenatal course and the neonatal and surgical care of newborns with gastroschisis and omphalocele are reviewed. For gastroschisis temporary intestinal coverage is often done before a more definitive operative closure that may be immediate or delayed. Outcomes in gastroschisis are determined by associated bowel injury. For omphalocele small defects are closed primarily while large defects are treated topically to allow initial skin coverage before a later definitive closure. Outcomes for omphalocele are determined mainly by the presence of associated anomalies.

PMID: 22595717 [PubMed - in process]

Pediatric Malignancies: Neuroblastoma, Wilm’s Tumor, Hepatoblastoma, Rhabdomyosarcoma, and Sacroccygeal Teratoma.

Surg Clin North Am. 2012 Jun;92(3):745-67

Authors: Davenport KP, Blanco FC, Sandler AD

Abstract

Common pediatric malignancies are reviewed: neuroblastoma, Wilms tumor, hepatoblastoma, rhabdomyosarcoma, and sacrococcygeal teratoma. Elements of presentation, diagnosis, staging, treatment, and longterm prognosis are discussed, with particular attention to surgical management.

PMID: 22595719 [PubMed - in process]

Vascular anomalies in pediatrics.

Surg Clin North Am. 2012 Jun;92(3):769-800

Authors: Fevurly RD, Fishman SJ

Abstract

Vascular tumors consist of lesions secondary to endothelial hyperplasia, incorporating both hemangiomas and less common pediatric vascular tumors. Vascular malformations arise by dysmorphogenesis and exhibit normal endothelial cell turnover. Some anomalies may incorporate multiple areas of the vascular tree. Use of this division has provided a clinically useful method of diagnosis and prognosis, as well as a guide to therapy. It is hoped that with continued investigation into the biology and pathogenesis of these lesions, a more comprehensive molecular classification will soon be developed.

PMID: 22595720 [PubMed - in process]

Pediatric surgery.

Surg Clin North Am. 2012 Jun;92(3):xvii-xix

Authors: Azarow KS, Cusick RA

PMID: 22595722 [PubMed - in process]

Evolution of general surgical problems in patients with left ventricular assist devices.

Surgery. 2012 May 8;

Authors: McKellar SH, Morris DS, Mauermann WJ, Park SJ, Zietlow SP

Abstract

BACKGROUND: Left ventricular assist devices (LVADs) are increasingly used to treat patients with end-stage heart failure. These patients may develop acute noncardiac surgical problems around the time of LVAD implantation or, as survival continues to improve, chronic surgical problems as ambulatory patients remote from the LVAD implant. Previous reports of noncardiac surgical problems in LVAD patients included patients with older, first-generation devices and do not address newer, second-generation devices. We describe the frequency and management of noncardiac surgical problems encountered during LVAD support with these newer-generation devices to assist noncardiac surgeons involved in the care of patients with LVADs. METHODS: We retrospectively reviewed the medical records of consecutive patients receiving LVADs at our institution. We collected data for any consultation by noncardiac surgeons within the scope of general surgery during LVAD support and subsequent treatment. RESULTS: Ninety-nine patients received implantable LVADs between 2003 and 2009 (first-generation, n = 19; second-generation, n = 80). Excluding intestinal hemorrhage, general surgical opinions were rendered for 34 patients with 49 problems, mostly in the acute recovery phase after LVAD implantation. Of those, 27 patients underwent 28 operations. Respiratory failure and intra-abdominal pathologies were the most common problems addressed, and LVAD rarely precluded operation. Patients with second-generation LVADs were more likely to survive hospitalization (P = .04) and develop chronic, rather than emergent, surgical problems. CONCLUSION: Patients with LVADs frequently require consultation from noncardiac surgeons within the scope of general surgeons and often require operation. Patients with second-generation LVADs are more likely to become outpatients and develop more elective surgical problems. Noncardiac surgeons will be increasingly involved in caring for patients with LVADs and should anticipate the problems unique to this patient population.

PMID: 22575878 [PubMed - as supplied by publisher]

Intraductal papillary mucinous neoplasm was associated with pancreatic carcinogenesis, but not with systemic carcinogenesis.

Surgery. 2012 May 8;

Authors: Kawakubo K, Tada M, Koike K

PMID: 22575879 [PubMed - as supplied by publisher]

Urokinase requires NAD(P)H oxidase to transactivate the epidermal growth factor receptor.

Surgery. 2012 May 8;

Authors: Duru EA, Fu Y, Davies MG

Abstract

BACKGROUND: Cell migration is an integral part of the development of intimal hyperplasia, and proteases are pivotal components in the process. Cell migration in response to urokinase is mediated through the aminoterminal fragment (ATF) of the protein. This study examines the role of NAD(P)H oxidase during epidermal growth factor receptor (EGFR) transactivation by ATF in human vascular smooth muscle cells (VSMC). METHODS: Human VSMCs were cultured in vitro. Linear wound and Boyden microchemotaxis assays of migration in response to ATF were performed in the presence and absence of NAD(P)H oxidase inhibitors (diphenyleneiodonium [DPI] and apocynin) and small interfering RNA (siRNA) to Nox1. Additional assays were performed to examine the upstream pathways that lead to NAD(P)H oxidase activity. Assays were also performed for EGFR activation. RESULTS: ATF produced concentration-dependent VSMC migration, which was inhibited by increasing concentrations of DPI and apocynin. ATF was shown to induce time-dependent EGFR phosphorylation, which peaked at 4-fold greater than control. This response was inhibited by DPI and apocynin in a concentration-dependent manner. ATF induced a concentration-dependent increase in intracellular oxygen free radical species, which was mitigated by the presence of DPI and apocynin. Inhibition of Gβγ by βARK(CT) reduced both NAD(P)H oxidase activity and EGFR activation. Inhibition of rac, which allows the NAD(P)H complex to assemble on the membrane, and inhibition of src, which induces assembly of the complex, both reduced ATF-dependent NAD(P)H oxidase activity and EGFR phosphorylation. siRNA to Nox1 prevented ATF-mediated EGFR activation and cell migration. CONCLUSION: ATF requires NAD(P)H oxidase activity through a Gβγ-, rac-, and src-mediated pathway to facilitate transactivation of EGFR and VSMC migration.

PMID: 22575880 [PubMed - as supplied by publisher]

Combination of total abdominal inferior vena cava resection with a novel technique of left renal outflow restoration.

Surgery. 2012 May 8;

Authors: Arkadopoulos N, Karmaniolou I, Ekonomopoulos N, Vassiliu P, Smyrniotis V

PMID: 22575881 [PubMed - as supplied by publisher]

Traumatic fracture-dislocation of the lumbar spine.

Surgery. 2012 May 8;

Authors: Tian NF, Mao FM, Xu HZ

PMID: 22575882 [PubMed - as supplied by publisher]

The long-term behavior of lightweight and heavyweight meshes used to repair abdominal wall defects is determined by the host tissue repair process provoked by the mesh.

Surgery. 2012 May 8;

Authors: Pascual G, Hernández-Gascón B, Rodríguez M, Sotomayor S, Peña E, Calvo B, Bellón JM

Abstract

BACKGROUND: Although heavyweight (HW) or lightweight (LW) polypropylene (PP) meshes are widely used for hernia repair, other alternatives have recently appeared. They have the same large-pore structure yet are composed of polytetrafluoroethylene (PTFE). This study compares the long-term (3 and 6 months) behavior of meshes of different pore size (HW compared with LW) and composition (PP compared with PTFE). METHODS: Partial defects were created in the lateral wall of the abdomen in New Zealand White rabbits and then repaired by the use of a HW or LW PP mesh or a new monofilament, large-pore PTFE mesh (Infinit). At 90 and 180 days after implantation, tissue incorporation, gene and protein expression of neocollagens (reverse transcription-polymerase chain reaction/immunofluorescence), macrophage response (immunohistochemistry), and biomechanical strength were determined. Shrinkage was measured at 90 days. RESULTS: All three meshes induced good host tissue ingrowth, yet the macrophage response was significantly greater in the PTFE implants (P < .05). Collagen 1/3 mRNA levels failed to vary at 90 days yet in the longer term, the LW meshes showed the reduced genetic expression of both collagens (P < .05) accompanied by increased neocollagen deposition, indicating more efficient mRNA translation. After 90-180 days of implant, tensile strengths and elastic modulus values were similar for all 3 implants (P > .05). CONCLUSION: Host collagen deposition is mesh pore size dependent whereas the macrophage response induced is composition dependent with a greater response shown by PTFE. In the long term, macroporous meshes show comparable biomechanical behavior regardless of their pore size or composition.

PMID: 22575883 [PubMed - as supplied by publisher]

Treatment with antithymocyte globulin ameliorates intestinal ischemia and reperfusion injury in mice.

Surgery. 2012 May 8;

Authors: Watson MJ, Ke B, Shen XD, Gao F, Busuttil RW, Kupiec-Weglinski JW, Farmer DG

Abstract

BACKGROUND: Antithymocyte therapy, specifically antithymocyte globulin (ATG; Thymoglobulin), is increasingly being used in organ transplantation to reduce allograft rejection. The T-lymphocyte has been purported to also play a role in ischemia and reperfusion injury (IRI); however, it has not been well studied. Our aim is to determine if ATG treatment impacts murine intestinal IRI. METHODS: Under anesthesia, male C57BL6 mice underwent 100 minutes of warm intestinal IRI by clamping the superior mesenteric artery. The treatment group received rabbit anti-murine ATG (10 mg/kg) intraperitoneally 6 hours before IRI. Separate survival and analysis groups were performed. Intestinal tissue was procured at 4 and 24 hours after IRI. Tissue analysis included hematoxylin-eosin staining, CD3, CD4, and CD8 immunostaining, myeloperoxidase assay (MPO), quantitative real-time polymerase chain reaction studies, and Western blot. RESULTS: ATG treatment led to marked improvement in 7-day survival and a reduction in tissue injury by histology. MPO was also reduced, and immunostaining confirmed a significant reduction in CD3(+), CD4(+), and CD8(+) infiltrating cells in the treatment group. Quantitative real-time polymerase chain reaction analysis revealed the decreased expression of tumor necrosis factor-α, interferon-inducible protein 10, monocyte chemotactic protein-1, interferon-γ, interleukin-2, and increased production of interleukins -13 and -10 in the treatment group. Western blot analysis revealed decreased caspase-3 and increased signal transducer and activator of transcription 6 levels in the ATG-treated group. CONCLUSION: This study is the first to show that ATG treatment ameliorates intestinal IRI. Treatment with ATG leads to reduced local infiltration by T-lymphocytes, with fewer inflammatory and chemotactic programs and less apoptosis. Treatment also is associated with a T(H)2-type cytokine switch. These novel findings suggest that T-lymphocytes represent important mediators of intestinal IRI and that ATG therapies may be beneficial in the prevention of IRI.

PMID: 22575884 [PubMed - as supplied by publisher]

Liver epithelial cells proliferate under hypoxia and protect the liver from ischemic injury via expression of HIF-1 alpha target genes.

Surgery. 2012 May 8;

Authors: Abe Y, Uchinami H, Kudoh K, Nakagawa Y, Ise N, Watanabe G, Sato T, Seki E, Yamamoto Y

Abstract

BACKGROUND: The remnant liver after extended liver resection is susceptible to ischemic injury, resulting in the failure of liver regeneration and liver dysfunction. The present study is aimed to investigate the protective role of the liver epithelial cells (LEC), a liver progenitor cell, on hepatocytes with ischemia in vitro and in vivo. METHODS: LECs were isolated from rats and cultured under hypoxic conditions (2% O(2)). The cell viability and intracellular ATP levels were measured. The activation of hypoxia-inducible factor-1α (HIF-1α) was assessed by immunofluorescence. The expression of pyruvate dehydrogenase kinase-1 (PDK-1), stromal cell-derived factor-1 (SDF-1), and chemokine receptor 4 (CXCR4) were measured. Hepatocytes were treated with SDF-1 or LEC-conditioned medium under hypoxia, and cell viability was assessed. Finally, hemorrhagic shock was induced in rats with in vivo induction of endogenous LECs, and liver damage was assessed. RESULTS: In LECs, but not in hepatocytes, cellular viability and intracellular ATP levels were maintained, and nuclear translocation of HIF-1α and expression of pyruvate dehydrogenase kinase-1 mRNA were increased under hypoxic culture conditions. LECs express SDF-1, and CXCR4 expression was increased in hepatocytes under hypoxia. The survival of hepatocytes under hypoxic condition was significantly increased after treatment with SDF-1 or LEC-conditioned medium. The protective effect of conditioned medium was impaired by CXCR4 antagonists. In vivo induction of endogenous LECs suppressed elevation of serum AST and ALT levels after hemorrhage shock and ischemia-reperfusion. CONCLUSION: LECs are resistant to hypoxia and have a protective role for hepatocytes against hypoxia. Our results suggest that induction of endogenous LECs protected the liver from lethal insults by paracrine signaling of SDF-1 and differentiation into parenchymal cells.

PMID: 22575885 [PubMed - as supplied by publisher]

Outcomes of PCI at hospitals with or without on-site cardiac surgery.

N Engl J Med. 2012 May 10;366(19):1792-802

Authors: Aversano T, Lemmon CC, Liu L,

Abstract

BACKGROUND: Performance of percutaneous coronary intervention (PCI) is usually restricted to hospitals with cardiac surgery on site. We conducted a noninferiority trial to compare the outcomes of PCI performed at hospitals without and those with on-site cardiac surgery.

METHODS: We randomly assigned participants to undergo PCI at a hospital with or without on-site cardiac surgery. Patients requiring primary PCI were excluded. The trial had two primary end points: 6-week mortality and 9-month incidence of major adverse cardiac events (the composite of death, Q-wave myocardial infarction, or target-vessel revascularization). Noninferiority margins for the risk difference were 0.4 percentage points for mortality at 6 weeks and 1.8 percentage points for major adverse cardiac events at 9 months.

RESULTS: A total of 18,867 patients were randomly assigned in a 3:1 ratio to undergo PCI at a hospital without on-site cardiac surgery (14,149 patients) or with on-site cardiac surgery (4718 patients). The 6-week mortality rate was 0.9% at hospitals without on-site surgery versus 1.0% at those with on-site surgery (difference, -0.04 percentage points; 95% confidence interval [CI], -0.31 to 0.23; P=0.004 for noninferiority). The 9-month rates of major adverse cardiac events were 12.1% and 11.2% at hospitals without and those with on-site surgery, respectively (difference, 0.92 percentage points; 95% CI, 0.04 to 1.80; P=0.05 for noninferiority). The rate of target-vessel revascularization was higher in hospitals without on-site surgery (6.5% vs. 5.4%, P=0.01).

CONCLUSIONS: We found that PCI performed at hospitals without on-site cardiac surgery was noninferior to PCI performed at hospitals with on-site cardiac surgery with respect to mortality at 6 weeks and major adverse cardiac events at 9 months. (Funded by the Cardiovascular Patient Outcomes Research Team [C-PORT] participating sites; ClinicalTrials.gov number, NCT00549796.).

PMID: 22443460 [PubMed - indexed for MEDLINE]

Lenalidomide after stem-cell transplantation for multiple myeloma.

N Engl J Med. 2012 May 10;366(19):1770-81

Authors: McCarthy PL, Owzar K, Hofmeister CC, Hurd DD, Hassoun H, Richardson PG, Giralt S, Stadtmauer EA, Weisdorf DJ, Vij R, Moreb JS, Callander NS, Van Besien K, Gentile T, Isola L, Maziarz RT, Gabriel DA, Bashey A, Landau H, Martin T, Qazilbash MH, Levitan D, McClune B, Schlossman R, Hars V, Postiglione J, Jiang C, Bennett E, Barry S, Bressler L, Kelly M, Seiler M, Rosenbaum C, Hari P, Pasquini MC, Horowitz MM, Shea TC, Devine SM, Anderson KC, Linker C

Abstract

BACKGROUND: Data are lacking on whether lenalidomide maintenance therapy prolongs the time to disease progression after autologous hematopoietic stem-cell transplantation in patients with multiple myeloma.

METHODS: Between April 2005 and July 2009, we randomly assigned 460 patients who were younger than 71 years of age and had stable disease or a marginal, partial, or complete response 100 days after undergoing stem-cell transplantation to lenalidomide or placebo, which was administered until disease progression. The starting dose of lenalidomide was 10 mg per day (range, 5 to 15).

RESULTS: The study-drug assignments were unblinded in 2009, when a planned interim analysis showed a significantly longer time to disease progression in the lenalidomide group. At unblinding, 20% of patients who received lenalidomide and 44% of patients who received placebo had progressive disease or had died (P<0.001); of the remaining 128 patients who received placebo and who did not have progressive disease, 86 crossed over to lenalidomide. At a median follow-up of 34 months, 86 of 231 patients who received lenalidomide (37%) and 132 of 229 patients who received placebo (58%) had disease progression or had died. The median time to progression was 46 months in the lenalidomide group and 27 months in the placebo group (P<0.001). A total of 35 patients who received lenalidomide (15%) and 53 patients who received placebo (23%) died (P=0.03). More grade 3 or 4 hematologic adverse events and grade 3 nonhematologic adverse events occurred in patients who received lenalidomide (P<0.001 for both comparisons). Second primary cancers occurred in 18 patients who received lenalidomide (8%) and 6 patients who received placebo (3%).

CONCLUSIONS: Lenalidomide maintenance therapy, initiated at day 100 after hematopoietic stem-cell transplantation, was associated with more toxicity and second cancers but a significantly longer time to disease progression and significantly improved overall survival among patients with myeloma. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00114101.).

PMID: 22571201 [PubMed - indexed for MEDLINE]

Lenalidomide maintenance after stem-cell transplantation for multiple myeloma.

N Engl J Med. 2012 May 10;366(19):1782-91

Authors: Attal M, Lauwers-Cances V, Marit G, Caillot D, Moreau P, Facon T, Stoppa AM, Hulin C, Benboubker L, Garderet L, Decaux O, Leyvraz S, Vekemans MC, Voillat L, Michallet M, Pegourie B, Dumontet C, Roussel M, Leleu X, Mathiot C, Payen C, Avet-Loiseau H, Harousseau JL,

Abstract

BACKGROUND: High-dose chemotherapy with autologous stem-cell transplantation is a standard treatment for young patients with multiple myeloma. Residual disease is almost always present after transplantation and is responsible for relapse. This phase 3, placebo-controlled trial investigated the efficacy of lenalidomide maintenance therapy after transplantation.

METHODS: We randomly assigned 614 patients younger than 65 years of age who had nonprogressive disease after first-line transplantation to maintenance treatment with either lenalidomide (10 mg per day for the first 3 months, increased to 15 mg if tolerated) or placebo until relapse. The primary end point was progression-free survival.

RESULTS: Lenalidomide maintenance therapy improved median progression-free survival (41 months, vs. 23 months with placebo; hazard ratio, 0.50; P<0.001). This benefit was observed across all patient subgroups, including those based on the β(2)-microglobulin level, cytogenetic profile, and response after transplantation. With a median follow-up period of 45 months, more than 70% of patients in both groups were alive at 4 years. The rates of grade 3 or 4 peripheral neuropathy were similar in the two groups. The incidence of second primary cancers was 3.1 per 100 patient-years in the lenalidomide group versus 1.2 per 100 patient-years in the placebo group (P=0.002). Median event-free survival (with events that included second primary cancers) was significantly improved with lenalidomide (40 months, vs. 23 months with placebo; P<0.001).

CONCLUSIONS: Lenalidomide maintenance after transplantation significantly prolonged progression-free and event-free survival among patients with multiple myeloma. Four years after randomization, overall survival was similar in the two study groups. (Funded by the Programme Hospitalier de Recherche Clinique and others; ClinicalTrials.gov number, NCT00430365.).

PMID: 22571202 [PubMed - indexed for MEDLINE]

Percutaneous coronary interventions without on-site cardiac surgical backup.

N Engl J Med. 2012 May 10;366(19):1814-23

Authors: Shahian DM, Meyer GS, Yeh RW, Fifer MA, Torchiana DF

PMID: 22571203 [PubMed - indexed for MEDLINE]

Lenalidomide in myeloma–a high-maintenance friend.

N Engl J Med. 2012 May 10;366(19):1836-8

Authors: Badros AZ

PMID: 22571206 [PubMed - indexed for MEDLINE]

Immediate laparoscopic adrenalectomy versus observation: cost evaluation for incidental adrenal lesions with atypical imaging characteristics.

Am J Surg. 2012 May 14;

Authors: Melck AL, Rosengart MR, Armstrong MJ, Stang MT, Carty SE, Yip L

Abstract

BACKGROUND: Because of controversy in the management of nonfunctional adrenal masses <6 cm with lipid-poor imaging characteristics, the study was conducted to compare the costs of observation versus immediate laparoscopic adrenalectomy. METHODS: A total of 370 patients who were evaluated for incidental adrenal masses between January 1999 and December 2007 were identified, and 32 (8.7%) patients had lesions with imaging characteristics that were inconsistent with a benign adenoma (ie, atypical appearing). Sixteen patients underwent immediate surgery and 16 had observation with serial imaging and biochemical studies. The associated total costs were subjected to intention-to-treat analysis. RESULTS: In the observation cohort, 7 patients converted and underwent adrenalectomy after a mean of 13.1 months. Initially, costs of immediate surgery exceeded those of observation ($12,015.72 vs $11,601.18, P = .10). After projecting costs of annual surveillance, a cost advantage for immediate surgery was demonstrated after 9 years (P = .02). CONCLUSIONS: In patients with <6 cm atypical-appearing adrenal lesions, the costs of surgery and of observation are initially equal. After 9 years, the costs of surveillance exceed that of initial laparoscopic adrenalectomy.

PMID: 22591697 [PubMed - as supplied by publisher]

Clinicopathologic characteristics of patients with non-B non-C hepatitis virus hepatocellular carcinoma after hepatectomy.

Am J Surg. 2012 May 14;

Authors: Kaibori M, Ishizaki M, Matsui K, Kwon AH

Abstract

BACKGROUND: A substantial population of hepatocellular carcinoma (HCC) patients is negative for markers of hepatitis B virus and hepatitis C virus (HCV) infection (non-B non-C hepatitis virus [NBC]). METHODS: Clinicopathologic data and outcomes were compared retrospectively for HCC patients with hepatitis B virus, HCV, and NBC who had undergone hepatectomy. RESULTS: The TNM stage was significantly higher, and the prevalence of cirrhosis was significantly lower, in the NBC group compared with the HCV group. Among patients with a maximum tumor diameter of 5 cm or less, the survival rates were significantly higher in the NBC group than in the HCV group. Multivariate analysis revealed that preoperative serum des-gamma-carboxy prothrombin (DCP) level was a prognostic factor for survival in NBC-HCC patients. The DCP/tumor size ratio was significantly higher in NBC-HCC patients with normal liver histology than in patients with hepatitis or cirrhosis. CONCLUSIONS: NBC-HCC patients had more advanced tumors compared with HCV-HCC patients, but significantly higher survival rates. Measurement of DCP potentially is significant for early diagnosis of NBC HCC, which may increase the chance of curative therapy without recurrence.

PMID: 22591698 [PubMed - as supplied by publisher]

The surgery clerkship: an opportunity for preclinical credentialing in urinary catheterization.

Am J Surg. 2012 May 14;

Authors: Yang RL, Reinke CE, Mittal MK, Kean CR, Diaz E, Fishman NO, Morris JB, Kelz RR

Abstract

BACKGROUND: At our hospital, medical students lost privileges to perform urinary catheterization because of concern regarding catheter-associated urinary tract infections. We hypothesized that trained medical students could perform urinary catheterization with the same proficiency as licensed practitioners. METHODS: Medical students completed a credentialing program in urinary catheterization. Prospectively, the rate of catheter-associated urinary tract infections after urinary catheterization performed by medical students was compared with the health system-wide rate of catheter-associated urinary tract infections after urinary catheterization performed by non-medical students using an incidence rate ratio (IRR). RESULTS: Over 9 months, a total of 432 and 55,401 catheter days accrued in patients who underwent urinary catheterization by medial students and non-medical students, resulting in 1 and 129 catheter-associated urinary tract infections, respectively. The incidence rate of catheter-associated urinary tract infections per 1,000 catheter days was 2.31 in the medical student-placed catheters and 2.33 in the non-MS-placed catheters (IRR = .99, P = .55). CONCLUSIONS: Preclinical credentialing in urinary catheterization resulted in the reinstatement of urinary catheterization privileges to qualified medical students. Student proficiency in urinary catheterization can match that of licensed practitioners.

PMID: 22591699 [PubMed - as supplied by publisher]

Facilitating safer surgery and anesthesia in a disaster zone.

Am J Surg. 2012 May 14;

Authors: Jawa RS, Zakrison TL, Richards AT, Young DH, Heir JS

PMID: 22591700 [PubMed - as supplied by publisher]

Intravenous Lornoxicam Is More Effective than Paracetamol as a Supplemental Analgesic After Lower Abdominal Surgery: A Randomized Controlled Trial.

World J Surg. 2012 May 15;

Authors: Mowafi HA, Elmakarim EA, Ismail S, Al-Mahdy M, El-Saflan AE, Elsaid AS

Abstract

BACKGROUND: The aim of this prospective, randomized, double-blind study was to determine the more effective supplemental analgesic, paracetamol or lornoxicam, for postoperative pain relief after lower abdominal surgery. METHODS: Sixty patients scheduled for lower abdominal surgery under general anesthesia were randomly allocated to receive either isotonic saline (control group), intravenous paracetamol 1 g every 6 h (paracetamol group), or lornoxicam 16 mg then 8 mg after 12 h (lornoxicam group). Additionally pain was treated postoperatively with morphine patient-controlled analgesia. Postoperative pain scores measured by the verbal pain score (VPS), morphine consumption, and the incidence of side effects were measured at 1, 2, 4, 8, 12, and 24 h postoperatively. RESULTS: Morphine consumption at 12 and 24 h was significantly lower in the lornoxicam group (19.25 ± 5.7 mg and 23.1 ± 6.5 mg) than in the paracetamol group (23.4 ± 6.6 mg and 28.6 ± 7.6 mg). Both treatment groups had less morphine consumption than the control group (28.5 ± 5 mg and 38.1 ± 6.6 mg) at 12 and 24 h, respectively. Additionally, VPS was reduced in the paracetamol and the lornoxicam groups compared with the control group both at rest and on coughing. Further analysis revealed that VPS in the lornoxicam group was significantly lower than that in the paracetamol group only during coughing. Drug-related side effects were comparable in all groups. CONCLUSIONS: Lornoxicam is superior to paracetamol for postoperative analgesia after lower abdominal surgery. However, paracetamol could be an alternative supplemental analgesic whenever an NSAID is unsuitable. Trial Registration: clinicaltrials.gov.identifier:NCT01564680.

PMID: 22584689 [PubMed - as supplied by publisher]

Learning Curve of Thoracoscopic Repair of Esophageal Atresia.

World J Surg. 2012 May 15;

Authors: van der Zee DC, Tytgat SH, Zwaveling S, van Herwaarden MY, Vieira-Travassos D

Abstract

BACKGROUND: Thoracoscopic repair of esophageal atresia is considered to be one of the more advanced pediatric surgical procedures, and it undoubtedly has a learning curve. This is a single-center study that was designed to determine the learning curve of thoracoscopic repair of esophageal atresia. METHODS: The study involved comparison of the first and second five-year outcomes of thoracoscopic esophageal atresia repair. RESULTS: The demographics of the two groups were comparable. There was a remarkable reduction of postoperative leakage or stenosis, and recurrence of fistulae, in spite of the fact that nowadays the procedure is mainly performed by young staff members and fellows. CONCLUSIONS: There is a considerable learning curve for thoracoscopic repair of esophageal atresia. Centers with the ambition to start up a program for thoracoscopic repair of esophageal atresia should do so with the guidance of experienced centers.

PMID: 22584690 [PubMed - as supplied by publisher]

Trauma Care and Case Fatality during a Period of Frequent, Violent Terror Attacks and Thereafter.

World J Surg. 2012 May 17;

Authors: Rivkind AI, Blum R, Gershenstein I, Stein Y, Coleman S, Mintz Y, Zamir G, Richter ED

Abstract

BACKGROUND: From September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized. METHODS: We tracked case fatality rates (CFRs) initially during a period of terror attacks (1999-2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (n = 2,000 patients), and 51 level I U.S. trauma centers (n = 265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010. RESULTS: Five-year HHSTU CFR (2.62 %) was less than half that in 51 U.S. centers (5.73 %). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISS > 25 accounted for 170 (89 %) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISS < 25. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9 % up to 2010. CONCLUSIONS: Sustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.

PMID: 22588239 [PubMed - as supplied by publisher]

Immunologic Response After Laparoscopic Colon Cancer Operation Within an Enhanced Recovery Program.

J Gastrointest Surg. 2012 May 15;

Authors: Wang G, Jiang Z, Zhao K, Li G, Liu F, Pan H, Li J

Abstract

OBJECTIVE: It has been demonstrated that colon operation combined with fast-track (FT) surgery and laparoscopic technique can shorten the length of hospital stay, accelerate recovery of intestinal function, and reduce the occurrence of post-operative complications. However, there are no reports regarding the combined effects of FT colon operation and laparoscopic technique on humoral inflammatory cellular immunity. METHODS: This was a prospective, controlled study. One hundred sixty-three colon cancer patients underwent the traditional protocol and open operation (traditional open group, n = 42), the traditional protocol and laparoscopic operation (traditional laparoscopic group, n = 40), the FT protocol and open operation (FT open group, n = 41), or the FT protocol and laparoscopic operation (FT laparoscopic group, n = 40). Blood samples were taken prior to operation as well as on days 1, 3, and 5 after operation. The number of lymphocyte subpopulations was determined by flow cytometry, and serum interleukin-6 and C-reactive protein levels were measured. Post-operative hospital stay, post-operative morbidity, readmission rate, and in-hospital mortality were recorded. RESULTS: Compared with open operation, laparoscopic colon operation effectively inhibited the release of post-operative inflammatory factors and yielded good protection via post-operative cell immunity. FT surgery had a better protective role with respect to the post-operative immune system compared with traditional peri-operative care. Inflammatory reactions, based on interleukin-6 and C-reactive protein levels, were less intense following FT laparoscopic operation compared to FT open operation; however, there were no differences in specific immunity (CD3+ and CD4+ counts, and the CD4+/CD8+ ratio) during these two types of surgical procedures. Post-operative hospital stay in patients randomized to the FT laparoscopic group was significantly shorter than in the other three treatment groups (P < 0.01). Post-operative complications in patients who underwent FT laparoscopic treatment were less than in the other three treatment groups (P < 0.05). There were no significant differences between the four treatment groups regarding readmission rate and in-hospital mortality. CONCLUSIONS: The laparoscopic technique and FT surgery rehabilitation program effectively inhibited release of post-operative inflammatory factors with a reduction in peri-operative trauma and stress, which together played a protective role on the post-operative immune system. Combining two treatment measures during colon operation produced better protective effects via the immune system. The beneficial clinical effects support that the better-preserved post-operative immune system may also contribute to the improvement of post-operative results in FT laparoscopic patients.

PMID: 22585532 [PubMed - as supplied by publisher]

Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature.

Am J Surg. 2012 May 10;

Authors: Tekatli H, Schouten N, van Dalen T, Burgmans I, Smakman N

Abstract

BACKGROUND: The treatment of inguinal hernia has changed considerably over the past 15 years. We reviewed the preclinical and clinical literature to find out the effect of inguinal hernia surgery on male fertility because it has been suggested that hernia surgery may impair testicular function and male fertility. DATA SOURCES: A search on Embase, MEDLINE, and the Cochrane Library was performed to find related articles. CONCLUSIONS: Animal models show substantial effects of hernia repair on the structures in the spermatic cord, which is more pronounced in mesh repairs. Although the number of studies and the included numbers of patients were limited, clinical studies indicate that these potential adverse effects do not seem to have a clinical impact on male fertility in humans with inguinal hernias. Future clinical studies, preferably with bilateral patients, are necessary to investigate the clinical relevance of the effects of inguinal hernia and hernia surgery on male fertility.

PMID: 22578405 [PubMed - as supplied by publisher]

Beta-blocker exposure in the absence of significant head injuries is associated with reduced mortality in critically ill patients.

Am J Surg. 2012 May 10;

Authors: Bukur M, Lustenberger T, Cotton B, Arbabi S, Talving P, Salim A, Ley EJ, Inaba K

Abstract

BACKGROUND: The effect of β-blockade in trauma patients without significant head injuries is unknown. The purpose of this investigation was to determine the impact of β-blocker exposure on mortality in critically injured trauma patients who did not sustain significant head injuries. METHODS: Critically ill trauma patients (Injury Severity Score ≥ 25) admitted to the surgical intensive care unit from January 2000 to December 2008 without severe traumatic brain injuries (head Abbreviated Injury Score ≥ 3) were included in this retrospective review. Patients who received β-blockers within 30 days of intensive care unit admission were compared with those who did not. The primary outcome measure evaluated was in-hospital mortality. RESULTS: During the 9-year study period, 663 critically injured patients (Injury Severity Score ≥ 25) were admitted to the intensive care unit. Of these, 98 patients (14.8%) received β-blockers. Patients exposed to β-blockers had significantly lower in-hospital mortality (11.2% vs 19.3%, P = .006). Stepwise logistic regression identified β-blocker use as an independent protective factor for mortality (adjusted odds ratio, .37; P = .007) in critically injured patients. CONCLUSIONS: Beta-blocker exposure was associated with reduced mortality in critically injured patients without head injuries. Prospective validation of this finding is warranted.

PMID: 22578406 [PubMed - as supplied by publisher]

The role of sentinel lymph node biopsy in select sarcoma patients: a meta-analysis.

Am J Surg. 2012 May 10;

Authors: Wright S, Armeson K, Hill EG, Streck C, Leddy L, Cole D, Esnaola N, Camp ER

Abstract

BACKGROUND: Sentinel lymph node (SLN) biopsy is a staging technique for occult lymph node disease. SLN biopsy has been applied to select patients with sarcoma, although the clinical utility remains uncertain. METHODS: A PubMed/MEDLINE literature search was performed, and SLN biopsy outcomes were analyzed using a Bayesian meta-analytic approach to obtain point and interval estimates of rates of interest. RESULTS: Sixteen studies involving SLN biopsy in patients with sarcoma were identified. Of 114 patients reported, 14 patients had positive SLNs (crude estimate, 12%; meta-analysis estimate, 17%). The meta-analysis false-negative rate was 29% (95% credible interval, 5%-59%). Recurrence and death rates in the SLN-positive group were higher than in the SLN-negative group. CONCLUSIONS: This investigation highlights the current role of SLN biopsy in select patients with sarcoma for tumor staging. Questions regarding the high false-negative rate and management of micrometastatic lymphatic disease in patients with sarcoma still exist.

PMID: 22578407 [PubMed - as supplied by publisher]

Management of the focal nodular hyperplasia of the liver: evaluation of the surgical treatment comparing with observation only.

Am J Surg. 2012 May 10;

Authors: Perrakis A, Demir R, Müller V, Mulsow J, Aydin U, Alibek S, Hohenberger W, Yedibela S

Abstract

BACKGROUND: Long-term results of both surgery and observation for patients with focal nodular hyperplasia (FNH) in a large single-center experience do not exist. Accordingly, the aim of this study was to compare long-term outcomes in patients with FNH who underwent either elective hepatectomy or observation alone. METHODS: A retrospective single-institution analysis of 185 patients with FNH, treated from 1990 to 2009, was performed. RESULTS: Seventy-eight patients underwent elective hepatectomy and 107 patients observation alone, with a median follow-up period of 113 months. There was no perioperative mortality. Postoperative complications were recorded in 12 patients, and 92% of patients reported symptomatic reductions. Among observation patients, 9 (13%) developed additional symptoms; tumor enlargement was seen in 3 patients (4%). CONCLUSIONS: Elective liver resection for FNH is a safe procedure at high-volume centers. This single-center experience showed that 13% of observed patients had protracted symptoms. This justifies the therapeutic algorithm that elective surgery should be considered in symptomatic patients or in those with marked enlargement.

PMID: 22578408 [PubMed - as supplied by publisher]

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion.

Am J Surg. 2012 May 10;

Authors: Brocker JA, Maher JL, Smith RW

Abstract

BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence. DATA SOURCES: Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized. CONCLUSIONS: Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

PMID: 22578409 [PubMed - as supplied by publisher]

Overexpression of LAPTM4B-35 is associated with poor prognosis in colorectal carcinoma.

Am J Surg. 2012 May 10;

Authors: Kang Y, Yin M, Jiang W, Zhang H, Xia B, Xue Y, Huang Y

Abstract

BACKGROUND: The purpose of this study was to determine whether lysosome-associated protein transmembrane-4 beta (LAPTM4B) overexpression is associated with the prognosis in patients with colorectal cancer. METHODS: LAPTM4B expression was evaluated in colorectal cancer patients by Western blot analysis and immunohistochemistry. Univariate and multivariate analyses were performed to determine the association between LAPTM4B expression and prognosis. RESULTS: Among the 136 patients with colorectal cancer, 51 patients had low LAPTM4B expression, and 85 patients had high LAPTM4B expression. The sensitivity and specificity of LAPTM4B overexpression were 62.5% and 100%, respectively. The 5-year overall survival (OS) rates for patients with high and low LAPTM4B expression were 37.38% and 98.04%, respectively (hazard ratio = 22.774; 95% confidence interval [CI], 5.287-98.091; P < .0001). The 5-year disease-free survival rate was 21.15% for patients in the high-expression group and 91.82% for patients in the low-expression group (hazard ratio = 11.674; 95% CI, 3.562-38.263; P < .0001). CONCLUSIONS: LAPTM4B overexpression is an independent factor in colorectal cancer prognosis, and it may be an important potential biomarker.

PMID: 22578410 [PubMed - as supplied by publisher]

Transanal endoscopic microsurgery: safe for midrectal lesions in morbidly obese patients.

Am J Surg. 2012 May 10;

Authors: Kumar AS, Chhitwal N, Coralic J, Stahl TJ, Ayscue JM, Fitzgerald JF, Smith LE

Abstract

BACKGROUND: Transanal endoscopic microsurgery is a safe option for proximal rectal tumors in morbidly obese patients for whom transabdominal pelvic dissection often is fraught with morbidity. METHODS: From a database of 318 patients who underwent transanal endoscopic microsurgery, we report a retrospective case-control study of 9 patients with a body mass index range of 35 to 66 with sessile rectal lesions 6 to 15 cm from the anal verge who underwent transanal endoscopic microsurgery. Case subjects were compared with 15 controls and matched for age, tumor type, and level of tumor. The average body mass index of controls was 30 (P < .001). By using t test analysis, perioperative outcomes (surgical time, blood loss, and hospital length of stay) and postoperative complications were compared. RESULTS: Sessile tumors were located 7 to 11 cm from the anal verge with a diameter of 1 to 4 cm. Patient and tumor factors such as age, distal tumor margin from anal verge, and tumor diameter were not significantly different between case subjects and controls. Surgical blood loss, surgical time, and hospital length of stay were not significantly different between the 2 groups. One complication occurred among the cases. No complications occurred in the control group. All patients had complete surgical resections with negative margins. CONCLUSIONS: Transanal endoscopic microsurgery in morbidly obese patients is a safe, feasible, and a viable alternative to low anterior resection.

PMID: 22578411 [PubMed - as supplied by publisher]

Routine peritoneal drainage of the surgical bed after elective distal pancreatectomy: is it necessary?

Am J Surg. 2012 May 10;

Authors: Paulus EM, Zarzaur BL, Behrman SW

Abstract

BACKGROUND: Recent literature suggests that peritoneal drainage (PD) is not helpful after elective pancreatectomy and may be detrimental. Data specific to distal pancreatectomy (DP) have not received prior evaluation. METHODS: We performed a retrospective review of patients who underwent DP. Factors examined included postoperative morbidity and the need for therapeutic intervention. RESULTS: Sixty-nine patients had DP, 30 without PD. Thirty-four patients suffered 45 complications, most were intra-abdominal in nature. Twelve, 19, and 3 patients required radiologic drainage, reoperation, or both, respectively. There was no difference between groups relative to intra-abdominal complications or the need for therapeutic intervention. Of 39 patients undergoing PD, 19 had abdominal morbidity. The drain was useful in identifying and/or treating the complication in 3 patients. CONCLUSIONS: First, PD after DP does not confer a reduction in morbidity or the need for therapeutic intervention versus patients with no drains. Second, the presence of a drain infrequently was helpful in detecting complications. Third, a multi-institutional, randomized study is recommended.

PMID: 22579230 [PubMed - as supplied by publisher]

Utility of shock index calculation in combat casualty triage protocol?

Am J Surg. 2012 May 9;

Authors: Pasquier P, Tourtier JP, Boutonnet M, Malgras B, Mérat S

PMID: 22579231 [PubMed - as supplied by publisher]

Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study.

Am J Surg. 2012 May 9;

Authors: van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF

Abstract

BACKGROUND: We investigated the impact of incisional hernia (IH) on quality of life and body image. METHODS: Open abdominal surgery patients were included in a prospective cohort study performed between 2007 and 2009 in an academic hospital. Main outcomes were incidence of IH after approximately 12 months and Short-Form 36 and body image questionnaire results. RESULTS: There were 374 patients who were examined after a median follow-up period of 16 months (range, 10-24 mo). Seventy-five patients had developed IH (20%); 63 (84%) were symptomatic. Adjusted for age, sex, and Charlson Comorbidity Index score, patients with IH reported significantly lower mean scores for components physical functioning (P = .033), role physical (P = .002), and physical component summary (P = .010). A trend toward significance was found for general health (P = .061). Patients with IH reported significantly lower mean cosmetic scores (P = .002), and body image and total body image scores (both P < .001). CONCLUSIONS: Patients with IH reported lower mean scores on physical components of health-related quality of life and body image.

PMID: 22579232 [PubMed - as supplied by publisher]

Volume-Outcome Association in Bariatric Surgery: A Systematic Review.

Ann Surg. 2012 May 11;

Authors: Zevin B, Aggarwal R, Grantcharov TP

Abstract

OBJECTIVE:: To systematically examine the association between annual hospital and surgeon case volume and patient outcomes in bariatric surgery. BACKGROUND:: Bariatric surgery remains a technically demanding field with significant risk for morbidity and mortality. To mitigate this risk, minimum annual hospital and surgeon case volume requirements are being set and certain hospitals are being designated as “Bariatric Surgery Centers of Excellence.” The effects of these interventions on patient outcomes remain unclear. METHODS:: A comprehensive systematic review on volume-outcome association in bariatric surgery was conducted by searching MEDLINE, Cochrane Database of Systematic Reviews, and Evidence Based Medicine Reviews databases. Abstracts of identified articles were reviewed and pertinent full-text versions were retrieved. Manual search of bibliographies was performed and relevant studies were retrieved. Methodological quality assessment and data extraction were completed in a systematic fashion. Pooling of results was not feasible due to the heterogeneity of the studies. A qualitative summary of results is presented. RESULTS:: From a total of 2928 unique citations, 24 studies involving a total of 458,032 patients were selected for review. Two studies were prospective cohorts (level of evidence [LOE] 1), 3 were retrospective cohorts (LOE 3), 2 were retrospective case controls (LOE 3), and 17 were retrospective case series (LOE 4). The overall methodological quality of the reviewed studies was fair. A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies. CONCLUSIONS:: There is strong evidence of improved patient outcomes in the hands of high-volume surgeons and high-volume centers. This study supports the concept of “Bariatric Surgery Center of Excellence” accreditation; however, future research into the quality of care characteristics of successful bariatric programs is recommended. Understanding the characteristics of high-volume surgeons, which lead to improved patient outcomes, also requires further investigation.

PMID: 22584692 [PubMed - as supplied by publisher]

Durability of Roux-en-Y Gastric Bypass Surgery: A Meta-Regression Study.

Ann Surg. 2012 May 11;

Authors: Attiah MA, Halpern CH, Balmuri U, Vinai P, Mehta S, Baltuch GH, Williams NN, Wadden TA, Stein SC

Abstract

OBJECTIVE:: The present meta-regression pools data from reports of long-term follow-up (>2 years) to assess durability of the efficacy associated with Roux-en-Y gastric bypass (RYGB) surgery. DATA SOURCES:: Medline and PubMed searches for articles pertaining to long-term weight loss after RYGB surgery were performed. BACKGROUND:: Various studies have consistently shown short-term (<2 years) efficacy of RYGB surgery for morbid obesity, corroborated by meta-analytic techniques. Relatively few studies have assessed efficacy over longer periods of time. This is the first meta-analysis to analyze long-term effects of RYGB surgery on weight loss. METHODS:: Twenty-two reports with a total of 4206 patient cases were included. Sixteen of the 22 studies had multiple follow-up times, ranging from 2 to 12.3 years (mean: 3.6 years). An inverse variance weighted model and meta-regression were used to generate the pooled percent mean excess weight loss (EWL) and the durability of EWL over time, respectively. RESULTS:: Meta-regression did not reveal any significant change in EWL over time. Pooled mean EWL was 66.5%, and there was no significant association between EWL and length of follow-up. CONCLUSIONS:: Pooling data from multiple studies meta-analytically revealed that weight loss after RYGB is maintained over the long-term. Further investigation would be necessary to ascertain similar durability in comorbidity reduction after RYGB surgery.

PMID: 22584693 [PubMed - as supplied by publisher]

Wound Protectors Reduce Surgical Site Infection: A Meta-Analysis of Randomized Controlled Trials.

Ann Surg. 2012 May 11;

Authors: Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG

Abstract

OBJECTIVE:: A meta-analysis of randomized clinical trials (RCTs) was conducted to evaluate whether wound protectors reduce the risk of surgical site infection (SSI) after gastrointestinal and biliary tract surgery. BACKGROUND:: The effectiveness of impervious wound edge protectors for reduction of SSI remains unclear. METHODS:: A systematic review was conducted in Medline, EMBASE, and the Cochrane Library to identify RCTs that evaluate the risk of SSI after gastrointestinal and biliary surgeries with and without the use of an impervious wound protector. The pooled risk ratio was estimated with random-effect meta-analysis. Sensitivity analyses were performed to examine the impact of structural design of wound protector, publication year, study quality, inclusion of emergent surgeries, preoperative antibiotic administration, and bowel preparation on the pooled risk of SSI. RESULTS:: Of the 347 studies identified, 6 RCTs representing 1008 patients were included. The use of a wound protector was associated with a significant decrease in SSI (RR = 0.55, 95% CI 0.31-0.98, P = 0.04). There was a nonsignificant trend toward greater protective effect in studies using a dual ring protector (RR = 0.31, 95% CI 0.14-0.67, P = 0.003), rather than a single ring protector (RR = 0.83, 95% CI 0.38-1.83, P = 0.64). Publication year (P = 0.03) and blinding of outcome assessors (P = 0.04) significantly modified the effect of wound protectors on SSI. CONCLUSIONS:: Our results suggest that wound protectors reduce rates of SSI after gastrointestinal and biliary surgery.

PMID: 22584694 [PubMed - as supplied by publisher]

Anastomotic Leak Is Not Associated With Oncologic Outcome in Patients Undergoing Low Anterior Resection for Rectal Cancer.

Ann Surg. 2012 May 11;

Authors: Smith JD, Paty PB, Guillem JG, Temple LK, Weiser MR, Nash GM

Abstract

OBJECTIVE:: To examine the association between anastomotic leak and oncologic outcome after anterior resection, stratifying for defunctioning stoma. BACKGROUND:: It has been hypothesized that anastomotic leak predisposes rectal cancer patients to local recurrence. Many have a defunctioning stoma to reduce risk of clinically significant leakage. METHODS:: The records of patients undergoing low anterior resection (1991-2010) for rectal adenocarcinoma (≤15 cm from anal verge) were retrospectively analyzed using a prospectively collected colorectal database. Data (age, gender, stage, defunctioning stoma, neoadjuvant treatment, distance from anal verge, anastomotic leak) were collected. Clinical leakage was defined as anastomotic complication requiring intervention or interventional radiology within 60 days of surgery. Estimated local recurrence, overall survival, and disease-specific survival were compared using log-rank method and Cox regression analysis. RESULTS:: 1127 patients were included, with 5.6-year median follow-up. The incidence of clinical anastomotic leak was 3.5%. Sixteen of 677 with defunctioning stoma (2.2%) developed clinical leak; 24 of 450 without stoma (6.3%) developed leak (P = 0.005). There were no perioperative deaths among patients with clinical leakage. When stratified for defunctioning stoma, there was no association between clinical leak and local recurrence, disease-free survival, or overall survival. On multivariable analysis, when controlling for neoadjuvant therapy, distance of tumor from anal verge, defunctioning stoma, and pathologic stage, clinical leak was not associated with time to local recurrence, disease-free survival, or overall survival. CONCLUSIONS:: In this cohort, anastomotic leakage was not associated with risk of local recurrence. Defunctioning stoma was associated with lower incidence of clinical leakage but not with difference in oncologic outcome. Careful patient selection for defunctioning stoma helps reduce risk of clinically significant anastomotic leak.

PMID: 22584695 [PubMed - as supplied by publisher]

The Role of Surgeon Error in Withdrawal of Postoperative Life Support.

Ann Surg. 2012 May 11;

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

Abstract

BACKGROUND:: Surgeons may be reluctant to withdraw postoperative life support after a poor outcome. METHODS:: A cross-sectional random sample was taken from a US mail survey of 2100 surgeons who routinely perform high-risk operations. We used a hypothetical vignette of a specialty-specific operation complicated by a hemiplegic stroke and respiratory failure. On postoperative day 7, the patient and family requested withdrawal of life-supporting therapy. We experimentally modified the timing and role of surgeon error to assess their influence on surgeons’ willingness to withdraw life-supporting care. RESULTS:: The adjusted response rate was 56%. Sixty-three percent of respondents would not honor the request to withdraw life-supporting treatment. Willingness to withdraw life-support was significantly lower in the setting of surgeon error (33% vs 41%, P < 0.008) and elective operations rather than in emergency cases (33% vs 41%, P = 0.01). After adjustment for specialty, years of experience, geographic region, and gender, odds of withdrawing life-supporting therapy were significantly greater in cases in which the outcome was not explicitly from error during an emergency operation as compared to iatrogenic injury in elective cases (odds ratio 1.95, 95% confidence intervals 1.26-3.01). Surgeons who did not withdraw life-support were significantly more likely to report the importance of optimism regarding prognosis (79% vs 62%, P < 0.0001) and concern that the patient could not accurately predict future quality of life (80% vs 68%, P < 0.0001). CONCLUSIONS:: Surgeons are more reluctant to withdraw postoperative life-supporting therapy for patients with complications from surgeon error in the elective setting. This may also be influenced by personal optimism and a belief that patients are unable to predict the value of future health states.

PMID: 22584696 [PubMed - as supplied by publisher]

Perioperative Risk of Laparoscopic Fundoplication: Safer than Previously Reported-Analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2009.

J Am Coll Surg. 2012 May 9;

Authors: Niebisch S, Fleming FJ, Galey KM, Wilshire CL, Jones CE, Litle VR, Watson TJ, Peters JH

Abstract

BACKGROUND: Several prospective randomized controlled trials show equal effectiveness of surgical fundoplication and proton pump inhibitor therapy for the treatment of gastroesophageal reflux disease. Despite this compelling evidence of its efficacy, surgical antireflux therapy is underused, occurring in a very small proportion of patients with gastroesophageal reflux disease. An important reason for this is the perceived morbidity and mortality associated with surgical intervention. Published data report perioperative morbidity between 3% and 21% and mortality of 0.2% and 0.5%, and current data are uncommon, largely from previous decades, and almost exclusively single institutional. STUDY DESIGN: The study population included all patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 through 2009 who underwent laparoscopic fundoplication with or without related postoperative ICD-9 codes. Comorbidities, intraoperative occurrences, and 30-day postoperative outcomes were collected and logged into statistical software for appropriate analysis. Postoperative occurrences were divided into overall and serious morbidity. RESULTS: A total of 7,531 fundoplications were identified. Thirty-five percent of patients were younger than 50 years old, 47.1% were 50 to 69 years old, and 16.8% were older than 69 years old. Overall, 30-day mortality was 0.19% and morbidity was 3.8%. Thirty-day mortality was rare in patients younger than age 70 years, occurring in 5 of 10,000 (0.05%). Mortality increased to 8 of 1,000 (0.8%) in patients older than 70 years (p < 0.0001). Complications occurred in 2.2% of patients younger than 50 years, 3.8% of those 50 to 69 years, and 7.3% of patients older than 69 years. Serious complications occurred in 8 of 1,000 (0.8%) patients younger than 50 years, 1.8% in patients 50 to 69 years, and 3.9% of those older than 69 years. CONCLUSIONS: Analysis of this large cohort demonstrates remarkably low 30-day morbidity and mortality of laparoscopic fundoplication. This is particularly true in patients younger than 70 years, who are likely undergoing fundoplication for gastroesophageal reflux disease. These data suggest that surgical therapy carries an acceptable risk profile.

PMID: 22578304 [PubMed - as supplied by publisher]

A 79 year old man with a lesion on his cheek.

BMJ. 2012;344:e482

Authors: Reid AW, Shelley OP

PMID: 22315244 [PubMed - indexed for MEDLINE]

Diagnosis and management of primary hyperparathyroidism.

BMJ. 2012;344:e1013

Authors: Pallan S, Rahman MO, Khan AA

PMID: 22431655 [PubMed - indexed for MEDLINE]

Is it time for medicine-based evidence?

JAMA. 2012 Apr 18;307(15):1641-3

Authors: Concato J

PMID: 22511693 [PubMed - indexed for MEDLINE]

Peripheral neuropathy after hip replacement failure: is vanadium the culprit?

Lancet. 2012 Apr 28;379(9826):1676

Authors: Moretti B, Pesce V, Maccagnano G, Vicenti G, Lovreglio P, Soleo L, Apostoli P

PMID: 22541583 [PubMed - indexed for MEDLINE]

A systematic review of the anal fistula plug for patients with Crohn’s and non-Crohn’s related fistula-in-ano.

Dis Colon Rectum. 2012 Mar;55(3):351-8

Authors: O’Riordan JM, Datta I, Johnston C, Baxter NN

Abstract

BACKGROUND: The management of fistula-in-ano is a balance between fistula cure and preservation of continence.

OBJECTIVE: The aim of this study is to summarize the anal fistula plug literature for Crohn’s and non-Crohn’s fistula-in-ano in a homogenous patient population.

DATA SOURCES: PubMed, MEDLINE, Embase, and Cochrane medical databases were searched from 1995 to 2011. Abstracts from The American Society of Colon and Rectal Surgeons, The Society for Surgery of the Alimentary Tract, The European Society of Coloproctology, and the Association of Coloproctology of Great Britain and Ireland meetings between 2007 and 2010 were also evaluated.

STUDY SELECTION: Studies were included if results for patients with and without Crohn’s disease could be differentiated. Patients with rectovaginal, anovaginal, rectourethral, or ileal-pouch vaginal fistulas were excluded as were studies where the mean or median follow-up was less than 3 months. Two researchers independently selected studies matching the inclusion criteria.

INTERVENTION: Anal fistula plug insertion was performed.

MAIN OUTCOME MEASURES: The primary outcomes measured were the overall fistula closure rates and length of follow-up.

RESULTS: Seventy-six articles or abstracts were identified from the title as being of relevance. Twenty studies (2 abstracts, 18 articles) were finally included. Study sample size ranged from 4 to 60 patients; 530 patients were included in all studies (488 non-Crohn’s and 42 Crohn’s patients). The plug extrusion rate was 8.7% (46 patients). The proportion of patients achieving fistula closure varied widely between studies for non-Crohn’s, ranging from 0.2 (95% CI 0.04-0.48) to 0.86 (95% CI 0.64-0.97). The pooled proportion of patients achieving fistula closure in patients with non-Crohn’s fistula-in-ano was 0.54 (95% CI 0.50-0.59). The proportion achieving closure in patients with Crohn’s disease was similar (0.55, 95% CI 0.39-0.70).

LIMITATIONS: This study was limited by the variability of operative technique and perioperative care between studies.

CONCLUSIONS: Fistula closure is achieved by using the anal fistula plug in approximately 54% of patients without Crohn’s disease. The anal fistula plug has not been adequately evaluated in the Crohn’s population.

PMID: 22469804 [PubMed - indexed for MEDLINE]

Defining a Successful Esophagectomy.

Ann Surg. 2012 May 10;

Authors: Donohoe CL, Reynolds JV

PMID: 22580934 [PubMed - as supplied by publisher]

Prospective, Randomized Assessment of the Acquisition, Maintenance, and Loss of Laparoscopic Skills.

Ann Surg. 2012 May 10;

Authors: Gallagher AG, Jordan-Black JA, O’Sullivan GC

Abstract

BACKGROUND:: Laparoscopic skills are difficult to learn. We, therefore, assessed the factors involved in skill acquisition, maintenance, and loss in 2 prospective, randomized studies. METHODS:: In study 1, 24 laparoscopic novices were randomly assigned to a control condition who performed the laparoscopic assessment task; Massed condition who trained on virtual reality (VR) simulation during 1 day or Interval condition who had the same amount of VR training distributed over 3 consecutive days. All groups also completed a novel laparoscopic box-trainer task on 5 consecutive days. In study 2, 16 laparoscopic novices were randomly assigned to a Practice or a No-practice condition. All subjects were required to train on a VR simulation curriculum for the same duration and skill attainment level. The week after completion of training, subjects in the Practice condition were allowed 1 complete practice trial on the simulator. Both groups completed the same tasks 2 weeks after completion of the training. RESULTS:: In study 1, the Interval trained group showed the fastest rate of learning and on completion of training significantly outperformed both the Massed and Control groups (P < 0.0001). In study 2, both groups showed significant skills improvement from training trial T1 to T3 (P < 0.0001). The subjects in the Practice group maintained or improved their skills at 1 week but those in the No practice group showed significant decline of skills at 2 weeks after training completion (P < 0.0001). CONCLUSIONS:: Laparoscopic skills are optimally acquired on an Interval training schedule. They significantly decline with 2 weeks of nonuse.

PMID: 22580935 [PubMed - as supplied by publisher]

Cholangiocarcinoma or IgG4-Associated Cholangitis: How Feasible It Is to Avoid Unnecessary Surgical Interventions?

Ann Surg. 2012 May 10;

Authors: Lytras D, Kalaitzakis E, Webster GJ, Imber CJ, Amin Z, Rodriguez-Justo M, Pereira SP, Olde Damink SW, Malago’ M

Abstract

OBJECTIVE:: To evaluate the experience of a tertiary hepatopancreaticobiliary (HPB) center in the diagnostic approach and management of patients with suspicion of cholangiocarcinoma (CCa), focusing on excluding patients with IgG4-associated cholangitis (IAC) from unnecessary major surgical interventions. METHODS:: Between January 2008 and September 2010, a total number of 152 patients with suspicion of CCa underwent evaluation through a HPB multidisciplinary team meeting. Patients without tissue diagnosis were managed surgically or medically on the basis of probable presence of IAC as underlying pathology. Serology, immunostaining, and imaging were reviewed and analyzed according to the HISORt (Histology, Imaging, Serology, Other organ involvement, Response to therapy) criteria for IAC. RESULTS:: Tissue diagnosis during the diagnostic workup was achieved in 104 patients (68%), whereas the remaining 48 were classified as “highly suspicious for CCa” (n = 35) or as “probable IAC” (n = 13). Among 16 “highly suspicious for CCa” patients who underwent surgery, pathology revealed 2 patients harboring IAC (n = 1) and a benign chronic inflammatory biliary stricture (n = 1), respectively. Among the 13 patients with primarily medical management as “probable IAC,” final diagnosis was CCa (n = 3) and IAC (n = 9), while 1 patient had no proven diagnosis. The accuracy of serum IgG4 for diagnosis of IAC reached 60%. Sensitivity and specificity of immunostaining for IAC in biopsy specimens were 56% and 89%, respectively. Imaging features suggesting IAC yielded sensitivity, specificity, and accuracy of 75%, 89%, and 83%, respectively. Initial imaging was revised at the referral institute in 75% of IAC patients (P = 0.009), while an isolated stricture (P = 0.038), a biliary mass (P = 0.006), and normal pancreas on computed tomography (P = 0.01) were statistically significant parameters for distinguishing between CCa and IAC. The mean time for establishing a diagnosis of IAC was 12.4 months (range: 2.5-32 months) CONCLUSIONS:: Differential diagnosis between CCa and IAC mandates high index of suspicion and low threshold for referral in high volume institutes. The delayed establishment of diagnosis particularly for CCa needs to be balanced versus avoiding unnecessary surgery for IAC. Imaging features may be most helpful for optimal management.

PMID: 22580936 [PubMed - as supplied by publisher]

Partial Pancreaticoduodenectomy Can Provide Cure for Duodenal Gastrinoma Associated With Multiple Endocrine Neoplasia Type 1.

Ann Surg. 2012 May 10;

Authors: Lopez CL, Falconi M, Waldmann J, Boninsegna L, Fendrich V, Goretzki PK, Langer P, Kann PH, Partelli S, Bartsch DK

Abstract

OBJECTIVE:: To evaluate the outcome of pancreaticoduodenectomy (PD) versus non-PD resections for the treatment of gastrinoma in multiple endocrine neoplasia type 1. BACKGROUND:: Gastrinoma in MEN1 is considered a rarely curable disease and its management is highly controversial both for timing and extent of surgery. METHODS:: Clinical characteristics, complications and outcomes of 27 prospectively collected MEN1 patients with biochemically proven gastrinoma, who underwent surgery, were analyzed with special regard to the gastrinoma type and the initial operative procedure. RESULTS:: Twenty-two (81%) patients with gastrinoma in MEN1 had duodenal gastrinomas and 5 patients (19%) had pancreatic gastrinomas. At the time of diagnosis, 21 (77%) gastrinomas were malignant (18 duodenal, 3 pancreatic), but distant metastases were only present in 4 (15%) patients. Patients with pancreatic gastrinomas underwent either distal pancreatic resections or gastrinoma enucleation with lymphadenectomy, 2 patients also had synchronous resections of liver metastases. One of these patients was biochemically cured after a median of 136 (77-312) months. Thirteen patients with duodenal gastrinomas underwent PD resections (group 1, partial PD [n = 11], total PD [n = 2]), whereas 9 patients had no-PD resections (group 2) as initial operative procedure. Perioperative morbidity and mortality, including postoperative diabetes, differed not significantly between groups (P > 0.5). All patients of group 1 and 5 of 9 (55%) patients of group 2 had a negative secretin test at hospital discharge. However, after a median follow-up of 136 (3-276) months, 12 (92%) patients of group 1 were still normogastrinemic compared to only 3 of 9 (33%) patients of group 2 (P = 0.023). Three (33%) patients of group 2 had to undergo up to 3 reoperations for recurrent or metastatic disease compared to none of group 1. CONCLUSIONS:: Duodenal gastrinoma in MEN1 should be considered a surgically curable disease. PD seems to be the adequate approach to this disease, providing a high cure rate and acceptable morbidity compared to non-PD resections.

PMID: 22580937 [PubMed - as supplied by publisher]

Human Equilibrative Nucleoside Transporter 1 Expression Predicts Survival of Advanced Cholangiocarcinoma Patients Treated With Gemcitabine-Based Adjuvant Chemotherapy After Surgical Resection.

Ann Surg. 2012 May 10;

Authors: Kobayashi H, Murakami Y, Uemura K, Sudo T, Hashimoto Y, Kondo N, Sueda T

Abstract

OBJECTIVE:: The aim of this study was to evaluate whether intratumoral human equilibrative nucleoside transporter 1 (hENT1) expression can predict the survival of advanced cholangiocarcinoma patients treated with adjuvant gemcitabine-based chemotherapy (AGC) after surgical resection. BACKGROUND:: There have been no reports concerning a useful predictive biomarker in patients with cholangiocarcinoma treated with adjuvant gemcitabine chemotherapy. METHODS:: Intratumoral hENT1 expression was investigated immunohistochemically in 105 patients with resected advanced cholangiocarcinoma. Relationships between intratumoral hENT1 expression and clinicopathological factors were evaluated by univariate and multivariate analyses. This study was a retrospective analysis on retrospectively collected tissue and data. RESULTS:: Fifty-one patients received AGC, and 54 did not. High and low intratumoral hENT1 expression was found in 74 (70%) and 31 patients (30%), respectively. There were no significant differences in clinicopathological factors between patients with high hENT1 expression and those with low hENT1 expression. Survival patients with high hENT1 expression were significantly better than those with low hENT1 expression among patients who received AGC (P = 0.008), but not among patients who did not (P = 0.894). Moreover, a significant difference in survival between patients who received AGC and those who did not was observed among patients with high hENT1 expression (P = 0.002), but not among patients with low hENT1 expression (P = 0.525). Intratumoral hENT1 expression was only an independent predictive factor for patients treated with AGC by multivariate analysis (P = 0.027). CONCLUSIONS:: Intratumoral hENT1 expression may be a potent predictive marker for advanced cholangiocarcinoma patients treated with AGC.

PMID: 22580938 [PubMed - as supplied by publisher]

Propranolol Induces Regression of Hemangioma Cells Through HIF-1α-Mediated Inhibition of VEGF-A.

Ann Surg. 2012 May 10;

Authors: Chim H, Armijo BS, Miller E, Gliniak C, Serret MA, Gosain AK

Abstract

OBJECTIVE:: To investigate the mechanism of propranolol on regression of infantile hemangiomas. BACKGROUND:: Propranolol has been found to be effective in treatment of severe hemangiomas of infancy. However, its mechanism of action is as yet unknown. METHODS:: Cultured proliferating and involuting hemangioma endothelial cells were treated with varying concentrations of propranolol for up to 4 days. Analysis was performed using cell viability, migration, and tubulogenesis assays, as well as quantitative RT-PCR and flow cytometry. Western blots and ELISA assays were used to assess protein expression. RESULTS:: Treatment with propranolol led to a dose dependent cytotoxic effect in hemangioma endothelial cells with decreased cell viability, migration, and tubulogenesis. This cytotoxic effect was VEGF (vascular endothelial growth factor) dependent, as demonstrated by decreased VEGF, VEGF-R1, and VEGF-R2 production. Decreased signaling through the VEGF pathway resulted in downregulation of PI3/Akt and p38/MAPK activity. Decreased VEGF activity was mediated through the hypoxia inducible factor (HIF)-1α pathway but not through NF-κβ signaling. CONCLUSIONS:: Collectively, these data suggest that propranolol exerts its suppressive effects on hemangiomas through the HIF-1α-VEGF-A angiogenesis axis, with effects mediated through the PI3/Akt and p38/MAPK pathways. These findings provide a plausible mechanism of action of propranolol on regression of infantile hemangiomas.

PMID: 22580939 [PubMed - as supplied by publisher]

Patient Selection for Cytoreductive Surgery in Colorectal Peritoneal Carcinomatosis Using Serum Tumor Markers: An Observational Cohort Study.

Ann Surg. 2012 May 10;

Authors: Cashin PH, Graf W, Nygren P, Mahteme H

Abstract

OBJECTIVE:: There were 2 objectives: first, to investigate how many patients were excluded from surgery on the basis of the radiological extent of the peritoneal carcinomatosis (PC) or the clinical examination; and second, to develop a score based primarily on serum tumor markers (STMs) that could predict short cancer-specific survival (<12 months). BACKGROUND:: Patient selection and prediction of prognosis is crucial for successful treatment of colorectal PC. METHODS:: All patients with colorectal PC referred for cytoreductive surgery and intraperitoneal chemotherapy (2005-2008) at Uppsala University hospital were included. Patients were divided into 2 groups-nonsurgery and surgery. Clinicopathological and laboratory parameters were collected in the surgery group. A Corep (COloREctal-Pc) score was developed using hazard ratios from histology, hematological status, serial serum tumor markers (STMs), and STM changes over time. Sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) were calculated in a second validating dataset (n = 24) with a survival cutoff of less than 12 months. RESULTS:: A total of 107 patients were included in the study, 42 in the nonsurgery group and 65 in the surgery group. In the nonsurgery group, 2 patients were excluded solely on the basis of the radiological extent of PC and 7 patients on clinical examination. The Corep score ranged from 0 to 18. A score of 6 or more showed a validated sensitivity of 80%, specificity 100%, PPV 1.0, and NPV 0.93. CONCLUSIONS:: Radiological extent of PC was not a main deciding factor for treatment decisions and had less impact than the clinical examination. The Corep score identified patients with short cancer-specific survival that may not be suitable for treatment.

PMID: 22580940 [PubMed - as supplied by publisher]

Reoperation Versus Clinical Recurrence Rate After Ventral Hernia Repair.

Ann Surg. 2012 May 10;

Authors: Helgstrand F, Rosenberg J, Kehlet H, Strandfelt P, Bisgaard T

Abstract

OBJECTIVE:: To compare the clinical recurrence rate with reoperation rate for recurrence after ventral hernia repair. BACKGROUND:: Reoperation is often used as an outcome measure after ventral hernia repair, but it is unknown whether reoperation rate reflects the overall clinical risk for recurrence. METHODS:: The study cohort was recruited from the Danish Ventral Hernia Database and the Danish National Patient Registry during January 1, 2007, to December 31, 2007. Inclusion criteria were primary umbilical/epigastric (umb/epi) or incisional hernia repair from a regional area of 2 million inhabitants. A prospective clinical follow-up was conducted in January 2011 using a validated questionnaire on reoperation and possible recurrence. Suspicion of recurrence was the criterion for clinical examination. A telephone interview and/or patients’ hospital files confirmed reoperation. RESULTS:: A total of 945 patients were eligible, and 902 patients responded to the questionnaire (response rate 95%) with a median postoperative follow-up of 41 months (range 0-48 months). The analysis comprised 646 patients with umb/epi and 256 patients with incisional hernia repair. Clinical examination was required in 241 patients. After umb/epi and incisional hernia repair, the cumulative risks of reoperation and overall recurrence (reoperation + clinical) were 4% and 15% (fourfold underestimation), and 8% and 37% (fivefold underestimation) (P < 0.001), respectively. CONCLUSIONS:: Reoperation rate for recurrence 41 months after primary umbilical/epigastric or incisional hernia repair underestimated overall risk of recurrence by four- to fivefolds. This study was registered in www.clinicaltrials.gov (NCT01325246).

PMID: 22580941 [PubMed - as supplied by publisher]

Progression Following Neoadjuvant Systemic Chemotherapy May Not Be a Contraindication to a Curative Approach for Colorectal Carcinomatosis.

Ann Surg. 2012 May 10;

Authors: Guillaume P, Delphine V, Eddy C, Benoit Y, Sylvie I, Noël GF, Faheez M, Olivier G

Abstract

OBJECTIVE:: The objective of this retrospective study was to evaluate the influence of neoadjuvant systemic chemotherapy on patients with colorectal carcinomatosis before a curative procedure. BACKGROUND:: Peritoneal carcinomatosis (PC) from colorectal cancer may be treated with a curative intent by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The role of perioperative systemic chemotherapy for this particular metastatic disease remains unclear. METHODS:: One hundred twenty patients with PC from colorectal cancer were consecutively treated by 131 procedures combining CRS with HIPEC. The response to neoadjuvant systemic chemotherapy was assessed on data from previous explorative surgery and/or radiological imaging. RESULTS:: Ninety patients (75%) were treated with neoadjuvant systemic chemotherapy in whom 32 (36%) were considered to have responded, 19 (21%) had stable disease, and 19 (21%) developed diseases progression. Response could not be evaluated in 20 patients (22%). On univariate analysis, the use of neoadjuvant systemic chemotherapy had a significant positive prognostic influence (P = 0.042). On multivariate analysis, the completeness of CRS and the use of adjuvant systemic chemotherapy were the only significant prognostic factors (P < 0.001 and P = 0.049, respectively). Response to neoadjuvant systemic chemotherapy had no significant prognostic impact with median survival of 31.4 months in patients showing disease progression. CONCLUSIONS:: In patients with PC from colorectal cancer without extraperitoneal metastases, failure of neoadjuvant systemic chemotherapy should not constitute an absolute contraindication to a curative procedure combining CRS and HIPEC.

PMID: 22580942 [PubMed - as supplied by publisher]

Factors Predictive of 30-Day Postoperative Mortality in HIV/AIDS Patients in the Era of Highly Active Antiretroviral Therapy.

Ann Surg. 2012 May 10;

Authors: Wiseman SM, Forrest JI, Chan JE, Zhang W, Yip B, Hogg RS, Lima VD, Montaner JS

Abstract

BACKGROUND:: Factors that predict HIV (human immunodeficiency virus)/AIDS patient postoperative mortality have remained poorly defined. OBJECTIVES:: The primary objective of this study was to identify factors predictive of short-term, postoperative mortality in HIV/AIDS patients. The secondary objective of this study was to develop a scoring system that would predict short-term postoperative mortality in HIV/AIDS patients. METHODS:: We retrospectively reviewed all HIV/AIDS patients who underwent surgical procedures in British Columbia, Canada, between April 1995 and March 2002. The primary outcome evaluated was 30-day postoperative mortality. Demographic, clinical, and hospitalization-related data were obtained and utilized to predict outcomes using a logistic regression model. RESULTS:: A total of 2305 procedures were carried out on 1322 patients during the study period. Admissions were classified as urgent/emergent for 1311 procedures (57%) and the overall 30-day postoperative mortality was 9.5% (126 deaths). Urgent/emergent admission, older age, prior surgery, a CD4 cell count of ≤ 50 cells/mm, a hemoglobin level ≤ 120 g/L, and a white blood cell count >11 g/L within 90 days before the surgical procedure was predictive of an increased 30-day postoperative mortality in a multivariate model. Using these variables, we formulated the HIV Surgical Mortality Score (HSMS) to obtain the median-estimated probability of postoperative death. CONCLUSIONS:: For accurate preoperative mortality risk stratification for HIV/AIDS patients, we have found that several clinical and laboratory variables must be evaluated. If appropriately validated, our proposed HSMS could be utilized to estimate the probability of short-term postoperative death among HIV/AIDS patients.

PMID: 22580943 [PubMed - as supplied by publisher]

A Randomized, Controlled, Double-Blind Crossover Study on the Effects of 2-L Infusions of 0.9% Saline and Plasma-Lyte 148 on Renal Blood Flow Velocity and Renal Cortical Tissue Perfusion in Healthy Volunteers.

Ann Surg. 2012 May 10;

Authors: Chowdhury AH, Cox EF, Francis ST, Lobo DN

Abstract

OBJECTIVE:: We compared the effects of intravenous infusions of 0.9% saline ([Cl] 154 mmol/L) and Plasma-Lyte 148 ([Cl] 98 mmol/L, Baxter Healthcare) on renal blood flow velocity and perfusion in humans using magnetic resonance imaging (MRI). BACKGROUND:: Animal experiments suggest that hyperchloremia resulting from 0.9% saline infusion may affect renal hemodynamics adversely, a phenomenon not studied in humans. METHODS:: Twelve healthy adult male subjects received 2-L intravenous infusions over 1 hour of 0.9% saline or Plasma-Lyte 148 in a randomized, double-blind manner. Crossover studies were performed 7 to 10 days apart. MRI scanning proceeded for 90 minutes after commencement of infusion to measure renal artery blood flow velocity and renal cortical perfusion. Blood was sampled and weight recorded hourly for 4 hours. RESULTS:: Sustained hyperchloremia was seen with saline but not with Plasma-Lyte 148 (P < 0.0001), and fall in strong ion difference was greater with the former (P = 0.025). Blood volume changes were identical (P = 0.867), but there was greater expansion of the extravascular fluid volume after saline (P = 0.029). There was a significant reduction in mean renal artery flow velocity (P = 0.045) and renal cortical tissue perfusion (P = 0.008) from baseline after saline, but not after Plasma-Lyte 148. There was no difference in concentrations of urinary neutrophil gelatinase-associated lipocalin after the 2 infusions (P = 0.917). CONCLUSIONS:: This is the first human study to demonstrate that intravenous infusion of 0.9% saline results in reductions in renal blood flow velocity and renal cortical tissue perfusion. This has implications for intravenous fluid therapy in perioperative and critically ill patients. NCT01087853.

PMID: 22580944 [PubMed - as supplied by publisher]

Trauma Center Quality Improvement Programs in the United States, Canada, and Australasia.

Ann Surg. 2012 May 10;

Authors: Stelfox HT, Straus SE, Nathens A, Gruen RL, Hameed SM, Kirkpatrick A

Abstract

OBJECTIVE:: To compare quality improvement (QI) programs of trauma centers in 4 high-income countries. BACKGROUND:: Injury is a leading cause of morbidity and mortality in countries around the world, but patient outcomes vary among countries with similar systems of trauma care. METHODS:: We surveyed medical directors and program managers from 330 trauma centers verified by professional trauma organizations in the United States (n = 263), Canada (n = 46), and Australasia (Australia, n = 18; New Zealand, n = 3) regarding their QI programs. Quality indicators were requested from all centers that measured quality of care. Follow-up interviews were performed with 75 centers purposively sampled across 6 baseline criteria. RESULTS:: A total of 251 centers (76% response rate) responded to the survey, with a similar distribution across countries. Trauma centers in the United States were more likely than those in Canada and Australasia to report measuring quality indicators (100% vs 94% vs 93%, P = 0.008), using report cards (53% vs 33% vs 31%, P = 0.033) and benchmarking (81% vs 61% vs 69%, P = 0.019). Centers in all 3 regions primarily used hospital process and outcome measures designed to establish whether care was safe (98% vs 97% vs 75%, P = 0.008), effective (97% vs 97% vs 92% P = 0.399), timely (88% vs 100% vs 92%, P = 0.055), and efficient (95% vs 100% vs 83%, P = 0.082). QI programs were largely local in nature, used different criteria to identify patients under QI purview, and employed diverse quality indicators and improvement strategies. Few centers evaluated the effectiveness of their QI program. CONCLUSIONS:: This study provides the first international comparison of trauma center QI programs and demonstrates broad implementation in verified trauma centers in the United States, Canada, and Australasia. Significant variation exists in how trauma centers perform QI activities. Opportunities exist for improving and standardizing QI processes.

PMID: 22580945 [PubMed - as supplied by publisher]

Identification of a Subgroup of Patients at Highest Risk for Complications After Surgical Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

Ann Surg. 2012 May 10;

Authors: Baratti D, Kusamura S, Mingrone E, Balestra MR, Laterza B, Deraco M

Abstract

OBJECTIVE:: To assess the influence of parietal and visceral peritonectomy procedures on moderate/severe morbidity in patients undergoing surgical cytoreducion and hyperthermic intraperitoneal chemotherapy (HIPEC) and to identify subgroups of patients at highest operative risk. BACKGROUND:: Cytoreducion with HIPEC is an effective but potentially morbid treatment option for peritoneal surface malignancies. Although complication rates have recently decreased with increasing experience, risk-factors for adverse operative outcome are still poorly understood. METHODS:: A prospective database of 426 combined procedures was reviewed. Multivariate analysis tested the correlation between major morbidity and 6 peritonectomies (greater and lesser omentectomy, pelvic, parietal anterior, left and right diaphragmatic peritonectomy), 14 visceral resections, 5 other operative factors, and 12 clinical variables. The extent of peritoneal involvement was quantified by peritoneal cancer index (PCI). RESULTS:: Mortality and major morbidity were 2.6% and 28.2%. PCI, number of visceral resections, poor performance status, and cisplatin dose more than 240 mg independently correlated to morbidity. The type and number of parietal peritonectomies and the type of visceral resections did not correlated to complications. Major morbidity rate was 65.7% in 35 (8.2%) patients with at least 2 of the following factors: PCI greater than 30, more than 5 visceral resections, poor performance status. Morbidity was 100% in 9 patients presenting all the risk factors. CONCLUSIONS:: Acceptable morbidity and low mortality may be achieved in high-volume centers. Operative outcome is mainly affected by a complex interplay of tumor, patient, and treatment-related factors. Preoperative and early intraoperative assessment of operative risk may identify a subset of patients unlikely to tolerate aggressive management.

PMID: 22580946 [PubMed - as supplied by publisher]

Frey Procedure in Patients with Chronic Pancreatitis: Short and Long-term Outcome from a Prospective Study.

J Gastrointest Surg. 2012 May 12;

Authors: Roch AM, Brachet D, Lermite E, Pessaux P, Arnaud JP

Abstract

BACKGROUND: The aim of this prospective study was to determine the short- and long-term results of the Frey procedure in the treatment of chronic pancreatitis. METHODS: From September 2000 to November 2009, 44 consecutive patients underwent the Frey procedure. Patients were included in the study before surgery and followed prospectively with assessment of pain relief, weight gain and exocrine/endocrine insufficiency. Twenty-one patients (47.7 %) were followed for more than 5 years. RESULTS: This study included 40 men (91 %) and four women (9 %) (mean age: 49 years) with a mean follow-up of 51.5 months. The primary etiology of chronic pancreatitis was chronic alcohol abuse in 38 patients (86.4 %). The major indication for surgery was disabling pain (95.5 %). There was no postoperative mortality. Postoperative morbidity occurred in 15 patients (34.1 %), with specific surgical complications in 11 patients (25 %). The percentage of pain-free patients after surgery was 68.3 %. Eight patients (18.1 %) and seven patients (16 %) developed diabetes de novo and exocrine insufficiency, respectively. The Body Mass Index showed statistically significant improvement during follow-up. Similar beneficial results concerning pain relief and weight gain persisted after the initial 5-year follow-up. CONCLUSIONS: The Frey procedure is an appropriate, safe and effective technique for management of patients with chronic pancreatitis in the absence of neoplasia, based on long-term follow-up.

PMID: 22580839 [PubMed - as supplied by publisher]

Antimesenteric Functional End-to-End Handsewn (Kono-S) Anastomosis.

J Gastrointest Surg. 2012 May 12;

Authors: Fichera A, Zoccali M, Kono T

Abstract

INTRODUCTION: Anastomotic recurrence is a frequent event after bowel resection for Crohn’s disease. To date, no anastomotic technique has been proven to be superior in reducing surgical recurrence rates in this setting. In this article, we describe our technique in performing a new antimesenteric functional end-to-end handsewn (Kono-S) anastomosis. METHODS: The segment of bowel to be resected is identified and mobilized. The bowel is then divided transversely with a linear stapler-cutter device. The intervening mesentery is divided close to the bowel. The corners of the two stapled lines are sutured together, and the two stapled lines are approximated with interrupted sutures. An antimesenteric longitudinal enterotomy is performed on both sides, starting no more than 1 cm away from the staple line, to allow a transverse lumen of 7-8 cm. The openings are closed transversely in two layers. RESULTS: From May 1, 2010 to July 31, 2011 we performed 46 Kono-S anastomoses. One patient had a contained anastomotic leak successfully treated conservatively. Currently, 18 patients (43 %) have undergone follow-up endoscopic surveillance with an average Rutgeert’s score of 0.7 (0-3) at a mean of 6.8 months. CONCLUSION: The Kono-S anastomosis is a safe anastomotic technique. Long-term studies are needed to confirm its efficacy in preventing surgical recurrence.

PMID: 22580840 [PubMed - as supplied by publisher]

Single-Incision Laparoscopic Cholecystectomy vs. Conventional Laparoscopic Cholecystectomy: a Meta-analysis of Randomized Controlled Trials.

J Gastrointest Surg. 2012 May 12;

Authors: Garg P, Thakur JD, Garg M, Menon GR

Abstract

INTRODUCTION: We analyzed different morbidity parameters between single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC). METHODS: Pubmed, Ovid, Embase, SCI database, Cochrane, and Google Scholar were searched. The primary endpoints analyzed were cosmetic result and the postoperative pain (at 6 and 24 h) and the secondary endpoints were operating time, hospital stay, incidence of overall postoperative complications, wound-related complications, and port-site hernia. RESULTS: Six hundred fifty-nine patients (SILC-349, CLC-310) were analyzed from nine randomized controlled trials. The objective postoperative pain scores at 6 and 24 h and the hospital stay were similar in both groups. The total postoperative complications, wound-related problems, and port-site hernia formation, though higher in SILC, were also comparable in both groups. SILC had significantly favorable cosmetic scoring compared to CLC [weighted mean difference = 1.0, p = 0.0001]. The operating time was significantly longer in SILC [weighted mean difference = 15.63, p = 0.0001]. CONCLUSIONS: Single-incision laparoscopic cholecystectomy does not confer any benefit in postoperative pain (6 and 24 h) and hospital stay as compared to conventional laparoscopic cholecystectomy while having significantly better cosmetic results at the same time. Postoperative complications, though higher in SILC, were statistically similar in both the groups.

PMID: 22580841 [PubMed - as supplied by publisher]

Topically Applied 2-Octyl Cyanoacrylate (Dermabond) for Prevention of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy.

J Gastrointest Surg. 2012 May 12;

Authors: Barakat O, Ozaki CF, Wood RP

Abstract

OBJECTIVE: We examined whether 2-octyl cyanoacrylate (Dermabond) topically applied to the pancreaticojejunostomy (PJ) anastomotic site after pancreaticoduodenectomy (PD) reduces the rate of postoperative pancreatic fistula (POPF). METHODS: Patients who underwent PD with duct-to-mucosa PJ were evaluated (n = 124). Outcome was compared between patients who received Dermabond (n = 75) after PD and historic patients who did not (n = 49). Risk factors for POPF were identified. RESULTS: Overall and clinically relevant rates of POPF were significantly lower in patients who received Dermabond than in patients who did not (2.6 % and 1.3 % vs. 22 % and 12 %, respectively; p = 0.001). In univariate analysis, pancreatic duct diameter ≤3 mm, low serum albumin level, and no Dermabond were independent risk factors for POPF; in multivariate analysis, no Dermabond was an independent risk factor for POPF. In patients with pancreatic duct diameter ≤3 mm, the rate of POPF was significantly lower in patients who received Dermabond than in patients who did not (3.5 % versus 36 %, respectively; p = 0.0001). Patients who received Dermabond had significantly shorter hospital stays and lower re-operation and re-admission rates. CONCLUSIONS: Topical application of Dermabond to the PJ anastomotic site after PD significantly reduced the rate of POPF, particularly in patients at risk.

PMID: 22580842 [PubMed - as supplied by publisher]

“Venous Cut-off Sign” as an Adjunct to the “Whirl Sign” in Recognizing Acute Small Bowel Volvulus via CT Scan.

J Gastrointest Surg. 2012 May 12;

Authors: Ho YC

Abstract

INTRODUCTION: A young adult patient was admitted for signs and symptoms of acute abdomen. MATERIALS AND METHODS: Urgent CT scan was performed and small bowel volvulus was confirmed. The “whirl sign” diagnostic of small bowel volvulus was present. RESULTS: Furthermore, the accompanying superior mesenteric vein was noted to be truncated at the point of torsion. CONCLUSION: The “venous cut-off sign” can be a useful adjunct sign to the diagnosis.

PMID: 22580843 [PubMed - as supplied by publisher]

Corneal trauma in a 6-year-old boy.

JAMA. 2012 May 9;307(18):1970-1

Authors: Tsui E, Salcone EM

PMID: 22570465 [PubMed - indexed for MEDLINE]

How to Train Surgical Residents to Perform Laparoscopic Roux-en-Y Gastric Bypass Safely.

World J Surg. 2012 May 11;

Authors: Iordens GI, Klaassen RA, van Lieshout EM, Cleffken BI, van der Harst E

Abstract

BACKGROUND: As a result of increasing numbers of patients with morbid obesity there is a worldwide demand for bariatric surgeons. The Roux-en-Y gastric bypass, nowadays performed mostly laparoscopically (LRYGB), has been proven to be a highly effective surgical treatment for morbid obesity. This procedure is technically demanding and requires a long learning curve. Little is known about implementing these demanding techniques in the training of the surgical resident. The aim of this study was to evaluate the safety and feasibility of the introduction of LRYGB into the training of surgical residents. METHODS: All patients who underwent LRYGB between March 2006 and July 2010 were retrospectively analyzed. The procedure was performed by a surgical resident under strict supervision of a bariatric surgeon (group I) or by a bariatric surgeon (group II). The primary end point was the occurrence of complications. Secondary end points included operative time, days of hospitalization, rate of readmission, and reappearance in the emergency department (ED) within 30 days. RESULTS: A total of 409 patients were found eligible for inclusion in the study: 83 patients in group I and 326 in group II. There was a significant difference in operating time (129 min in group I vs. 116 min in group II; p < 0.001) and days of hospitalization. Postoperative complication rate, reappearance in the ED, and rate of readmission did not differ between the two groups. CONCLUSIONS: Our data suggest that under stringent supervision and with sufficient laparoscopic practice, implementation of LRYGB as part of surgical training is safe and results in only a slightly longer operating time. Complication rates, days of hospitalization, and the rates of readmission and reappearance in the ED within 30 days were similar between the both groups. These results should be interpreted by remembering that all procedures in group I were performed in a training environment so occasional intervention by a bariatric surgeon, when necessary, was inevitable.

PMID: 22576184 [PubMed - as supplied by publisher]

Transcatheter aortic-valve replacement for inoperable severe aortic stenosis.

N Engl J Med. 2012 May 3;366(18):1696-704

Authors: Makkar RR, Fontana GP, Jilaihawi H, Kapadia S, Pichard AD, Douglas PS, Thourani VH, Babaliaros VC, Webb JG, Herrmann HC, Bavaria JE, Kodali S, Brown DL, Bowers B, Dewey TM, Svensson LG, Tuzcu M, Moses JW, Williams MR, Siegel RJ, Akin JJ, Anderson WN, Pocock S, Smith CR, Leon MB,

Abstract

BACKGROUND: Transcatheter aortic-valve replacement (TAVR) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The outcomes beyond 1 year in such patients are not known.

METHODS: We randomly assigned patients to transfemoral TAVR or to standard therapy (which often included balloon aortic valvuloplasty). Data on 2-year outcomes were analyzed.

RESULTS: A total of 358 patients underwent randomization at 21 centers. The rates of death at 2 years were 43.3% in the TAVR group and 68.0% in the standard-therapy group (P<0.001), and the corresponding rates of cardiac death were 31.0% and 62.4% (P<0.001). The survival advantage associated with TAVR that was seen at 1 year remained significant among patients who survived beyond the first year (hazard ratio, 0.58; 95% confidence interval [CI], 0.36 to 0.92; P=0.02 with the use of the log-rank test). The rate of stroke was higher after TAVR than with standard therapy (13.8% vs. 5.5%, P=0.01), owing, in the first 30 days, to the occurrence of more ischemic events in the TAVR group (6.7% vs. 1.7%, P=0.02) and, beyond 30 days, to the occurrence of more hemorrhagic strokes in the TAVR group (2.2% vs. 0.6%, P=0.16). At 2 years, the rate of rehospitalization was 35.0% in the TAVR group and 72.5% in the standard-therapy group (P<0.001). TAVR, as compared with standard therapy, was also associated with improved functional status (P<0.001). The data suggest that the mortality benefit after TAVR may be limited to patients who do not have extensive coexisting conditions. Echocardiographic analysis showed a sustained increase in aortic-valve area and a decrease in aortic-valve gradient, with no worsening of paravalvular aortic regurgitation.

CONCLUSIONS: Among appropriately selected patients with severe aortic stenosis who were not suitable candidates for surgery, TAVR reduced the rates of death and hospitalization, with a decrease in symptoms and an improvement in valve hemodynamics that were sustained at 2 years of follow-up. The presence of extensive coexisting conditions may attenuate the survival benefit of TAVR. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.).

PMID: 22443478 [PubMed - indexed for MEDLINE]

Two-year outcomes after transcatheter or surgical aortic-valve replacement.

N Engl J Med. 2012 May 3;366(18):1686-95

Authors: Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, Fontana GP, Dewey TM, Thourani VH, Pichard AD, Fischbein M, Szeto WY, Lim S, Greason KL, Teirstein PS, Malaisrie SC, Douglas PS, Hahn RT, Whisenant B, Zajarias A, Wang D, Akin JJ, Anderson WN, Leon MB,

Abstract

BACKGROUND: The Placement of Aortic Transcatheter Valves (PARTNER) trial showed that among high-risk patients with aortic stenosis, the 1-year survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical replacement. However, longer-term follow-up is necessary to determine whether TAVR has prolonged benefits.

METHODS: At 25 centers, we randomly assigned 699 high-risk patients with severe aortic stenosis to undergo either surgical aortic-valve replacement or TAVR. All patients were followed for at least 2 years, with assessment of clinical outcomes and echocardiographic evaluation.

RESULTS: The rates of death from any cause were similar in the TAVR and surgery groups (hazard ratio with TAVR, 0.90; 95% confidence interval [CI], 0.71 to 1.15; P=0.41) and at 2 years (Kaplan-Meier analysis) were 33.9% in the TAVR group and 35.0% in the surgery group (P=0.78). The frequency of all strokes during follow-up did not differ significantly between the two groups (hazard ratio, 1.22; 95% CI, 0.67 to 2.23; P=0.52). At 30 days, strokes were more frequent with TAVR than with surgical replacement (4.6% vs. 2.4%, P=0.12); subsequently, there were 8 additional strokes in the TAVR group and 12 in the surgery group. Improvement in valve areas was similar with TAVR and surgical replacement and was maintained for 2 years. Paravalvular regurgitation was more frequent after TAVR (P<0.001), and even mild paravalvular regurgitation was associated with increased late mortality (P<0.001).

CONCLUSIONS: A 2-year follow-up of patients in the PARTNER trial supports TAVR as an alternative to surgery in high-risk patients. The two treatments were similar with respect to mortality, reduction in symptoms, and improved valve hemodynamics, but paravalvular regurgitation was more frequent after TAVR and was associated with increased late mortality. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.).

PMID: 22443479 [PubMed - indexed for MEDLINE]

Strategies of radioiodine ablation in patients with low-risk thyroid cancer.

N Engl J Med. 2012 May 3;366(18):1663-73

Authors: Schlumberger M, Catargi B, Borget I, Deandreis D, Zerdoud S, Bridji B, Bardet S, Leenhardt L, Bastie D, Schvartz C, Vera P, Morel O, Benisvy D, Bournaud C, Bonichon F, Dejax C, Toubert ME, Leboulleux S, Ricard M, Benhamou E,

Abstract

BACKGROUND: It is not clear whether the administration of radioiodine provides any benefit to patients with low-risk thyroid cancer after a complete surgical resection. The administration of the smallest possible amount of radioiodine would improve care.

METHODS: In our randomized, phase 3 trial, we compared two thyrotropin-stimulation methods (thyroid hormone withdrawal and use of recombinant human thyrotropin) and two radioiodine ((131)I) doses (i.e., administered activities) (1.1 GBq and 3.7 GBq) in a 2-by-2 design. Inclusion criteria were an age of 18 years or older; total thyroidectomy for differentiated thyroid carcinoma; tumor-node-metastasis (TNM) stage, ascertained on pathological examination (p) of a surgical specimen, of pT1 (with tumor diameter ≤1 cm) and N1 or Nx, pT1 (with tumor diameter >1 to 2 cm) and any N stage, or pT2N0; absence of distant metastasis; and no iodine contamination. Thyroid ablation was assessed 8 months after radioiodine administration by neck ultrasonography and measurement of recombinant human thyrotropin-stimulated thyroglobulin. Comparisons were based on an equivalence framework.

RESULTS: There were 752 patients enrolled between 2007 and 2010; 92% had papillary cancer. There were no unexpected serious adverse events. In the 684 patients with data that could be evaluated, ultrasonography of the neck was normal in 652 (95%), and the stimulated thyroglobulin level was 1.0 ng per milliliter or less in 621 of the 652 patients (95%) without detectable thyroglobulin antibodies. Thyroid ablation was complete in 631 of the 684 patients (92%). The ablation rate was equivalent between the (131)I doses and between the thyrotropin-stimulation methods.

CONCLUSIONS: The use of recombinant human thyrotropin and low-dose (1.1 GBq) postoperative radioiodine ablation may be sufficient for the management of low-risk thyroid cancer. (Funded by the French National Cancer Institute [INCa] and the French Ministry of Health; ClinicalTrials.gov number, NCT00435851; INCa number, RECF0447.).

PMID: 22551127 [PubMed - indexed for MEDLINE]

Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer.

N Engl J Med. 2012 May 3;366(18):1674-85

Authors: Mallick U, Harmer C, Yap B, Wadsley J, Clarke S, Moss L, Nicol A, Clark PM, Farnell K, McCready R, Smellie J, Franklyn JA, John R, Nutting CM, Newbold K, Lemon C, Gerrard G, Abdel-Hamid A, Hardman J, Macias E, Roques T, Whitaker S, Vijayan R, Alvarez P, Beare S, Forsyth S, Kadalayil L, Hackshaw A

Abstract

BACKGROUND: It is not known whether low-dose radioiodine (1.1 GBq [30 mCi]) is as effective as high-dose radioiodine (3.7 GBq [100 mCi]) for treating patients with differentiated thyroid cancer or whether the effects of radioiodine (especially at a low dose) are influenced by using either recombinant human thyrotropin (thyrotropin alfa) or thyroid hormone withdrawal.

METHODS: At 29 centers in the United Kingdom, we conducted a randomized noninferiority trial comparing low-dose and high-dose radioiodine, each in combination with either thyrotropin alfa or thyroid hormone withdrawal before ablation. Patients (age range, 16 to 80 years) had tumor stage T1 to T3, with possible spread to nearby lymph nodes but without metastasis. End points were the rate of success of ablation at 6 to 9 months, adverse events, quality of life, and length of hospital stay.

RESULTS: A total of 438 patients underwent randomization; data could be analyzed for 421. Ablation success rates were 85.0% in the group receiving low-dose radioiodine versus 88.9% in the group receiving the high dose and 87.1% in the thyrotropin alfa group versus 86.7% in the group undergoing thyroid hormone withdrawal. All 95% confidence intervals for the differences were within ±10 percentage points, indicating noninferiority. Similar results were found for low-dose radioiodine plus thyrotropin alfa (84.3%) versus high-dose radioiodine plus thyroid hormone withdrawal (87.6%) or high-dose radioiodine plus thyrotropin alfa (90.2%). More patients in the high-dose group than in the low-dose group were hospitalized for at least 3 days (36.3% vs. 13.0%, P<0.001). The proportions of patients with adverse events were 21% in the low-dose group versus 33% in the high-dose group (P=0.007) and 23% in the thyrotropin alfa group versus 30% in the group undergoing thyroid hormone withdrawal (P=0.11).

CONCLUSIONS: Low-dose radioiodine plus thyrotropin alfa was as effective as high-dose radioiodine, with a lower rate of adverse events. (Funded by Cancer Research UK; ClinicalTrials.gov number, NCT00415233.).

PMID: 22551128 [PubMed - indexed for MEDLINE]

Images in clinical medicine. Lymphangioma circumscriptum.

N Engl J Med. 2012 May 3;366(18):1724

Authors: Tan SK, Tay YK

PMID: 22551131 [PubMed - indexed for MEDLINE]

Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial.

Am J Surg. 2012 May 8;

Authors: Fiori E, Lamazza A, Schillaci A, Femia S, Demasi E, Decesare A, Sterpetti AV

Abstract

BACKGROUND: Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. METHODS: In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. RESULTS: There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125-612 days) in patients who had stents and 280 days (range, 135-591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. CONCLUSIONS: Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

PMID: 22575396 [PubMed - as supplied by publisher]

Safety of methylene blue dye for lymphatic mapping in patients taking selective serotonin reuptake inhibitors.

Am J Surg. 2012 May 8;

Authors: Shah-Khan MG, Lovely J, Degnim AC

Abstract

Methylene blue dye has an important role in lymphatic mapping for sentinel lymph node surgery. A recent safety announcement from the US Food and Drug Administration warned physicians about possible serious central nervous system reactions in patients on serotonergic medications who received intravenous methylene blue for the identification of parathyroid glands. This report summarizes evidence from the Food and Drug Administration’s announcement and methylene blue pharmacokinetics. The authors conclude that the use of methylene blue dye at low doses for lymphatic mapping likely carries very little risk for serotonin neurotoxicity, although breast surgeons should be aware of this potential complication in the event of mental status or neuromuscular changes in patients after lymphatic mapping.

PMID: 22575397 [PubMed - as supplied by publisher]

Disability index in a randomized controlled trial of emergency sclerotherapy versus portacaval shunt for bleeding varices in cirrhosis.

Am J Surg. 2012 May 8;

Authors: Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL

Abstract

BACKGROUND: Disability has not been studied after emergency treatment of bleeding esophageal varices (BEV). We created a disability index (DI) in a randomized controlled trial comparing emergency endoscopic therapy (EST) versus emergency portacaval shunt (EPCS). METHODS: There were 211 unselected, consecutive patients with cirrhosis and acute BEV who were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic work-up and treatment were performed within 8 hours. Ninety-six percent underwent more than 10 years follow-up evaluation. Disability was measured by assessing 9 factors to create a DI. RESULTS: Ten-year survival was 8% after EST versus 51% after EPCS (P < .001). EPCS had a significantly better DI. The EST and EPCS values were as follows: liver function improvement: not applicable and ++; worsening liver function, ++ and not applicable; portal-systemic encephalopathy (PSE) incidence, 36 and 15; PSE episodes, 179 and 94; packed red blood cell units, 1,005 and 320; hospital readmissions, 387 and 292; and number of readmission days, 9.6 and 4.7. All of the P values were less than .001. CONCLUSIONS: EPCS resulted in a markedly better DI than EST, a significantly higher survival rate, better control of bleeding, and a lower incidence of PSE. EPCS is an effective first-line emergency treatment of BEV.

PMID: 22575398 [PubMed - as supplied by publisher]

Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988-2007.

Am J Surg. 2012 May 8;

Authors: Scott FI, Osterman MT, Mahmoud NN, Lewis JD

Abstract

BACKGROUND: Postoperative adhesions are common after surgery and can cause small-bowel obstruction (SBO) and require adhesiolysis. The impact that laparoscopy and other surgical advances have had on rates of SBO and adhesiolysis remains controversial. This study examines trends in discharges from US hospitals for SBO and adhesiolysis from 1988 to 2007. METHODS: We performed an analysis of secular trends for SBO and adhesiolysis, using the National Hospital Discharge Survey. Spearman correlation coefficients were calculated to assess trends over time. RESULTS: Rates of SBO were stable over time (ρ = .140; P = .28). Adhesiolysis rates were stable over time (ρ = -.18; P = .17), although there were significant downward trends in patients older than age 65 (ρ = -.55; P = .01) and age 15 to 44 (ρ = -.84; P < .01). CONCLUSIONS: There has been no significant change in overall rates of SBO or adhesiolysis from 1988 to 2007. For adhesiolysis, there were decreasing trends when stratified by age. Further research is required to understand the factors associated with adhesion-related complications.

PMID: 22575399 [PubMed - as supplied by publisher]

Influence of obesity on complications and costs after intestinal surgery.

Am J Surg. 2012 May 8;

Authors: Wakefield H, Vaughan-Sarrazin M, Cullen JJ

Abstract

BACKGROUND: Obesity is a risk factor for many comorbid conditions that increase the cost of health care. We sought to examine the effect of obesity on surgical complications and cost in a group of patients undergoing intestinal surgery. METHODS: Using the Veterans Affairs Surgical Quality Improvement Program (VASQIP), which includes clinical data abstracted from medical records for Veterans Affairs (VA) surgical patients, and the VA Decision Support System, which provides the costs of individual patient encounters on the basis of relative values assigned to intermediate products, we examined surgical complications and costs of care in 4,881 patients undergoing intestinal surgery in 2006. Patients were classified into 4 groups based on body mass index (BMI): malnourished (<18), normal weight (18-30), obesity class I to II (30-40), and obesity class III (>40). Patient endpoints included the occurrence of any complication and surgical costs incurred within 30 days of surgery. Endpoints were compared across the 4 BMI categories in unadjusted analyses and risk-adjusted analyses and hospital-level variation using multivariable models. RESULTS: After controlling for patient risk factors and hospital-level variation, patients in obesity class I to II were 1.21 times more likely to have any complication and patients in obesity class III were 1.41 times more likely to have any complication when compared with normal-weight patients. Similarly, patients in obesity class I to II were 1.44 times more likely to develop a wound complication compared with normal-weight patients, and patients in class III were 1.84 times more likely to develop a wound complication and 1.55 times more likely to develop a respiratory complication compared with normal-weight patients. In contrast, costs were greatest for malnourished patients at $45,000 compared with normal-weight patients at $37,000. However, after controlling for patient risk factors and variation in costs attributable to the admitting hospital, there were no significant cost differences between the 4 BMI categories. CONCLUSIONS: Obesity leads to increased wound and respiratory complications in intestinal surgery. Nevertheless, obesity alone is not an independent risk factor for increased costs in intestinal surgery.

PMID: 22575400 [PubMed - as supplied by publisher]

Randomized clinical trial comparing the effect of computed tomography in the trauma room versus the radiology department on injury outcomes.

Br J Surg. 2012 Jan;99 Suppl 1:105-13

Authors: Saltzherr TP, Bakker FC, Beenen LF, Dijkgraaf MG, Reitsma JB, Goslings JC, , Bossuyt PM, Jin PH, Luitse JS, Ponsen KJ, Henny CP, Giannakopoulos GF

Abstract

BACKGROUND: Computed tomography (CT) of injured patients in the radiology department requires potentially dangerous and time-consuming patient transports and transfers. It was hypothesized that CT in the trauma room would improve patient outcome and workflow.

METHODS: A randomized trial compared the effect of locating a CT scanner in the trauma room versus the radiology department in two Dutch trauma hospitals. Injured patients aged at least 16 years were assigned randomly to one of these hospitals at the time of transport. The primary outcome measure was the number of non-institutionalized days within the first year after randomization. Subgroup analyses were performed in patients with multiple trauma or severe traumatic brain injury (TBI).

RESULTS: Some 1124 patients were included, of whom 1045 were available for analysis. The median number of non-institutionalized days was 360 days in the intervention group versus 362 days for the control group (P = 0.068). The time from arrival to the first CT imaging was 13 min shorter in the intervention group (36 versus 49 min; P < 0.001). Patient transfers and transports were reduced by more than half in the intervention group. For both multiple trauma (265 patients) and TBI (121) subgroups, differences in mortality and out-of-hospital days favoured the intervention group, but were not statistically significant.

CONCLUSION: A CT scanner located in the trauma room reduces the time to acquire CT images and improves workflow, but does not lead to substantial improvements in clinical outcomes in a general trauma population. Observed beneficial effects on outcomes in patients with multiple trauma or severe TBI were not statistically significant. Registration number: ISRCTN55332315 (http://www.controlled-trials.com).

PMID: 22441863 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients.

Br J Surg. 2012 Jan;99 Suppl 1:52-8

Authors: Sierink JC, Saltzherr TP, Reitsma JB, Van Delden OM, Luitse JS, Goslings JC

Abstract

BACKGROUND: The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS: A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS: Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION: This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

PMID: 22441856 [PubMed - indexed for MEDLINE]

Critique of “Evidence-Based Surgical Hypothesis: The case against BRCA1 and 2 testing”.

Surgery. 2012 Apr;151(4):634-7

Authors: Nussbaum RL

PMID: 22306835 [PubMed - indexed for MEDLINE]

A critical analysis of the American Joint Committee on Cancer (AJCC) staging system for differentiated thyroid carcinoma in young patients on the basis of the Surveillance, Epidemiology, and End Results (SEER) registry.

Surgery. 2012 Apr 11;

Authors: Tran Cao HS, Johnston LE, Chang DC, Bouvet M

Abstract

BACKGROUND: Differentiated thyroid carcinomas (DTC) are the only tumors for which age is a determinant of stage in the American Joint Committee on Cancer’s (AJCC) staging protocol. In this study, we re-examined the relationship between age, extent of disease, and prognosis by using a large dataset with longer follow-up times. METHODS: We examined the Surveillance, Epidemiology, and End Results (SEER) registry data 1973 to 2005 for patients with DTC as their only known malignancy. We used Cox multivariate analyses to generate mortality hazard ratios, controlling for several variables, to evaluate the effects of age and disease extent. RESULTS: We identified 55,402 patients with DTC. Of these, 49,240 had sufficient data to generate a TNM stage on the basis of AJCC guidelines. Within stage II, younger patients (<45 years) have worse outcomes than older patients (P < .001). Younger patients had an 11-fold increase in mortality between stages I and II, whereas there was no difference for older patients. When we uniformly applied the 45-and-older staging protocol to all patients, we found that stages III-IVc had a significantly greater risk of mortality for all patients compared with stage I. CONCLUSION: The presence of regional and metastatic thyroid cancer bears prognostic significance for all ages. Under current AJCC guidelines, young patients with metastatic thyroid cancer may be understaged.

PMID: 22503316 [PubMed - as supplied by publisher]

Ki-67 predicts disease recurrence and poor prognosis in pancreatic neuroendocrine neoplasms.

Surgery. 2012 Apr 11;

Authors: Hamilton NA, Liu TC, Cavatiao A, Mawad K, Chen L, Strasberg SS, Linehan DC, Cao D, Hawkins WG

Abstract

BACKGROUND: Pancreatic neuroendocrine neoplasms are rare malignancies for which the ideal staging method remains controversial. Ki-67 is a cell proliferation marker that has been shown to have some utility in predicting prognosis in neuroendocrine neoplasms. We sought to test the predictive ability of Ki-67 staining for disease recurrence and overall survival (OS) in pancreatic neuroendocrine neoplasms. METHODS: The medical records of patients who underwent pancreatic resection for pancreatic neuroendocrine neoplasms at a tertiary referral hospital from 1994 to 2009 were reviewed. The pathologic specimens of all were stained for Ki-67 and recorded as percentage of cells staining positive per high-powered field. The 10-year disease-free and OSs were analyzed. RESULTS: We identified 140 patients. Gender and age were not associated with increased risk of disease recurrence. Patients with tumors >4 cm or with Ki-67 staining >9% were more likely to have disease recurrence (P = .0454 and .047) and have decreased OS (P < .0001 and .0007). CONCLUSION: Increasing tumor size and increasing Ki-67 staining both correlate with increased risk of disease recurrence and decreased OS. Designing a staging system that incorporates both of these clinical variables will enable better identification of patients at risk for recurrent pancreatic neuroendocrine neoplasms.

PMID: 22503317 [PubMed - as supplied by publisher]

Delivery of interferon alpha using a novel Cox2-controlled adenovirus for pancreatic cancer therapy.

Surgery. 2012 Apr 11;

Authors: Armstrong L, Davydova J, Brown E, Han J, Yamamoto M, Vickers SM

Abstract

BACKGROUND: Combination therapy with interferon alpha (IFN) is correlated with improved survival in patients with pancreatic ductal adenocarcinoma (PDAc) but frequently presents side effects. We designed a novel targeted adenovirus with replication restricted to cyclooxygenase 2 (Cox2)-overexpressing PDAcs and hypothesize that the locally delivered therapeutic gene IFN can augment oncolytic effects while minimizing systemic toxicity. METHODS: IFN-expressing vectors were tested in vitro with the use of 4 PDAc cell lines with cytocidal effect measured by crystal violet and colorimetrically and IFN production assayed by ELISA. Cox2 promoter activity was checked by a luciferase reporter assay. In vivo, subcutaneous tumor xenografts with 2 PDAc cell lines in nude mice were treated with a single intratumoral viral dose. RESULTS: All PDAc cell lines were Cox2-positive. Oncolysis from the novel Cox2-controlled virus was comparable or superior to Adwt, the wild-type virus without safety features. The absence of cytocidal effect in Cox2-negative cells with the novel virus indicated cancer specificity. In vivo, stronger tumor suppression from the novel virus was seen when compared with nonreplicating IFN-expressing vectors. CONCLUSION: We demonstrated the potent therapeutic effects of a novel tumor-specific conditionally replicative IFN-expressing adenovirus. With potential to locally deliver IFN and avoid systemic toxicity, this strategy may therefore expand the application of this robust and promising therapy.

PMID: 22503318 [PubMed - as supplied by publisher]

Prevalence of alcohol misuse among men and women undergoing major noncardiac surgery in the Veterans Affairs health care system.

Surgery. 2012 Apr 11;

Authors: Bradley KA, Rubinsky AD, Sun H, Blough DK, Tønnesen H, Hughes G, Beste LA, Bishop MJ, Hawn MT, Maynard C, Harris AS, Hawkins EJ, Bryson CL, Houston TK, Henderson WG, Kivlahan DR

Abstract

BACKGROUND: Patients who screen positive for alcohol misuse on the Alcohol Use Disorder Identification Test Consumption Questionnaire (AUDIT-C ≥5 points) have significantly increased postoperative complications. Severe alcohol misuse (AUDIT-C ≥9 points) is associated with increased postoperative health care use; however, little is known about the prevalence of alcohol misuse in demographic and clinical subgroups of surgical patients. METHODS: The prevalence of alcohol misuse was evaluated among 10,284 patients (9,771 men and 513 women) who underwent major noncardiac surgery in Veterans Affairs (VA) hospitals during the fiscal years 2004 to 2006 and completed the AUDIT-C. Sex-stratified analyses evaluated prevalence rates of alcohol misuse (AUDIT-C ≥5) and severe misuse (AUDIT-C ≥9) across demographic and clinical subgroups. RESULTS: Overall, 1,607 (16%) men and 24 (5%) women screened positive for alcohol misuse (AUDIT-C ≥5) in the year before operation, with 4% and 2% screening positive for severe misuse (AUDIT-C ≥9), respectively. Alcohol misuse was more common among men who were <60 years of age, divorced or separated, current smokers, or American Stoke Association class 1 or 2, and those with cirrhosis/hepatitis or substance use disorders. Among patients with alcohol misuse, 36% of men and 58% of women were American Society of Anesthesiologists class 1 or 2, and most did not have diagnoses that were commonly associated with alcohol misuse. CONCLUSION: Alcohol misuse is relatively common in male surgical patients. Moreover, surgical patients undergoing operation who screen positive for alcohol misuse are often relatively healthy, without health problems that might alert providers to their alcohol misuse in the absence of screening.

PMID: 22503319 [PubMed - as supplied by publisher]

Safety and feasibility of using low-dose perioperative intravenous steroids in inflammatory bowel disease patients undergoing major colorectal surgery: A pilot study.

Surgery. 2012 Apr 11;

Authors: Zaghiyan K, Melmed G, Murrell Z, Fleshner P

Abstract

BACKGROUND: High-dose perioperative corticosteroids are the standard of care for steroid-treated patients undergoing surgery. There is little evidence, however, to support this practice. We investigated the safety of perioperative low-dose steroids in patients with inflammatory bowel disease (IBD) undergoing major colorectal surgery. METHODS: Steroid-treated IBD patients undergoing major colorectal surgery were treated with the intravenous equivalent of their preoperative steroid dose in the perioperative period. Patients who were not taking steroids at the time of operation but who were treated with steroids within 1 year of surgery received no perioperative corticosteroids. Perioperative vital signs were analyzed. Hemodynamic instability was defined as heart rate >120 beats per minute, heart rate <60 beats per minute, or systolic blood pressure <90 mm Hg. RESULTS: Thirty-two procedures were performed on 10 patients on steroids at the time of operation and 22 patients had who stopped steroids within 1 year of surgery. Five patients (16%) developed tachycardia and 8 patients (25%) had bradycardia. Hypotension occurred in 5 (16%) patients. All cases of hemodynamic instability resolved with no intervention, fluid boluses, or blood transfusion. No patients required vasopressors or high-dose corticosteroids for adrenal insufficiency. CONCLUSION: In steroid-treated IBD patients undergoing major colorectal surgery, the use of low-dose perioperative corticosteroids seems safe. A prospective study assessing perioperative corticosteroid dosing is in progress.

PMID: 22503320 [PubMed - as supplied by publisher]

Safety skills training for surgeons: A half-day intervention improves knowledge, attitudes and awareness of patient safety.

Surgery. 2012 Apr 11;

Authors: Arora S, Sevdalis N, Ahmed M, Wong H, Moorthy K, Vincent C

Abstract

BACKGROUND: Education and training of health care professionals is necessary to achieve sustainable improvements in patient safety. Despite its inherently risky nature, little training specifically in safety has been conducted in the surgical disciplines. In this study we explored the effects of a safety skills training program on surgical residents’ knowledge, attitudes, and awareness of patient safety. METHODS: A half-day training program incorporating safety awareness, analysis, and improvement skills was delivered to surgical residents from 19 hospitals in London, United Kingdom. Participants were assessed in terms of safety knowledge (MCQs) and attitudes to safety (validated questionnaire; scale 1 to 5) before and after training. To determine long-term effects, 6 months after training participants identified and reported on observed safety events in their own workplace by using an observational form for data collection. RESULTS: A total of 27 surgeons participated in the training program. Knowledge of safety significantly improved after the course (mean pre = 45.26% vs mean post = 70.59%, P < .01) as did attitudes to error analysis and improving safety (mean pre 3.50 vs mean post 3.97, P < .001) and ability to influence safety (mean pre 3.22 vs mean post 3.49, P < .01). After the course, participants reported richer, detailed sets of observations demonstrating enhanced understanding, recognition, and analysis of patient safety issues in their workplace. CONCLUSION: Safety skills training with positive educational outcomes can be delivered in a half day. Such a course may allow patient safety to be integrated into any curriculum, thereby training the next generation of the healthcare workforce to maintain the safety momentum.

PMID: 22503321 [PubMed - as supplied by publisher]

Surgical resident participation in laparoscopic Roux-en-Y bypass: Is it safe?

Surgery. 2012 Apr 11;

Authors: Fanous M, Carlin A

Abstract

BACKGROUND: The majority of bariatric surgeons use dedicated surgical assistants when performing laparoscopic Roux-en-Y gastric bypass (LGBP) because of the technical difficulty and steep learning curve involved in the operation. At our institution, either a senior surgical resident (SSR) or a physician assistant (PA) participates in LGBP cases. The PA’s role is confined to assisting, whereas the SSR progressively acts as the operating surgeon. We were interested in evaluating patient outcomes to determine whether any differences existed between the LGBP operations in which either the PA or the SSR participated. METHODS: All patients undergoing LGBP between January 2007 and December 2009 in our prospectively collected bariatric database were reviewed. Demographics, baseline measures, intraoperative parameters, and outcomes were compared. RESULTS: A total of 711 patients were identified. The group involving PAs included 343 patients, and the group involving SSRs included 368 patients. Preoperative comorbidities, including diabetes, hypertension, coronary artery disease, asthma, sleep apnea, hyperlipidemia, musculoskeletal disability, and depression, were similar in both groups. Personal histories of venous thromboembolism were higher in the PA group (5.1% vs 2.5%; P = .075). The mean body-mass indexes (BMI) (53 ± 9 vs 51 ± 8 kg/m(2); P = .006) and weights (323 ± 67 vs 306 ± 59 lbs; P < .001) in the PA group were significantly higher than in the SSR group. The proportion of males was higher in the PA group (24% vs 16%; P = .008). The operative time was significantly shorter in the PA group (121 ± 36 vs 164 ± 30 minutes; P < .001). There was no significant difference between the groups in intraoperative complications, length of hospital stay, 30-day complications, or reoperations within 1 year. There were no mortalities in either group. The 1-year percent excess weight loss (64% vs 66%) was similar in the PA and SSR groups, respectively. CONCLUSION: SSR participation in LGBP prolongs operative time but does not increase complications, mortality rates, or length of stay. Therefore, SSR participation in LGBP is safe and produces outcomes comparable to those performed with PAs.

PMID: 22503322 [PubMed - as supplied by publisher]

Previous percutaneous coronary intervention increases morbidity after coronary artery bypass grafting.

Surgery. 2012 Apr 11;

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

Abstract

BACKGROUND: We hypothesized that the incidence of previous percutaneous coronary intervention (PCI) is increasing and that prior PCI influences patient morbidity and mortality after coronary artery bypass grafting (CABG). METHODS: A total of 34,316 patients underwent isolated CABG operations at 16 different statewide, institutions from 2001 to 2008. Patients were stratified into prior PCI (n = 4346; 12.7%) and no prior PCI (n = 29,970). Patient risk factors, intraoperative variables, and outcomes were compared by univariate and multivariate analyses. RESULTS: The incidence of prior PCI in CABG has risen from <1% to 22.0% from 2001 to 2008 (P < .001). Prior PCI patients were younger (P < .001) and more commonly had previous myocardial infarction (P < .001), but less commonly had heart failure (P < .001). The operative mortality was similar between groups (2.3% vs 1.9%; P = .13). Prior PCI patients had more major complications (15.0% vs 12.0%; P < .001), longer hospitalization (P = .01), and higher readmission rates (P = .01). Importantly, by multivariate analyses, prior PCI was not associated with mortality, but was an independent predictor of major complications after CABG (odds ratio, 1.15; P = .01). CONCLUSION: The incidence of prior PCI in patients undergoing CABG is increasing. Previous PCI is associated with a higher risk of major complications, greater hospital length of stay, and higher readmission rates after CABG.

PMID: 22503323 [PubMed - as supplied by publisher]

Laparoscopic cholecystectomy: What is the price of conversion?

Surgery. 2012 Apr 11;

Authors: Lengyel BI, Panizales MT, Steinberg J, Ashley SW, Tavakkoli A

Abstract

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. Conversion to an open procedure is sometimes deemed necessary, especially in complex cases in which a prolonged laparoscopic operative time is anticipated. A prolonged LC case is thought to be associated with increased complications and cost and therefore generally discouraged. The purpose of this study was to test this assumption, and compare outcomes and cost of converted and prolonged LC cases. METHODS: By using institutional National Surgical Quality Improvement Program and financial databases, we retrospectively reviewed and compared prolonged laparoscopic cases (Long-LC) with converted (CONV) procedures. Surgical times, length of stay (LOS), 30-day complications, operative room, and total hospital charges were compared between the 2 groups. RESULTS: A total of 101 Long-LC and 66 CONV cases met our inclusion criteria. Long-LC cases were 19 minutes longer than CONV cases (123 vs 104 min; P < .01). No differences in postoperative complications were found between the 2 groups (P > .05). When Poisson regression was used, we found that LOS was significantly shorter in the Long-LC compared with CONV group (1 day vs 4 days; P < .01). Long-LC cases had greater operative charges ($15,278 vs $13,128; P < .01). However, hospital charges for Long-LC cases were 26% less than for CONV cases ($23,946 vs $32,446; P < .01). CONCLUSION: Conversion is associated with a 3-day increase in LOS. Long-LC cases have greater operative room charges, but overall hospital charges were 26% less than CONV cases. Our data suggest that decision making regarding conversion should focus on safety and not time considerations.

PMID: 22503324 [PubMed - as supplied by publisher]

Impact of perioperative administration of synbiotics in patients with esophageal cancer undergoing esophagectomy: A prospective randomized controlled trial.

Surgery. 2012 Apr 12;

Authors: Tanaka K, Yano M, Motoori M, Kishi K, Miyashiro I, Ohue M, Ohigashi H, Asahara T, Nomoto K, Ishikawa O

Abstract

BACKGROUND: The clinical value of synbiotics in patients undergoing esophagectomy remains unclear. This study investigated the effects of synbiotics on intestinal microflora and surgical outcomes in a clinical setting. METHODS: We studied 70 patients with esophageal cancer who were scheduled to undergo esophagectomy. They were randomly allocated to 2 groups: 1 group received synbiotics before and after surgery, and the other did not. Fecal microflora and organic acid concentrations were determined. Postoperative infections, abdominal symptoms, and duration of systemic inflammatory response syndrome (SIRS) were recorded. RESULTS: Of the patients, 64 completed the trial (synbiotics, 30; control, 34). The counts of beneficial bacteria and harmful bacteria in the group given synbiotics were significantly larger and smaller, respectively, than those in the control group on postoperative day (POD) 7. The concentrations of total organic acid and acetic acid were higher in the synbiotics group than in the control group (P < .01), and the intestinal pH in the synbiotics group was lower than that in the control (P < .05) on POD 7. The rate of infections was 10% in the synbiotics group and 29.4% in the control group (P = .0676). The duration of SIRS in the synbiotics group was shorter than in the control group (P = .0057). The incidence of interruption or reduction of enteral nutrition by abdominal symptoms was 6.7% in the synbiotics group and 29.4% in the control group (P = .0259). CONCLUSION: Perioperative administration of synbiotics in patients with esophagectomy is useful because they suppress excessive inflammatory response and relieve uncomfortable abdominal symptoms through the adjustment of the intestinal microfloral environment.

PMID: 22503510 [PubMed - as supplied by publisher]

Development and evaluation of a decision-based simulation for assessment of team skills.

Surgery. 2012 Apr 12;

Authors: Andrew B, Plachta S, Salud L, Pugh CM

Abstract

BACKGROUND: There is a need to train and evaluate a wide variety of nontechnical surgical skills. The goal of this project was to develop and evaluate a decision-based simulation to assess team skills. METHODS: The decision-based exercise used our previously validated Laparoscopic Ventral Hernia simulator and a newly developed team evaluation survey. Five teams of 3 surgical residents (N = 15) were tasked with repairing a 10 × 10-cm right upper quadrant hernia. During the simulation, independent observers (N = 6) completed a 6-item survey assessing: (1) work quality; (2) communication; and (3) team effectiveness. After the simulation, team members self-rated their performance by using the same survey. RESULTS: Survey reliability revealed a Cronbach’s alpha of r = .811. Significant differences were found when we compared team members’ (T) and observers’ (O) ratings for communication (T = 4.33/5.00 vs O = 3.00/5.00, P < .01) and work quality (T = 4.33/5.00 vs O = 3.33/5.00, P < .05). The team with the greatest survey ratings was the only group to successfully complete the task. CONCLUSION: The team evaluation survey had good reliability and correlated with task performance on the simulator. Our current and previous work provides strong evidence that nontechnical and team related skills can be assessed without simulating a crisis situation.

PMID: 22503511 [PubMed - as supplied by publisher]

Is subtotal thyroidectomy a cost-effective treatment for Graves disease? A cost-effectiveness analysis of the medical and surgical treatment options.

Surgery. 2012 Apr 12;

Authors: Zanocco K, Heller M, Elaraj D, Sturgeon C

Abstract

BACKGROUND: The 3 treatment options for Graves disease (GD) are antithyroid drugs (ATDs), radioactive iodine (RAI), and thyroid surgery. We hypothesized that thyroid surgery is cost-effective for Graves disease when compared to RAI or ATD. METHODS: Cost-effectiveness analysis was performed to compare operative strategies to medical treatment strategies for GD. The decision model, based on a reference case, included treatment outcomes, probabilities, and costs derived from literature review. Outcomes were weighted using quality of life utility factors, yielding quality-adjusted life years (QALYs). The uncertainty of costs, probabilities, and utility estimates in the model were examined by univariate and multivariate sensitivity analysis and Monte Carlo simulation. RESULTS: The subtotal thyroidectomy strategy produced the greatest QALYs, 25.783, with an incremental cost-effectiveness ratio of $26,602 per QALY, reflecting a gain of 0.091 QALYs at an additional cost of $2416 compared to RAI. Surgery was cost-effective when the initial postoperative euthyroid rate was greater than 49.5% and the total cost was less than $7391. Monte Carlo simulation showed the subtotal thyroidectomy strategy to be optimal in 826 of 1000 cases. CONCLUSION: This study demonstrates that subtotal thyroidectomy can be a cost-effective treatment for GD. However, a 49.5% initial postoperative euthyroid rate was a necessary condition for cost-effective surgical management of GD.

PMID: 22503512 [PubMed - as supplied by publisher]

Peroxisome proliferator-activated receptor β/δ agonist GW0742 ameliorates cerulein- and taurocholate-induced acute pancreatitis in mice.

Surgery. 2012 Apr 20;

Authors: Paterniti I, Mazzon E, Riccardi L, Galuppo M, Impellizzeri D, Esposito E, Bramanti P, Cappellani A, Cuzzocrea S

Abstract

BACKGROUND: Peroxisome proliferator-activated receptors (PPARs) are ligand activated transcription factors belonging to the nuclear receptor superfamily. PPARs activation has a profound impact on the local immune response with consequences affecting the progression of chronic inflammatory diseases. Relatively little is known on the role of PPAR-β/δ in the regulation of inflammatory responses. The aim of the present study was to evaluate the influence of PPAR-β/δ receptor in a model of edematous pancreatitis induced in mice by administration of cerulein at supramaximal doses, as well as in necrohemorrhagic model induced by intraductal administration of sodium taurocholate (STC). MEASUREMENTS: Mice were treated with cerulein (50 μg/kg) or STC (5%). GW0742 (0.3 mg/kg) was intraperitoneally administered 1 and 6 hours after cerulein injection or was injected 2 hours before STC infusion. The pancreas and exopancreatic organs were carefully removed for microscopic examination. Pancreatic weight, serum amylase, lipase, tumor necrosis factor-α and interleukin-1β levels, as well as cytokines, adhesion molecules, nitrotyrosine, poly (ADP-ribose), inducible nitric oxide, FAS ligand, Bax, Bcl-2 expression by immunohistochemistry, and myeloperoxidase activity of the pancreas were assayed. Moreover, the involvement of nuclear factor-κB pathway was investigated by Western blot analysis. RESULTS: Intraperitoneal injection of cerulein in mice resulted in severe, acute pancreatitis characterized by edema, neutrophil infiltration and apoptosis, and elevated serum levels of amylase and lipase. Taurocholate challenge caused a clear increase in serum amylase, neutrophil infiltration, and tissue damage in the pancreas. Tissue and inflammatory changes in the pancreata were significantly less in GW0742 group than in cerulein or STC groups. In addition, the pancreatic water content was reduced in mice treated with PPAR-β/δ agonist. In the mild pancreatitis, GW0742 was also able to decrease the expression of proinflammatory cytokines and enzymes, as well as of proteins involved in apoptosis and nuclear factor-Kappa B pathway. CONCLUSION: GW0742 attenuated pancreatic damage in 2 different experimental models of pancreatitis in mice.

PMID: 22521259 [PubMed - as supplied by publisher]

Routine Anterior Approach During Right Hepatectomy: Results of a Prospective Randomised Controlled Trial.

J Gastrointest Surg. 2012 May 9;

Authors: Capussotti L, Ferrero A, Russolillo N, Langella S, Lo Tesoriere R, Viganò L

Abstract

TRIAL DESIGN: A prospective randomised controlled trial was designed to evaluate the advantages of routine application of the anterior approach during right hepatectomy. METHODS: The study was conducted between March 2005 and April 2009 in a tertiary hepatobiliary-pancreatic centre. Patients scheduled for right hepatectomy for primary or metastatic tumours, without infiltration of segment 1, inferior vena cava or main bile duct, were randomly assigned to right hepatectomy using either an anterior or a classic approach. The primary study endpoint was overall blood loss. RESULTS: Sixty-six patients were randomly allocated to undergo right hepatectomy with an anterior (AA group n = 33) or a classic approach (CA group n = 33). Sixty-five patients were included in the analysis (33 in AA group and 32 in CA group). There was no significant difference in patient age, diagnosis, preoperative hepatic biochemistry and tumour size between the two groups. Overall blood loss (437 ml ± 664 in AA group vs.500 ml ± 532.3 in CA group; p = 0.960) and bleeding during transection (p = 0.973) were similar between two groups. Perioperative blood transfusion rates were 18 % in the AA group and 9.3 % in the CA group (p = 0.253). Time of parenchymal transsection was significantly longer in AA group (75.1 ± 26.6 min vs. 56.7 ± 17.5 min, p = 0.01). There was no difference between both groups for postoperative prothrombin time, serum transaminase and total bilirubin levels. One patient died in each group (p = 0.746). The two groups had similar morbidity rates. CONCLUSION: Routine application of the anterior approach during right hepatectomy does not decrease intraoperative blood loss and morbidity rate.

PMID: 22570073 [PubMed - as supplied by publisher]