Surgery - Articles in Press

Treatment with antithymocyte globulin ameliorates intestinal ischemia and reperfusion injury in mice - Corrected Proof

2012-05-10

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 TH2-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.

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

2012-05-10

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% O2). 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.

Urokinase requires NAD(P)H oxidase to transactivate the epidermal growth factor receptor - Corrected Proof

Enrico A. Duru, Yuyang Fu, Mark G. Davies — 2012-05-10

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 βARKCT 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.

Evolution of general surgical problems in patients with left ventricular assist devices - Corrected Proof

2012-05-10

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.

Intraductal papillary mucinous neoplasm was associated with pancreatic carcinogenesis, but not with systemic carcinogenesis - Corrected Proof

Kazumichi Kawakubo, Minoru Tada, Kazuhiko Koike — 2012-05-10

We read with great interest the article by Lubezky et al, a retrospective analysis of extrapancreatic malignancies (EPM), family history of malignancy and germline mutations in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. They concluded that their frequency was significantly higher than that in patients with pancreatic ductal adenocarcinoma.

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

2012-05-10

Vascular leiomyosarcomas are extremely rare sarcomas that originate from the smooth muscle cells of the vessel wall. Most of them affect primarily the inferior vena cava (IVC). Radical operative resection provides the only possibility for long-term survival. Total abdominal IVC resection without reconstruction may be possible when adequate collateral circulation has developed. However, no effort should be spared to secure the renal outflow; to this end, various methods have been proposed. We report a case of resection of an IVC leiomyosarcoma without reconstruction, but with diversion of the left renal outflow to the inferior mesenteric vein.

Traumatic fracture–dislocation of the lumbar spine - Corrected Proof

Nai-Feng Tian, Fang-Min Mao, Hua-Zi Xu — 2012-05-10

A 50-year-old man riding a motorcycle was involved in a collision with a car. He was transferred to the emergency department of our hospital immediately after the accident. The physical examination on admission revealed stable vital signs, abrasions over his bilateral extremities, and painful swelling in his back with a marked step-like deformity. The neurologic examination revealed incomplete motor paralysis and sporadic skin sensibility impairment in his lower limbs. Bilateral ankle and knee jerks were absent, but decreased anal reflex was observed. A lateral radiograph () and computed tomographic scan () of the lumbar spine revealed complete anterior dislocation of the L3 vertebra. The spinal column was shortened because the L3 and L4 vertebrae were located in the same transverse plane (, A). The posterior structures of the L2 and L3 vertebrae were split off from the vertebral bodies, resulting in a widened spinal canal at displaced level (, B). Because the patient was hemodynamically stable and had no overt sign of important organ injuries, he received the emergency operation by posterior decompression, reduction, reconstruction, and long-segment fixation. The patient's neurologic function of the lower limbs obtained abatement postoperatively and the patient was put on a rehabilitation program.

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 - Corrected Proof

2012-05-10

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.

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

2012-04-23

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.

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

Brandon Andrew, Stephen Plachta, Lawrence Salud, Carla M. Pugh — 2012-04-16

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.

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

Kyle Zanocco, Michael Heller, Dina Elaraj, Cord Sturgeon — 2012-04-16

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.

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

2012-04-16

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.

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

2012-04-13

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.

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

2012-04-13

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.

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

2012-04-13

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.

Previous percutaneous coronary intervention increases morbidity after coronary artery bypass grafting - Corrected Proof

2012-04-13

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.

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

Medhat Fanous, Arthur Carlin — 2012-04-13

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/m2; 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.

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 - Corrected Proof

Hop S. Tran Cao, Lily E. Johnston, David C. Chang, Michael Bouvet — 2012-04-13

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.

Laparoscopic cholecystectomy: What is the price of conversion? - Corrected Proof

2012-04-13

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.

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

2012-04-13

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.

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

Karen Zaghiyan, Gil Melmed, Zuri Murrell, Phillip Fleshner — 2012-04-13

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.

Endoscopic adrenalectomy in large adrenal tumors - Corrected Proof

Reza Asari, Oskar Koperek, Bruno Niederle — 2012-04-09

Background: The purpose of this study was to evaluate the frequency of malignancy, oncologic outcome and perioperative morbidity between small (≤60 mm) and large (>60 mm) adrenal tumors treated by endoscopic adrenalectomy (EA).Methods: EA was performed in 289 consecutive patients with a mean follow-up of 87.7 ± 45.1 months. Patients were divided in those with tumor size ≤60 mm (group 1; n = 252) and >60 mm (group 2; n = 37). Data on patient's age, gender, hormone function, tumor side, operation time, postoperative complications, conversion to open approach, and rate of malignancy were analyzed. Furthermore, disease-free survival in malignant tumors was estimated and compared between both groups.Results: Patient age (P = .43), gender (P = .09), tumor side (P = .17), and operative time (P = .33) showed no difference in both groups. Functioning tumors were observed in 85% of patients in group 1 compared with 46% in group 2 (P = .0001). Seven (2.8%) patients in group 1 and 7 (18.9%) in group 2 had malignant tumors (P = .0001). Neither rate of conversion (P = .71) and postoperative complication (P = .27) nor recurrence of malignancy (P = .48) differed between both groups. Estimated disease-free survival after 5 years in malignant lesions was 87.5 ± 11.7% for group 1 and 62.5 ± 21.3% for group 2 (P = .49).Conclusion: EA is a safe and feasible procedure in the majority of large adrenal tumors. Tumor size does not affect the outcome of surgery. In case of malignancy, it does not increase the rate of local recurrence. In experienced hands, tumor size should not influence the decision of surgical access (endoscopic versus open).

Superior mesenteric artery syndrome - Corrected Proof

Shefali Agrawal, Harshad Patel — 2012-04-09

A 54-year-old man presented to the emergency department with an acute exacerbation of episodic vomiting and epigastric pain. He admitted to a weight loss of 20 kg since the onset of symptoms 6 months earlier. His medical history was significant for substance abuse and chronic dementia with no history of previous abdominal surgery. The patient’s vital signs were stable and his abdomen was soft, distended, and nontender. The placement of a nasogastric tube was followed by the drainage of 1.5 L of bilious fluid. Laboratory data were within normal limits. A computed tomographic (CT) scan of the abdomen revealed complete obstruction of the third portion of the duodenum with marked proximal gastroduodenal distension (). Also noted on the CT scan was compression of the left renal vein with a left varicocele. CT angiography revealed a diminished aortomesenteric angle of 22° (normal, 38–65°) and distance of 8 mm (normal, 10–28 mm), confirming a diagnosis of superior mesenteric artery (SMA) syndrome (). Esophagogastroduodenoscopy revealed no intrinsic duodenal pathology. A duodenojejunostomy was performed with an uneventful postoperative course. At 18 months postsurgery, the patient’s body weight had increased with complete resolution of the symptoms.

Cheating experience: Guiding novices to adopt the gaze strategies of experts expedites the learning of technical laparoscopic skills - Corrected Proof

2012-04-01

Background: Previous research has demonstrated that trainees can be taught (via explicit verbal instruction) to adopt the gaze strategies of expert laparoscopic surgeons. The current study examined a software template designed to guide trainees to adopt expert gaze control strategies passively, without being provided with explicit instructions.Methods: We examined 27 novices (who had no laparoscopic training) performing 50 learning trials of a laparoscopic training task in either a discovery-learning (DL) group or a gaze-training (GT) group while wearing an eye tracker to assess gaze control. The GT group performed trials using a surgery-training template (STT); software that is designed to guide expert-like gaze strategies by highlighting the key locations on the monitor screen. The DL group had a normal, unrestricted view of the scene on the monitor screen. Both groups then took part in a nondelayed retention test (to assess learning) and a stress test (under social evaluative threat) with a normal view of the scene.Results: The STT was successful in guiding the GT group to adopt an expert-like gaze strategy (displaying more target-locking fixations). Adopting expert gaze strategies led to an improvement in performance for the GT group, which outperformed the DL group in both retention and stress tests (faster completion time and fewer errors).Conclusion: The STT is a practical and cost-effective training interface that automatically promotes an optimal gaze strategy. Trainees who are trained to adopt the efficient target-locking gaze strategy of experts gain a performance advantage over trainees left to discover their own strategies for task completion.

Multiple duodenal stromal tumors revealing type 1 neurofibromatosis: An indication for pancreas-preserving duodenectomy - Corrected Proof

2012-03-29

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Type 1 neurofibromatosis (von Recklinghausen disease) is known to be associated with GIST.

Prognostic significance of tumor deposits in gastric cancer patients who underwent radical surgery - Corrected Proof

2012-03-05

Background: To investigate the prognostic significance of tumor deposits (TDs) in gastric cancers patients who underwent radical surgery.Methods: Clinicopathologic and prognostic data from 2998 gastric cancer patients who underwent R0 surgery with D2/D3 lymphadenectomy were retrospectively reviewed. A TD was defined as discrete foci of tumor found in the perigastric fat or in adjacent ligament away from the leading edge of the tumor and showing no evidence of residual lymph node tissue, but within the lymph drainage area of the primary carcinoma.Results: TDs were detected in 17.8% of patients. TDs were more frequently observed in cancers of larger size, of Borrmann type 4, with lymphovascular invasion, deeper in depth of invasion, and with extended lymph node metastasis. Multivariate analysis confirmed the presence of TDs as 1 of independent factors predicting a poorer outcome. When stratified by pN category, significant differences in survival were observed between patients with and without TDs for those in pN0/pT1–3, pN1/pT3, pN2/pT1–3 and pN3/pT2–3 category, but not for those in pT4a and pT4b category. Moreover, for cancers in each pN category, the prognosis for patients with TDs in pT1–4a category was similar with that of those without TDs in pT4a category, but significantly better than that of those with or without TDs in pT4b category. A revised pT category and a revised pTNM system were proposed, in which all the cancers with TDs in pT1–4a category were incorporated into those without TDs in pT4a category according to the pN category. Further analysis revealed the revised pT category and the revised pTNM system had better homogeneity, discriminatory ability, and monotonicity of gradients than the American Joint Committee on Cancer (AJCC) pT category and the AJCC pTNM system, respectively, representing optimum prognostic stratification.Conclusion: TDs significantly correlated with gastric cancer patients’ survival. It might be more suitable for TDs to be treated as a form of serosal invasion. Consequently, en bloc resection of the primary carcinoma is crucially important, and adjuvant chemotherapy should always be considered if TDs have been detected.

Laryngeal approach to the recurrent laryngeal nerve involved by thyroid cancer at the ligament of Berry - Corrected Proof

2012-03-05

Background: Thyroid cancer often involves the RLN at the ligament of Berry, which makes preservation of the nerve difficult. If the portion of RLN is resected, finding the peripheral RLN for reconstruction is difficult. Here we describe a laryngeal approach performed before dissecting the RLN to overcome these problems.Methods: Between January 2007 and April 2011, 13 patients with papillary thyroid carcinoma had unilateral RLN involvement by the cancer at the ligament of Berry. Preoperatively, 8 had functioning vocal cords and 5 had unilateral paralysis. The laryngeal approach involves dividing the inferior pharyngeal constrictor muscle along the lateral edge of the thyroid cartilage and identifying the nerve under the muscle or behind the thyroid cartilage. This procedure was performed before resecting the tumor in 10 patients (Group 1) and after resection in the remaining 3 (Group 2).Results: In Group 1, the RLN could be preserved with sharp dissection in 3 with functioning vocal cords preoperatively. Postoperatively they restored vocal cord function. The remaining 7 needed resection of the portion of RLN. RLN reconstruction was easily, since the peripheral RLN had already been identified. All patients in Group 2 needed resection of the portion of RLN. The peripheral RLN was identified in 2, and ansa-RLN anastomosis was performed. However, this was not possible in 1 patient.Conclusion: In patients with thyroid cancer involving the RLN at the ligament of Berry, performing the laryngeal approach before dissecting the nerve facilitates preservation or reconstruction of the nerve.

Acoustic radiation force impulse imaging predicts postoperative ascites resulting from curative hepatic resection for hepatocellular carcinoma - Corrected Proof

2012-03-05

Background: Measurement of liver stiffness using Virtual Touch Tissue Quantification (VTTQ) based on acoustic radiation force impulse imaging reflects the degree of hepatic fibrosis and reserve. This prospective study investigated how well the VTTQ value predicts the development of postoperative complications before curative hepatic resection for hepatocellular carcinoma (HCC).Methods: The study enrolled 50 consecutive patients between February 2009 and October 2010 whose preoperative VTTQ values were determined before they underwent curative hepatic resection for HCC. We assessed the relationship between postoperative complications and VTTQ values.Results: The study included 41 (82%) patients with chronic hepatitis and 9 (18%) with nonviral cirrhosis. The mean VTTQ value was 1.60 (m/sec), which correlated with the fibrosis stage (P = .0058). The VTTQ value was the only variable correlated with postoperative ascites that did not respond to pharmacologic treatment and required invasive management. Univariate and subsequent multivariate analyses revealed that the preoperative VTTQ value was the only independent risk factor for predicting the development of postoperative ascites (cutoff, 1.68 cm/sec; P = .007; odds ratio, 76.481). The area under the receiver operating characteristic curve for the diagnosis of postoperative ascites using VTTQ values was 0.90, whereas those using the aspartate transaminase-to-platelet ratio index and indocyanine green retention rate at 15 minutes values were 0.68 and 0.55, respectively.Conclusion: These data suggest that the VTTQ value is a reliable surrogate marker for predicting postoperative ascites before curative hepatic resection for HCC.

Unique moments in time: What patients teach us - Corrected Proof

Jon A. van Heerden — 2012-03-05

He was a mid-career airline captain. Investigations confirmed the presence of bilateral, symptomatic pheochromocytomas, for which the gold standard of treatment was (and still is) a bilateral total adrenalectomy with subsequent steroid hormone replacement. He balked at this advice; quite frankly, to my surprise, he outright refused! His reasoning was that he would lose his job (be fired) if that operation (bilateral total adrenalectomy) was done. Aviation rules stipulate that pilots may not fly if they have no adrenal glands (“loss of the fight and flight” response). Interestingly, pilots, however, may command a plane if they have bilateral pheochromocytomas! We faced a dilemma and a therapeutic challenge.

Spleen-preserving distal pancreatectomy with splenic vessels excision - Corrected Proof

Cosimo Sperti, Valentina Beltrame, Beatrice Bellamio, Claudio Pasquali — 2012-03-05

Spleen preservation during distal pancreatectomy for benign diseases of the pancreas has been proposed to reduce the complications of splenectomy. A simplified technique for spleen preservation that involves excision of the splenic artery and vein has been reported (ie, Warshaw operation). In recent years, this technique has gained the favor of many surgeons, both for the laparotomic and laparoscopic approaches, because of its quickness and simplicity.

Intestinal and multivisceral autotransplantation for tumors of the root of the mesentery: Long-term follow-up - Corrected Proof

2012-03-05

Objective: To present the indications, techniques, short- and long-term outcomes after visceral exenteration, ex vivo resection, and intestinal/multivisceral autotransplantation.Patients and Methods: All patients who have undergone this procedure at our center were studied. Technique, postoperative complications, survival, tumor recurrence, and functional status were recorded.Results: Ten patients, 4 children and 6 adults, have undergone these procedures since January 1999. Seven patients are alive at 13–138 months later, 6 with functioning autografts and one after rescue with an allotransplantation.Conclusion: Intestinal/multivisceral autotransplantation is a potentially valuable option for some otherwise unresectable neoplasms of the root of the mesentery.

A 5-year review of a trauma-trained hospitalist program for trauma patients: A matched cohort study - Corrected Proof

2012-03-05

Background: Level I trauma centers have requirements on the percentage of trauma patients admitted to either a trauma surgeon or surgical subspecialist; however, surgical resources are in steady decline. Therefore, a trauma system might better utilize its surgical resources if trained hospitalists admitted a larger percentage of mild to moderately injured trauma patients. The objective of this report is to provide a 5-year evaluation of a trauma medical service (TMED) at treating mild to moderately injured trauma patients.Methods: Adult trauma patients consecutively admitted to a Level I trauma center between January 2006 and December 2010 were analyzed. Patients admitted to trauma surgical services were matched 1:1 to those admitted to TMED, via propensity scores. Paired t tests examined differences in hospital duration of stay (DOS), and exact conditional logistic regression examined differences in the odds of having a delayed diagnosis, developing a complication, and dying.Results: Of 1,202 TMED patients, 494 were matched; matched TMED patients had similar patient outcomes to nonmatched TMED patients. There were no differences between study groups in the mean hospital DOS, the proportion having a delayed diagnosis, or in the odds of dying in the hospital (P > .05 for all). The TMED group had a nominally higher complication rate (P = .12) owing to a higher rate of urinary tract infections.Conclusion: Since its inception, the TMED service has successfully and safely treated mild to moderately injured trauma patients, and decreased the dependency on trauma surgical services. Trauma centers might utilize declining surgical services more efficiently with the addition of trauma medical hospitalists.

Sentinel lymph node biopsy in management of early breast cancer: Is it rational to omit blue dye injection? - Corrected Proof

Ahmad Kaviani, Behnoud Baradaran Noveiry, Morteza Noaparast — 2012-03-05

Up to now, there has been no other method comparable with axillary lymph node dissection, the gold standard of breast cancer staging, than sentinel lymph node biopsy (SNB). Sentinel nodes can be mapped by means of both blue dye, radioisotope labeled colloid (RI), and lymphoscintigraphy. Bines et al in 2008 and, more recently, Kang et al in 2010 reported that when RI mapping agent is available, blue dye provides no further assistance; therefore, considering its side effects, their dye should be avoided. Although concordance between the 2 methods is accepted, underestimation in lymphatic involvement can be a serious mistake.

Midline abdominal wall incisional hernia after aortic reconstructive surgery: A prospective study - Corrected Proof

2012-03-01

Background and Purpose: To evaluate rate of formation of midline abdominal wall incisional hernia (MAIH) after elective open repair of abdominal aortic aneurysm (AAA) and revascularization for aortoiliac occlusive disease (AOD).Methods: AAA and AOD patients operated electively via a primary midline abdominal incision at our institution over a decade were entered in this prospective study. Patients who had already undergone midline laparotomy or had an MAIH after previous celiotomy were excluded. Patients were examined for MAIH 6-monthly for 2 years, then yearly.Results: We included 1,065 patients who underwent aortic reconstructive surgery (412 with AAA and 653 with AOD). The follow-up (mean ± standard deviation) was 6.4 ± 3.8 years (range, 0.5–12.7). Wounds were closed with a suture length-to-wound length (SL:WL) ratio of at least 4:1 in 58% (239 of 653) of AAA patients and 66% (431 of 653) of AOD patients (P = .01). There were 124 (11.6%) MAIHs, with an incidence of 12.4% (51 of 412) in the AAA group and 11.2% (73 of 653) in the AOD group (P = .62), and 3 (0.4%) wound infections (all among the AOD patients), none of which resulted in MAIH. At multivariate analysis, a SL:WL ratio of <4:1 was the only independent predictor of MAIH in AAA (P = .004) and AOD patients (P < .001).Conclusion: AAA and AOD patients had a similar incidence of MAIH, which seems related to the wound closure technique. A SL:WL ratio of at least 4:1 is recommended. Further clinical studies are required to determine possible technical and perioperative variables that may be modified to decrease the incidence of MAIH development after aortic reconstructive surgery.

Laparoscopic simulation training: Testing for skill acquisition and retention - Corrected Proof

2012-02-20

Background: Simulation in laparoscopy leads to skill acquisition. Although many curricula for simulation training have been described, the nature of skill deterioration remains unclear. We evaluated skill acquisition and retention after laparoscopic simulation training.Methods: Thirty-six novices in surgery (medical students) underwent a 5-day curriculum consisting of 9 skills of increasing complexity. Each subject underwent baseline and post-training evaluation after completion of the course. Skill retention testing was measured after 6 weeks (group 1; n = 18) and after 11 weeks (group 2; n = 18). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance.Results: Comparison of the baseline and post-training values revealed a significant learning outcome for all exercises in both groups (P < .001). In group 1, skill retention testing found no significant decrease in skill level when compared to post-training values in all but 1 task (extracorporeal knot tying; P = .007). In group 2, differences between skill retention and post-training evaluation were observed for 5 of the 9 tasks (transfer task, positioning, loop tie, extracorporeal knot, and intracorporeal knot; P ≤ .05 for each).Conclusion: Basic laparoscopic skills can be learned successfully by novices in surgery using a compact curriculum. These skills are retained for at least 6 weeks. Eleven weeks after initial training, skill deterioration is likely, and therefore an opportunity for practice and repetition is desirable.

Risk of second primary malignancy in differentiated thyroid carcinoma treated with radioactive iodine therapy - Corrected Proof

2012-02-17

Background: Differentiated thyroid cancer survivors are at increased risk of nonsynchronous second primary malignancy, but the cause remains unclear. This study aimed to evaluate the association between radioiodine therapy and risk of nonsynchronous second primary malignancy and to examine whether the risk of nonsynchronous second primary malignancy in differentiated thyroid cancer survivors treated with radioiodine therapy is increased relative to the general population.Methods: Among 895 radiation-naïve patients with differentiated thyroid cancer, 643 (71.8%) received ≥1 course of radioiodine therapy (radioiodine therapy–positive group) and 252 (28.2%) received no radioiodine therapy (radioiodine therapy–negative group). After a median follow-up of 93.5 months (range, 23.4–570.8), 64 (7.2%) patients developed ≥1 nonsynchronous second primary malignancy. Potential risk factors for nonsynchronous second primary malignancy were entered into a multivariable regression model and cancer incidence in the radioiodine therapy–positive and –negative groups were compared to that of the general population by estimating the standardized incidence ratios.Results: The 20-year cumulative nonsynchronous second primary malignancy risk in radioiodine therapy–positive group was significantly higher than radioiodine therapy–negative group (13.5% vs 3.1%; P = .015). Cumulative radioiodine therapy activity of 3.0 to 8.9 GBq (relative risk, 2.77; 95% CI, 1.079–7.154; P = .034) was the only independent risk factor for nonsynchronous second primary malignancy after adjusting for age, sex, period of differentiated thyroid cancer diagnosis, and stage of differentiated thyroid cancer. For females, the standardized incidence ratio in the radioiodine therapy–positive group was 1.54 (95% CI, 1.11–2.08) and in the radioiodine therapy–negative group it was 0.92 (95% CI, 0.37–1.90).Conclusion: Differentiated thyroid cancer female survivors treated by radioiodine therapy appeared to be at elevated risk of nonsynchronous second primary malignancy when compared to the general population and this risk was not apparent in those not previously treated by radioiodine therapy.

Response to “Single nucleotide polymorphisms and development of hereditary medullary thyroid cancer in V804M RET families: Disease modification or linkage disequilibrium?” - Corrected Proof

Alexander L. Shifrin, Yen-Hong Kuo, Jennifer Ogilvie — 2012-02-17

We appreciate your thoughtful comments regarding our paper. With our response, we hope to address the issues that were presented. Our research purpose in analyzing these 2 “independent” families was in no way to perform a genome-wide association study (GWAS). GWAS requires hundreds to thousands of individuals from independent families (affected/unaffected) to be tested to determine genotype/phenotype associations. As stated in our conclusion, we consider the single nucleotide polymorphisms (SNPs) we identified to be candidates for further GWAS study and invite collaboration with other researchers to determine the significance of these SNPs. Other published studies have presented similar data. We believe that our data, although limited, may encourage additional researchers to study the impact of SNPs, and to collaborate with other researchers to establish the clinical relevance of these SNPs.

Mortality risk after liver transplantation in hepatocellular carcinoma recipients: A nonlinear predictive model - Corrected Proof

Ming Zhang, Fei Yin, Bo Chen, Bo Li, You Ping Li, Lu Nan Yan, Tian Fu Wen — 2012-02-17

Background: The balanced application of a model for the estimate of outcomes of liver transplantation, in concert with assessment of disease severity, would not only improve transplant outcomes and maximize patient benefit from transplantation, but also facilitate informed decision making by patients and their relatives when considering transplantation. So far, however, linear discriminating methods have failed to attain sufficient power to predict post-transplant prognosis. Therefore, our aim was to develop a cancer-specific prognostic model by a nonlinear methodology based on pretransplant characteristics.Methods: With data collected retrospectively from 290 liver transplant recipients with HCC from February 1999 to August 2009, a multilayer perceptron (MLP) neural network was constructed to predict mortality risk after transplantation. Its predictive performances at posttransplant 1-, 2-, and 5-year intervals were evaluated using a receiver operating characteristic curve.Results: By the forward stepwise selection in MLP network, donor age, donor body mass index, recipient hemoglobin, serum concentrations of total bilirubin, alkaline phosphatase, creatinine, aspartate aminotransferase, international normalized ratio of prothrombin time, and Na+; alpha fetoprotein categorization, total diameter, number of tumor lesions, presence of imaging macrovascular invasion, and lobe distribution of the tumor were identified to be the optimal input features. The MLP, employing 24 inputs and 7 hidden neurons, yielded c-statistics of 0.909 (P < .001) in the 1-year, 0.888 (P < .001), in the 2-year, and 0.845 (P < .001) in the 5-year prediction.Conclusion: Post-transplant prognosis is a multidimensional, nonlinear problem, and the specific MLP can achieve high accuracy in the prediction of posttransplant mortality risk for HCC recipients. The pattern recognition methodologies like MLP hold promise for solving outcome prediction after liver transplantation.

Be cautious in caudate lobectomy for patients with solitary caudate lobe hepatocellular carcinoma and severe cirrhosis - Corrected Proof

Hongyu Li — 2012-02-13

We recently read the article by Sakamoto et al regarding caudate lobectomy for solitary hepatocellular carcinoma (HCC). The author noted that the prognosis of these patients was as good as that of patients with solitary HCC in other liver segments. Caudate lobe is a structurally separate and distinct liver lobe. It has its own independent vascularization and biliary drainage. Various methods are available for the caudate lobectomy. Although the authors of previous studies confirm that it is safe to perform complete caudate lobectomy, 1 of these patients in our medical unit experienced fatal portal hypertension and acute liver failure after caudate lobectomy and died because of multiple organ dysfunction.

Recommendation for standardized surgical management of primary adrenocortical carcinoma - Corrected Proof

Sébastien Gaujoux, Murray F. Brennan — 2012-02-10

Background: Operative resection is the only potentially curative treatment for primary adrenocortical carcinoma (ACC), but standards of operative care are not defined with regards to the extent of local resection. We propose recommendations for operative management.Methods: Anatomic and clinical literature review focusing on local management of ACC, including lymphadenectomy and resection of adjacent organs or large vessels.Results: First-order drainage nodes of the adrenal gland include the renal hilum lymph nodes, the celiac lymph nodes, and the para-aortic and paracaval lymph nodes, mainly above the renal pedicle and ipsilateral to the adrenal glands. Lymph node involvement occurs in about 20% of patients with ACC, and is an important prognostic factor, but lymphadenectomy is performed infrequently. The adrenal glands and kidneys are contained in the same anatomic space, but systematic en bloc nephrectomy has no proven benefits for survival. Direct invasion of the kidney or adjacent organs is rare, but major venous invasion with tumor thrombus is relatively common. Both are associated with decreased survival, but complete resection can lead to long-term survival.Conclusion: Standardization of regional lymphadenectomy including first-order drainage nodes is proposed. Systematic nephrectomy is not necessary in the absence of gross local invasion, but locally involved organs or large veins should be resected en bloc, with tumor thrombus embolectomy, if R0 resection is possible. Operative standardization improves tumor staging, potentially decreases local recurrence, and may be associated with better survival. Evidence-based standards of operative care and prospective investigations within international collaborating groups are necessary.

The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: A systematic review - Corrected Proof

2012-02-10

Background: To determine the role of liver resection in patients with liver and extrahepatic colorectal cancer metastases and the role of chemotherapy in patients in conjunction with liver resection.Methods: MEDLINE and EMBASE databases were searched for articles published between 1995 and 2010, along with hand searching.Results: A total of 4875 articles were identified, and 83 were retained for inclusion. Meta-analysis was not performed because of heterogeneity and poor quality of the evidence. Outcomes in patients who had liver and lung metastases, liver and portal node metastases, and liver and other extrahepatic disease were reported in 14, 10, and 14 studies, respectively. The role of perioperative chemotherapy was assessed in 30 studies, including 1 randomized controlled trial and 1 pooled analysis. Ten studies assessed the role of chemotherapy in patients with initially unresectable disease, and 5 studies assessed the need for operation after a radiologic complete response.Conclusion: The review suggests that: (1) select patients with pulmonary and hepatic CRC metastases may benefit from resection; (2) perioperative chemotherapy may improve outcome in patients undergoing a liver resection; (3) patients whose CRC liver metastases are initially unresectable may benefit from chemotherapy to identify a subgroup who may benefit later from resection; (4) after radiographic complete response (RCR), lesions should be resected if possible.

Quantification of hypercoagulable state after blunt trauma: Microparticle and thrombin generation are increased relative to injury severity, while standard markers are not - Corrected Proof

2012-02-10

Background: Major trauma is an independent risk factor for developing venous thromboembolism. While increases in thrombin generation and/or procoagulant microparticles have been detected in other patient groups at greater risk for venous thromboembolism, such as cancer or coronary artery disease, this association has yet to be documented in trauma patients. This pilot study was designed to characterize and quantify thrombin generation and plasma microparticles in individuals early after traumatic injury.Methods: Blood was collected in the trauma bay from 52 blunt injured patients (cases) and 19 uninjured outpatients (controls) and processed to platelet poor plasma to allow for (1) isolation of microparticles for identification and quantification by flow cytometry, and (2) in vitro thrombin generation as measured by calibrated automatic thrombography. Data collected are expressed as either mean ± standard deviation or median with interquartile range.Results: Among the cases, which included 39 men and 13 women (age, 40 ± 17 years), the injury severity score was 13 ± 11, the international normalized ratio was 1.0 ± 0.1, the thromboplastin time was 25 ± 3 seconds, and platelet count was 238 ± 62 (thousands). The numbers of total (cell type not specified) procoagulant microparticles, as measured by Annexin V staining, were increased compared to nontrauma controls (541 ± 139/μL and 155 ± 148/μL, respectively; P < .001). There was no significant difference in the amount of thrombin generated in trauma patients compared to controls; however, peak thrombin was correlated to injury severity (Spearman correlation coefficient R, 0.35; P = .02).Conclusion: Patients with blunt trauma have greater numbers of circulating procoagulant microparticles and increased in vitro thrombin generation. Future studies to characterize the cell-specific profiles of microparticles and changes in thrombin generation kinetics after traumatic injury will determine whether microparticles contribute to the hypercoagulable state observed after injury.

Gastric volvulus after sleeve gastrectomy for morbid obesity - Corrected Proof

2012-02-10

Background: Laparoscopic sleeve gastrectomy in morbid obesity has proved to be a safe and reproducible technique. Sleeve gastrectomy, however, is not free of complications. On the other hand, gastric volvulus is reported in those subjects where, either because of laxity of the gastric anatomical fixations or incorrect position of the stomach, rotation or turning is facilitated.Case: We report the case of a patient with morbid obesity (Bone mass index / BMI 63 Kg/m2), who in the post-operative period immediately following a sleeve gastrectomy, presented early symptoms of upper gastrointestinal occlusion indicative of gastric volvulus of the gastric sleeve.Results: The patient developed a partial obstruction secondary to a mixed volvulus mechanism (organo-axial and partially mesenteric-axial) after sleeve gastrectomy. We performed a laparoscopic antrectomy of the gastric sleeve and then a gastroileal anastomosis, a form of biliopancreatic diversion, with a common channel of 80 cm and alimentary limb of 160 cm). 18 months after, the patient has a BMI of 28 kg/m2 and enjoys a good quality of life.Conclusion: Sleeve gastrectomy leaves the stomach with no fixations along the entire greater curvature, which may predispose to volvulus. This complication is a rare finding and not reported to date following this intervention, but still needs to be considered in this type of patient.

Social media in low-resource settings: A role for Twitter and Facebook in global surgery? - Corrected Proof

Jeffrey J. Leow, Marcos E. Pozo, Reinou S. Groen, Adam L. Kushner — 2012-02-10

The world has witnessed recently how social media web sites, such as Twitter and Facebook, played pivotal roles in the mass mobilization of populations and the coordination of demonstrations in the Middle East. In our increasingly “flat,” interconnected world of advanced telecommunications and computer technology, we as medical professionals must stay current and explore how best to fit these technologies into our medical practice. Recently, there has been increased discussion in the medical and surgical literature regarding the role of social media in medicine.

Liver resection for liver metastases from nondigestive endocrine cancer: Extrahepatic disease burden defines outcome - Corrected Proof

2012-02-10

Background: For patients with hepatic nondigestive endocrine metastases (HNEM), the role of liver resection is not well-defined.Methods: We reviewed outcomes for patients who underwent liver resection for HNEM at 2 centers to identify predictors of survival.Results: From 1991 to 2010, 51 patients underwent liver resection for HNEM. Primary tumor types were adrenal gland (n = 26), thyroid (n = 11), testicular germ cell (n = 9), and ovarian granulosa cell (n = 5). 28 patients (55%) had synchronous or early (diagnosed within 12 months after primary tumor resection) liver metastases. At liver resection, 26 patients (51%) had extrahepatic metastases, and 7 (14%) had ≥2 sites of extrahepatic metastases. 32 patients (63%) had major liver resection and 19 (37%) had a simultaneous extrahepatic procedure. 90-day postoperative morbidity and mortality rates were 27% and 2%, respectively. After median follow-up of 20 months (range, 1–144), the 5-year overall and recurrence-free survival rates were 58% and 37%, respectively. Survival was not affected by primary tumor type. In multivariate analysis, ≥2 sites of extrahepatic metastases (hazard ratio [HR] = 4.80; 95% confidence interval [CI] = 1.18–19.50; P = .028) and interval of ≤12 months between primary tumor resection and diagnosis of liver metastases (HR = 5.33; 95% CI = 1.11–25.71; P = .037) were associated with worse overall survival after liver resection.Conclusion: For selected patients, liver resection for HNEM is associated with long-term survival. The number of extrahepatic sites of metastasis and the timing of appearance of liver metastases should be considered in patient selection.

Effects of ileal interposition on glucose metabolism in obese rats with diabetes - Corrected Proof

2012-02-10

Background: Ileal interposition (IT), in which the distal ileum is transposed isoperistaltically into the proximal jejunum, is considered as a procedure for metabolic or antidiabetes surgery. Our aim was to study the effects of IT on glycemic control, fat metabolism, and hormonal changes in obese rats with spontaneous diabetes.Methods: Animals were divided into either an IT or a sham (SH) group. They underwent an oral glucose tolerance test (OGTT) before and 4 and 8 weeks after the operation. All animals were killed 10 weeks after operation for analyses of tissue weight (liver, pancreas, epididymal fat, brown fat), immunoblotting of uncoupling protein-1 (UCP1) protein in brown adipose tissue (BAT), and fasting plasma levels of glucose, insulin, glucagon-like peptide (GLP)-1, peptide YY (PYY), glucose-dependent insulinotropic polypeptide (GIP), and leptin.Results: Body weight increased postoperatively in both groups compared with preoperative weight, but it did not differ between the 2 groups. Eight weeks postoperatively, integrated blood glucose levels during the OGTT were decreased in IT compared with SH (P < .05). Fasting plasma levels of insulin, GLP-1, and GIP did not differ between the 2 groups, but PYY levels were higher in the IT animals (P < .01). The weight of epididymal and BATs, homeostasis model assessment insulin resistance, and fasting plasma leptin levels were decreased in the IT group (P < .05). Expression of UCP1 was higher in IT than SH animals (P < .05).Conclusion: These results suggest that IT improves glucose and lipid metabolism by decreasing insulin resistance and epididymal fat, and increased expression of UCP1 in BAT might be among the mechanisms responsible.

Ectopic lingual thyroid with a multinodular goiter - Corrected Proof

2011-10-17

A 60-year old Chinese man presented complaining of dysphagia and fullness in his throat. Clinically, a large mass was palpable at the root of his tongue and computed tomography showed its extension to completely occlude the oropharynx (). Although his thyroid gland was notably absent, his thyroid function tests were normal and technetium Tc-99m scans revealed a distinctive uptake in the mass that was subsequently excised via a trans-cervical, trans-hyoid approach (). Histologic analysis confirmed the diagnosis of a multinodular goiter and he was immediately started on a course of thyroxine supplements. Follow-up visits have been largely unremarkable with significant amelioration of his complaints.

Telling the tale of Rapunzel syndrome - Corrected Proof

Vladimir Neychev, John Famiglietti, Pierre F. Saldinger — 2011-10-14

A 26-year-old woman was brought to the emergency department with mild abdominal discomfort, increasing nausea, and worsening constipation over the previous several days. She had a history of attention deficit hyperactivity disorder, mild mental retardation, and laparotomy for gastroduodenal trichobezoar at 11 years of age. The physical examination revealed diffuse nonspecific abdominal pain and a firm mass palpable in the epigastric region. Laboratory studies were unremarkable. Abdominal radiography suggested another bezoar, which was confirmed by upper gastrointestinal study with oral contrast (). Laparotomy was performed, and a large trichobezoar (490 g) forming a cast of the entire distal esophagus, stomach, and duodenal sweep was removed (). She recovered from the surgical procedure without complications and was discharged to home on postoperative day 4 with a recommendation for psychiatric follow-up.

An extremely rare portal annular pancreas for pancreaticoduodenectomy with a special note on the pancreatic duct management in the dorsal pancreas - Corrected Proof

Ippei Matsumoto, Makoto Shinzeki, Takumi Fukumoto, Yonson Ku — 2011-10-14

A previously healthy 81-year-old woman with general fatigue was admitted to our hospital in June 2009. Her blood chemistry data were within normal limits except for slightly elevated liver function values. Serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen were both normal. Gastroduodenoscopy showed an erosive tumor in the ampulla of Vater. Dynamic computed tomography (CT) revealed bilateral intrahepatic biliary dilatation, and the superior mesenteric vein (SMV) circumferentially embedded in the body of the pancreas, as well as a slightly dilated main pancreatic duct (MPD) in the tissue behind the SMV (). The MPD was found posteriorly to the SMV and the accessory pancreatic duct (APD) was seen anteriorly to the SMV. The 2 ducts joined in the body of the pancreas to the left side of the SMV. A preoperative diagnosis was cancer of the ampulla of Vater accompanying a portal annular pancreas (PAP). The patient underwent pancreaticoduodenectomy (PD). Intraoperatively, after transection of the pancreas on the SMV, we saw the parenchyma of the uncinate process communicating behind the SMV with the body of the pancreas (, A). We inserted a small tube into the cut orifice of the distal APD and performed intraoperative pancreatography. The dilated MPD and the point of the ductal conjunction were confirmed (, B and C). Pancreaticojejunostomy was performed after a second pancreatic transection at the distal side of the ductal conjunction. Histologically, the resected specimen revealed an adenocarcinoma of the ampulla of Vater. The postoperative course was uneventful and the patient was discharged on postoperative day 32.

Pancreatic acinar cell carcinoma - Corrected Proof

Gianpiero Gravante, Robert N. Williams, Ashley R. Dennison, David J. Bowrey — 2011-10-10

A 79-year-old man had multiple admissions with abdominal pain and significant weight loss. A gastroscopy revealed mild esophagitis and gastritis, while a computed tomographic scan revealed a 9.1 × 8.5 cm (on axial section) heterogeneous solid-appearing rounded lesion in the lesser curvature of the stomach. The mass compressed the tail of the pancreas, was in close contact with the 3rd and 4th parts of the duodenum, and was thought to represent a gastrointestinal stromal tumor–type tumor. A second computed tomographic scan performed 1 month later revealed an increase in size. A splenectomy, distal pancreatectomy, and partial gastrectomy (posterior stomach) were performed. Postoperative recovery was uneventful.