Showing papers in "Annals of Surgery in 2007"

Cholangiocarcinoma: Thirty-one-Year Experience With 564 Patients at a Single Institution

Abstract: Objective:To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer.Summary Background Data:The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most

The TME Trial After a Median Follow-Up of 6 Years: Increased Local Control but No Survival Benefit in Irradiated Patients With Resectable Rectal Carcinoma

Abstract: Objective To investigate the efficacy of preoperative short-term radiotherapy in patients with mobile rectal cancer undergoing total mesorectal excision (TME) surgery. Summary background data Local recurrence is a major problem in rectal cancer treatment. Preoperative short-term radiotherapy has shown to improve local control and survival in combination with conventional surgery. The TME trial investigated the value of this regimen in combination with total mesorectal excision. Long-term results are reported after a median follow-up of 6 years. Methods One thousand eight hundred and sixty-one patients with resectable rectal cancer were randomized between TME preceded by 5 x 5 Gy or TME alone. No chemotherapy was allowed. There was no age limit. Surgery, radiotherapy, and pathologic examination were standardized. Primary endpoint was local control. Results Median follow-up of surviving patients was 6.1 year. Five-year local recurrence risk of patients undergoing a macroscopically complete local resection was 5.6% in case of preoperative radiotherapy compared with 10.9% in patients undergoing TME alone (P Conclusions With increasing follow-up, there is a persisting overall effect of preoperative short-term radiotherapy on local control in patients with clinically resectable rectal cancer. However, there is no effect on overall survival. Since survival is mainly determined by distant metastases, efforts should be directed towards preventing systemic disease.

Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial.

Abstract: Purpose: Oncologic concerns from high wound recurrence rates prompted a multi-institutional randomized trial to test the hypothesis that disease-free and overall survival are equivalent, regardless of whether patients receive laparoscopic-assisted or open colectomy. Methods: Eight hundred seventy-two patients with curable colon cancer were randomly assigned to undergo laparoscopic-assisted or open colectomy at 1 of 48 institutions by 1 of 66 credentialed surgeons. Patients were followed for 8 years, with 5-year data on 90% of patients. The primary end point was time to recurrence, tested using a noninferiority trial design. Secondary endpoints included overall survival and disease-free survival. (Kaplan-Meier) Results: As of March 1, 2007, 170 patients have recurred and 252 have died. Patients have been followed a median of 7 years (range 5-10 years). Disease-free 5-year survival (Open 68.4%, Laparoscopic 69.2%, P = 0.94) and overall 5-year survival (Open 74.6%, Laparoscopic 76.4%, P = 0.93) are similar for the 2 groups. Overall recurrence rates were similar for the 2 groups (Open 21.8%, Laparoscopic 19.4%, P = 0.25). These recurrences were distributed similarly between the 2 treatment groups. Sites of first recurrence were distributed similarly between the treatment arms (Open: wound 0.5%, liver 5.8%, lung 4.6%, other 8.4%; Laparoscopic: wound 0.9%, liver 5.5%, lung 4.6%, other 6.1%). Conclusion: Laparoscopic colectomy for curable colon cancer is not inferior to open surgery based on long-term oncologic endpoints from a prospective randomized trial.

Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?

Abstract: Objectives: Coagulopathy following major trauma is conventionally attributed to activation and consumption of coagulation factors. Recent studies have identified an acute coagulopathy present on admission that is independent of injury severity. We hypothesized that early coagulopathy is due to tissue hypoperfusion, and investigated derangements in coagulation associated with this. Methods: This was a prospective cohort study of major trauma patients admitted to a single trauma center. Blood was drawn within 10 minutes of arrival for analysis of partial thromboplastin and prothrombin times, prothrombin fragments 12, fibrinogen, thrombomodulin, protein C, plasminogen activator inhibitor-1, and D-dimers. Base deficit (BD) was used as a measure of tissue hypoperfusion. Results: A total of 208 patients were enrolled. Patients without tissue hypoperfusion were not coagulopathic, irrespective of the amount of thrombin generated. Prolongation of the partial thromboplastin and prothrombin times was only observed with an increased BD. An increasing BD was associated with high soluble thrombomodulin and low protein C levels. Low protein C levels were associated with prolongation of the partial thromboplastin and prothrombin times and hyperfibrinolysis with low levels of plasminogen activator inhibitor-1 and high D-dimer levels. High thrombomodulin and low protein C levels were significantly associated with increased mortality, blood transfusion requirements, acute renal injury, and reduced ventilator-free days. Conclusions: Early traumatic coagulopathy occurs only in the presence of tissue hypoperfusion and appears to occur without significant consumption of coagulation factors. Alterations in the thrombomodulin-protein C pathway are consistent with activated protein C activation and systemic anticoagulation. Admission plasma thrombomodulin and protein C levels are predictive of clinical outcomes following major trauma.

Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass.

Abstract: Objective:To evaluate the physiologic importance of the satiety gut hormones.Background:Controversy surrounds the physiologic role of gut hormones in the control of appetite. Bariatric surgery remains the most effective treatment option for obesity, and gut hormones are implicated in the reduction o

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial.

Abstract: Objective: To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival. Background: A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available. Methods: A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy. Results: After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02). Conclusion: There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.

A Multicenter Study on Oncologic Outcome of Laparoscopic Gastrectomy for Early Cancer in Japan

Abstract: Background: Laparoscopic surgery for gastric cancer is technically feasible, but it is not widely accepted because it has not been evaluated from the standpoint of oncologic outcome. We conducted a retrospective, multicenter study of a large series of patients in Japan to evaluate the short- and long-term outcomes of laparoscopic gastrectomy for early gastric cancer (EGC).

Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004.

Abstract: BACKGROUND:: Effective combat trauma management strategies depend upon an understanding of the epidemiology of death on the battlefield. METHODS:: A panel of military medical experts reviewed photographs and autopsy and treatment records for all Special Operations Forces (SOF) who died between October 2001 and November 2004 (n = 82). Fatal wounds were classified as nonsurvivable or potentially survivable. Training and equipment available at the time of injury were taken into consideration. A structured analysis was conducted to identify equipment, training, or research requirements for improved future outcomes. RESULTS:: Five (6%) of 82 casualties had died in an aircraft crash, and their bodies were lost at sea; autopsies had been performed on all other 77 soldiers. Nineteen deaths, including the deaths at sea were noncombat; all others were combat related. Deaths were caused by explosions (43%), gunshot wounds (28%), aircraft accidents (23%), and blunt trauma (6%). Seventy of 82 deaths (85%) were classified as nonsurvivable; 12 deaths (15%) were classified as potentially survivable. Of those with potentially survivable injuries, 16 causes of death were identified: 8 (50%) truncal hemorrhage, 3 (19%) compressible hemorrhage, 2 (13%) hemorrhage amenable to tourniquet, and 1 (6%) each from tension pneumothorax, airway obstruction, and sepsis. The population with nonsurvivable injuries was more severely injured than the population with potentially survivable injuries. Structured analysis identified improved methods of truncal hemorrhage control as a principal research requirement. CONCLUSIONS:: The majority of deaths on the modern battlefield are nonsurvivable. Improved methods of intravenous or intracavitary, noncompressible hemostasis combined with rapid evacuation to surgery may increase survival. Language: en

Hospital volume and late survival after cancer surgery

Abstract: Context:Although hospital procedure volume is clearly related to operative mortality with many cancer procedures, its effect on late survival is not well characterized.Objective:To examine relationships between hospital volume and late survival after different types of cancer resections.Design:Using

Extent of surgery affects survival for papillary thyroid cancer.

Abstract: Papillary thyroid cancer (PTC) is the most common but least aggressive histologic subtype of thyroid cancer. The American Cancer Society estimates that approximately 33,550 people in the United States will be diagnosed with thyroid cancer in 2007, and 1530 will die of the disease.1 Most patients with PTC have an excellent prognosis. However, recent studies have demonstrated an increasing incidence of PTC, particularly due to the detection of tumors <2 cm.2,3 Moreover, mortality rates may be increasing for certain subgroups.4 For decades, there has been considerable debate regarding the extent of surgery for PTC, particularly for tumors 1.0 to 1.5 cm. However, a difference in survival favoring total thyroidectomy over lobectomy has only been demonstrated for tumors >3 cm.10–12 Thus, these guidelines advocating near-total or total thyroidectomy for PTC ≥1.0 cm are not based on data demonstrating a difference in survival, but rather on the possibility of multifocal disease, recurrence, and other practicalities of treatment and follow up.6,13 Prospective randomized clinical trials assessing the impact of surgical management on PTC outcomes are impractical and have not been performed because they would require a large number of patients to be followed for an extended period of time.14 We hypothesized that total thyroidectomy for PTC results in improved outcomes compared with lobectomy. Using the National Cancer Data Base (NCDB), we identified 52,173 patients who underwent surgery for PTC in the United States from 1985 to 1998. The objective of this study was to determine whether total thyroidectomy resulted in improved recurrence and long-term survival rates for patients with PTC. Furthermore, we sought to determine whether a specific tumor size threshold could be identified above which total thyroidectomy was associated with a decreased risk of recurrence and death.

Weight Gain After Short- and Long-Limb Gastric Bypass in Patients Followed for Longer Than 10 Years

Abstract: In the past, we reported the results of gastric bypass in 274 patients consecutively operated upon, who were followed for a mean of 5.5 ± 1.5 years (range, 3–8.4 years).1,2 We were concerned with weight loss and how this was influenced by preoperative weight, time to follow-up, and the presence of a long- or short-limb bypass. We emphasized clinical classification of all patients as excellent, good, or failure on the basis of final body mass indices.3 We also compared our results of gastric bypass to those reported by Marceau et al4 with biliopancreatic diversion with duodenal switch because they, uniquely, in the literature provided data on the above-mentioned variables with a similar follow-up time. It is the purpose of the present study to report follow-up on the same patients after a mean of 11.4 years (range, 4.7–14.9 years) and again to compare the results to those achieved with biliopancreatic diversion and duodenal switch with follow-up of all patients greater than 10 years.5

Anastomotic Leaks After Intestinal Anastomosis: It's Later Than You Think

Abstract: Anastomotic disruption is perhaps the most dreaded complication after intestinal surgery. Some leaks presents in a dramatic fashion early in the postoperative period, leaving little doubt about the diagnosis. However, many others present in a far more subtle fashion, often relatively late in the postoperative period, and can be difficult to distinguish from other postoperative infectious complications. It is this latter scenario where definitions are critical and retrospective analyses become rather suspect. In this light, it is not surprising that the reported incidence of anastomotic leakage varies so dramatically in the literature.1–7 The aim of this study was to use a rigorous, prospectively maintained complication database to more accurately define the incidence and presentation of anastomotic leakage after intestinal anastomosis.

Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

Abstract: Objective: To better understand the impact of a microscopically positive margin (R1) on patterns of disease recurrence and survival after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma. Summary Background Data: A positive resection margin after PD is considered to be a poor prognostic factor, and some have proposed that an R1 margin may be a biologic predictor of more aggressive disease. The natural history of patients treated with contemporary multimodality therapy who underwent a positive margin PD has not been described. Methods: We analyzed our experience from 1990 to 2004, which included the prospective use of a standardized system for pathologic analysis of all PD specimens. All patients who underwent PD met objective computed tomographic criteria for resection. Standard pathologic evaluation of the PD specimen included permanent section analysis of the final bile duct, pancreatic, and superior mesenteric artery (SMA) margins. First recurrences (all sites) were defined as local, regional, or distant. Survival and follow-up were calculated from the date of initial histologic diagnosis to the dates of first recurrence or death and last contact, respectively. Results: PD was performed on 360 consecutive patients with pancreatic adenocarcinoma. Minimum follow-up was 12 months (median, 51.9 months). The resection margins were negative (R0) in 300 patients (83.3%) and positive (R1) in 60 (16.7%); no patients had macroscopically positive (R2) margins. By multivariate analysis (MVA), high mean operative blood loss and large tumor size were independent predictors of an R1 resection. Patients who underwent an R1 resection had a median overall survival of 21.5 months compared with 27.8 months in patients who underwent an R0 resection. After controlling for other variables on MVA, resection status did not independently affect survival. By MVA, only lymph node metastases, major perioperative complications, and blood loss adversely affected survival. Conclusions: There was no statistically significant difference in patient survival or recurrence based on R status. However, this series is unique in the incorporation of a standardized surgical technique for the SMA dissection, the prospective use of a reproducible system for pathologic evaluation of resection margins, the absence of R2 resections, and the frequent use of multimodality therapy. (Ann Surg 2007;246: 52‐60)

National Failure to Operate on Early Stage Pancreatic Cancer

Abstract: Pancreatic cancer is the fourth leading cause of cancer deaths in the United States. In 2007, the American Cancer Society estimates that over 37,000 patients will be diagnosed with pancreatic cancer, and more than 33,000 will die of the disease.1 Patients with pancreatic cancer have a particularly dismal prognosis due to multiple factors, including late presentation, aggressive tumor biology, complex surgical management, and the lack of effective systemic therapies.2,3 Overall survival rates have remained relatively unaffected with fewer than 5% of all patients surviving 5 years after diagnosis.4 Surgery remains the only potentially curative treatment of localized pancreatic cancer.3 During the last 20 years, significant advances in preoperative evaluation, surgical techniques, and postoperative care have reduced the perioperative morbidity and mortality associated with pancreatic surgery.5–8 Mortality after pancreaticoduodenectomy has dropped from ∼25% in the 1960s to less than 3% in some high-volume centers,7–11 and recent studies have suggested improvements in long-term survival rates after resection for localized disease that approach 30%.12 Despite numerous studies and guidelines establishing pancreatectomy as the primary treatment modality for localized pancreatic adenocarcinoma, pessimistic attitudes toward all patients with pancreatic cancer have perhaps led to skepticism regarding the efficacy of resection. Clinicians have long recognized that a diagnosis of pancreatic cancer encompasses little variability in long-term outcomes; however, these views are outdated in light of recent evidence. Our hypothesis was that these attitudes affect utilization of surgery for early stage pancreatic cancer after controlling for age, comorbidities, and patient refusal to undergo surgery. The objectives of this study were 1) to evaluate and characterize the utilization of surgery for pancreatic adenocarcinoma, 2) to identify factors predicting failure to undergo surgery for localized disease, and 3) to evaluate the effect of surgery on survival.

Evaluation of 300 minimally invasive liver resections at a single institution: less is more.

Abstract: Minimally invasive liver resection (MILR) represents a natural extension of the continued evolution of minimally invasive surgery in general and laparoscopic liver surgery in particular. The growing experience with laparoscopic procedures, the ongoing technological advances in laparoscopic devices, and an increased patient awareness of the availability of these techniques have created an evolving interest in the application of these techniques to liver surgery and liver resection.1 The surgical skills required for MILR have evolved in parallel with the adaptation of laparoscopic techniques to these procedures. Whereas laparoscopic ablative procedures require laparoscopic surgical skills that may include operative ultrasonography and liver mobilization, they typically do not necessitate either hilar dissection or parenchymal transection.2,3 In contrast, laparoscopic approaches to liver cysts4–6 and wedge resection of peripheral solid tumors7–9 may require more aggressive mobilization of the affected hemiliver(s) and transection of liver parenchyma and, therefore, are more technically demanding and potentially more hazardous. Anatomic hemihepatectomies require a clear understanding of liver anatomy, experience with liver surgery, and, additionally, the ability to deal laparoscopically with major vascular and biliary structures, both outside the parenchyma of the liver and during parenchymal transection.10 Finally, both segmental and sectional resections performed laparoscopically can be more technically demanding than hemihepatectomies, given that these are often performed without inflow control at the hilum and also because the area of parenchymal transection can be quite extensive. Hand-assist during these laparoscopic procedures can afford several benefits that include the ability to use the surgeon’s hand to help stabilize and mobilize the liver and, in cases of hemorrhage, the use of temporary digital control by the direct application of pressure.11 Despite these technical challenges, MILR has been used increasingly in the management of liver tumors over the past decade. Beginning in 1993, the Division of Transplantation at Northwestern Memorial Hospital has been involved in the care of patients with hepatobiliary pathology, such as benign and malignant liver tumors. Standard open surgical techniques were used exclusively until the late 1990s. When the minimally invasive liver surgery program was instituted by one of the authors (A.K.) in 2001, a database was initiated that has registered the details of each case performed regardless of surgical approach. The database is not limited to liver resections and also includes other minimally invasive liver surgery such as laparoscopic ablation of liver tumors and is maintained in real-time. In this study, we will report on the evolution of MILR at our center and review and evaluate our collective experience with these procedures.

Two Thousand Transhiatal Esophagectomies Changing Trends, Lessons Learned

Abstract: In 1978, the senior author reported at the Annual Meeting of the American Association for Thoracic Surgery his experience with 28 “blunt” transhiatal esophagectomies, 4 for benign disease and 22 for esophageal carcinoma.1 The concept of resecting the esophagus without performing a thoracotomy had been proposed initially in 1913 by the German anatomist, Denk, who used an instrument similar to a Mayo vein stripper to mobilize the intrathoracic esophagus.2 In 1933, the British surgeon, Turner, carried out the first successful transhiatal blunt esophagectomy for carcinoma and reestablished continuity of the alimentary tract using an antethoracic skin tube at a second operation.3 But as safe open thoracotomy became a reality with the advent of general endotracheal anesthesia, and it was possible to resect the esophagus under direct vision, transhiatal esophagectomy without thoracotomy (THE) was performed only sporadically, usually as a concomitant procedure with laryngopharyngoesophagectomy for pharyngeal or cervical esophageal carcinomas when the stomach was used to restore continuity of the alimentary tract.4–6 Kirk used this approach for palliation of incurable esophageal carcinoma in 5 patients.7 Thomas and Dedo treated 4 patients with pharyngoesophageal caustic strictures by blunt thoracic esophagectomy without thoracotomy, mobilization of the stomach through the posterior mediastinum, and then a pharyngogastric anastomosis.8 The first transhiatal esophagectomy performed by the senior author (MBO) in 1976 was unplanned and without prior knowledge of the historical precedent for the procedure. Avoidance of (1) combined thoracic and abdominal incisions in debilitated patients with esophageal obstruction and (2) a mediastinal anastomosis with its potential for mediastinitis from a leak formed the basis for advocating this approach. This newly “resurrected” operation was not initially well received, and critics of transhiatal esophagectomy were quick to point out that the operation violated basic surgical principles of adequate hemostasis and exposure and was an inadequate “cancer operation” because it precluded an en bloc mediastinal lymph node dissection. Following our 1978 publication, multiple reports of series of transhiatal esophagectomies amply addressed the initial criticism of transhiatal esophagectomy. The 1999 report of the University of Michigan Section of Thoracic Surgery’s 22 year experience with 1085 transhiatal esophagectomies provided a benchmark standard for the operation.9 Since 2000, mortality after esophageal resection has been shown to be strongly related to the hospital volume of the procedure.10–13 In the subsequent 8.5 years since our 1999 report, an additional 944 of these operations have been performed for diseases of the intrathoracic esophagus bringing our experience with transhiatal esophagectomy to more than 2000. This experience of a high volume esophageal surgery center has resulted in a progressive reduction in the historic morbidity and mortality of esophageal resection. The changing trends and lessons learned in this cumulative experience are the subject of this report.

Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years.

Abstract: Objective:To complete a long-term (>10 years) follow-up of patients undergoing isolated roux-en-Y gastric bypass for severe obesity. Background:Long-term results of gastric bypass in patients followed for longer than 10 years is not reported in the literature. Methods:Accurate weights were recorded on 228 of 272 (83.8%) of patients at a mean of 11.4 years (range, 4.7–14.9 years) after surgery. Results were documented on an individual basis for both long- and short-limb gastric bypass and compared with results at the nadir BMI and % excess weight loss (%EWL) at 5 years and >10 years post surgery. Results:There was a significant (P < 0.0001) increase in BMI in both morbidly obese (BMI < 50 kg/m2) and super obese patients (BMI > 50 kg/m2) from the nadir to 5 years and from 5 to 10 years. The super obese lost more rapidly from time zero and gained more rapidly after reaching the lowest weight at approximately 2 years than the morbidly obese patients. There was no difference in results between the long- and short-limb operations. There was a significant increase in failures and decrease in excellent results at 10 years when compared with 5 years. The failure rate when all patients are followed for at least 10 years was 20.4% for morbidly obese patients and 34.9% for super obese patients. Conclusions:The gastric bypass limb length does not impact long-term weight loss. Significant weight gain occurs continuously in patients after reaching the nadir weight following gastric bypass. Despite this weight gain, the long-term mortality remains low at 3.1%.

The Prevalence and Prognostic Value of BRAF Mutation in Thyroid Cancer

Abstract: Objective: To examine the prevalence of BRAF mutation among thyroid cancer histologic subtypes and determine the association of BRAF mutation with indicators of poor prognosis for papillary thyroid cancer and patient outcome. Background Data: The appropriate extent of surgical treatment, adjuvant therapy and follow-up monitoring for thyroid cancer remains controversial. Advances in the molecular biology of thyroid cancer have helped to identify candidate markers of disease aggressiveness. A commonly found genetic alternation is a point mutation in the BRAF oncogene (BRAF V600E), which is primarily found in papillary thyroid cancer and is associated with more aggressive disease. Methods: BRAF V600E mutation status was determined in 347 tumor samples from 314 patients with thyroid cancer (245 with conventional papillary thyroid cancer, 73 with follicular thyroid cancer, and 29 with the follicular variant of papillary thyroid cancer). Univariate and multivariate analyses were performed to determine the association of BRAF V600E with clinicopathologic factors and patient outcome. Results: The prevalence of BRAF V600E mutation was higher in conventional papillary thyroid cancer (51.0%) than in follicular variant of papillary thyroid cancer (24.1%) and follicular thyroid cancer (1.4%) (P < 0.0001). In patients with conventional papillary thyroid cancer, BRAF V600E mutation was associated with older age (P = 0.0381), lymph node metastasis (P = 0.0323), distant metastasis (P = 0.045), higher TNM stage (I and II vs. III and IV, P = 0.0389), and recurrent and persistent disease (P = 0.009) with a median follow-up time of 6.0 years. Multivariate analysis showed that BRAF V600E mutation [OR (95% CI) = 4.2 (1.2-14.6)] and lymph node metastasis [OR (95% CI) = 7.75 (2.1-28.5)] were independently associated with recurrent and persistent disease in patients with conventional papillary thyroid cancer. Conclusions: BRAF V600E mutation is primarily present in conventional papillary thyroid cancer. It is associated with an aggressive tumor phenotype and higher risk of recurrent and persistent disease in patients with conventional papillary thyroid cancer. Testing for this mutation may be useful for selecting initial therapy and for follow-up monitoring.

Perioperative mortality for pancreatectomy: a national perspective.

Abstract: Objective:To analyze in-hospital mortality after pancreatectomy using a large national database.Summary and Background Data:Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic can

Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery.

Abstract: Objective:The aim of this study was to compare learning curves for laparoscopic cholecystectomy (LC) after training on a proficiency based virtual reality (VR) curriculum with that of a traditionally trained group.Summary Background Data:Simulator-based training has been shown to improve technical p

Partial hepatectomy with wide versus narrow resection margin for solitary hepatocellular carcinoma: a prospective randomized trial.

Abstract: Objective:To compare the efficacy and safety of partial hepatectomy aiming grossly at a narrow (1 cm) and a wide (2 cm) resection margin in patients with macroscopically solitary hepatocellular carcinoma (HCC).Summary Background Data:For HCC treated with partial hepatectomy, the extent of the margin

Liver transplantation criteria for hepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA.

Abstract: The incidence of hepatocellular carcinoma (HCC) in the United States has nearly doubled over the last 2 decades, and an estimated 8500 to 11,000 new cases of HCC occur annually in the United States.1,2 This increase has been attributed to infections with hepatitis C virus (HCV) from the 1970s and 1980s, and HCV-associated HCC is expected to further double within the next 20 years.3,4 Outcomes for patients with HCC have been historically poor, regardless of treatment, with overall 5-year survival rates of 20% to 40%. For patients with HCC and end-stage cirrhosis, survival without liver transplantation is often less than 1 year. Over the past quarter century, orthotopic liver transplantation (OLT) has been established as a durable therapy for all forms of end-stage liver disease.5,6 OLT appears ideally suited for HCC, as it provides complete oncologic resection and correction of the underlying liver dysfunction. Early experience with OLT for HCC resulted in poor post-transplant survival and high recurrence rates that were attributed to suboptimal patient selection.7–10 In 1996, Mazzaferro and colleagues reported improved results with OLT in patients with a single tumor ≤5 cm or no more than 3 tumors, each no larger than 3 cm.11 For patients meeting these so-called Milan criteria, overall and recurrence-free survivals were 85% and 92%, respectively, and overall recurrence rate was 8% at 4 years’ follow-up.11 As the Milan criteria consistently have been associated with improved survival,11,12 they are currently used by the United Network for Organ Sharing (UNOS) and Medicare to guide patient selection for cadaveric OLT for HCC. More recent studies have proposed expanded criteria to offer OLT to a broader group of patients with HCC.13–16 Using explant pathologic data, Yao and coworkers at the University of California, San Francisco (UCSF) reported 5-year post-transplantation survival of 75% in patients with tumors as large as 6.5 cm and cumulative tumor burden ≤8 cm.13 These results have been challenged because of a small sample size and use of explant pathology, rather than preoperative imaging, as the determinant for tumor stage. As a result, the role of OLT for tumors beyond the conventional Milan criteria remains controversial. Currently, preoperative imaging criteria based on size and number of tumors are used to select candidates for OLT. The Model for End Stage Liver Disease (MELD) scoring system introduced in 2002 now offers priority for patients with HCC within conventional Milan criteria.17 The present study was undertaken to examine outcomes for a large series of patients who received OLT for HCC in a single institution. The goal was to determine whether expansion of Milan criteria, based on preoperative imaging and explant pathology, could be justified by post-transplant survival of at least 50% at 5 years, as proposed by Llovet.18–20

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review.

Abstract: Colorectal cancer can result in malignant obstruction of the colon or rectum, through the presence of either intrinsic or extrinsic tumors. Acute or subacute bowel obstruction can lead to abdominal pain, nausea, vomiting, bowel rupture, and eventual death if left untreated. Conventional therapies for relieving malignant colorectal obstruction include surgical resection (potentially curative) or palliative colostomy. Resection is more frequently an option in patients with less advanced cancer, and is ideally carried out as a single-stage procedure, with anastomosis to restore bowel continuity. Multistage procedures may also be undertaken, with resection and stoma formation in one procedure, followed by restoration of continuity in another procedure.1 However, a significant proportion of patients receiving a staged procedure never undergo reversal of the colostomy.2 Permanent stoma creation is the standard treatment of bowel obstruction caused by nonresectable tumors, relieving the symptoms of bowel obstruction. Although it is the standard treatment modality, stoma creation is associated with high morbidity and mortality rates, particularly when undertaken under emergency conditions.1 Furthermore, stoma creation is recognized as having a highly negative impact on patients' psychosocial well-being3 and can be a burden to caregivers as well as the patient during the final months of their life. Endoscopic treatments to palliate rectal obstruction have also been developed in recent years but are not yet a standard treatment option. Medical management, including the use of opioids, anticholinergics, and antiemetics, is most commonly used in hospices and palliative care settings to assist in maintaining an acceptable quality of life in patients with terminal illness. Self-expanding metallic stents (SEMS) are expandable metallic tubes that are advanced to the site of the obstruction along a guidewire in a collapsed state, under fluoroscopic and/or endoscopic guidance. Once deployed, the stents slowly expand radially to their maximum diameter under their own force, thereby achieving patency of the obstructed anatomy. Almost all stenting procedures are carried out transanally, and are generally well tolerated by patients with only conscious sedation, or no anesthesia. The value of stent placement is as a minimally invasive alternative to open surgical techniques, such as resection or stoma creation. SEMS may be used as a definitive palliative measure or can be used as a “bridge to surgery” to allow stabilization of the patient's condition before surgery is carried out as an elective procedure at a later date. A number of stents have been designed specifically for use in the lower gastrointestinal tract and are available in a variety of lengths and diameters, so that the appropriate stent can be selected based on factors such as the length of the obstructed section of bowel and anatomic location of the obstruction. While stenting procedures are becoming a more frequent treatment modality, it is currently unclear whether stenting represents a safe and effective alternative to surgical procedures for the treatment of malignant colorectal obstructions. The aim of this review is to assess the safety and efficacy of SEMS placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature.

Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology.

Abstract: Objective: Determine whether size and other preoperative parameters predict malignant or invasive intraductal papillary mucinous neoplasia (IPMN). Background Data: From 1991 to 2006, 150 patients underwent 156 operations for IPMN. Methods: Prospectively collected, retrospective review of a single academic institution's experience. All preoperative parameters including a detailed radiologic-based classification of IPMN type, location, distribution, size, number, cytology, and mural nodularity were correlated with IPMN pathology. Results: Malignant IPMN was present in 32% of cases, whereas 19% of cases were invasive. IPMN type and main pancreatic duct diameter were significant predictors of malignant IPMN (P < 0.001). Side-branch lesion number was negatively associated with invasive IPMN (P = 0.03). Side-branch size, location, and distribution did not predict IPMN pathology. The presence of mural nodules was associated with malignant and invasive IPMN (P < 0.001; P < 0.02). Atypical cytopathology was significantly associated with malignant and invasive IPMN (P < 0.001; P < 0.001). Multivariate analysis demonstrated mural nodularity and atypical cytopathology were predictive of malignancy and/or invasion in branch-type IPMN. Conclusions: To lower the rate of invasive pathology, surgery should be recommended for fit patients with main-duct IPMN and for branch-duct IPMN with mural nodularity or positive cytology irrespective of location, distribution, or size.

Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management.

Abstract: Objective: Appendicitis has been declining in frequency for several decades. During the past 10 years, its preoperative diagnosis has been made more reliable by improved computed tomography (CT) imaging. Thresholds for surgical exploration have been lowered by the increased availability of laparoscopic exploration. These innovations should influence the number of appendectomies performed in the United States. We analyzed nationwide hospital discharge data to study the secular trends in appendicitis and appendectomy rates.

A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer

Abstract: Objective:A prospective randomized controlled trial (RCT) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer.Aims:This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT.Methods:Patients f

Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone.

Abstract: Objective: To investigate the pattern of nodal metastasis, morbidity, recurrence rates of papillary thyroid carcinoma (PTC), and parathyroid hormone (PTH) responses following neck dissection (ND) plus total thyroidectomy (TT).

Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain.

Abstract: Several medical centers in the United States, Canada, and Europe have recently noted an increase in the incidence and severity of Clostridium difficile-associated disease (CDAD). In Pittsburgh, 10% of patients with CDAD diagnosed in 2000 to 2001 required an emergency colectomy.1 Enhanced severity of CDAD has also been reported in several other American states.2 The largest epidemic occurred in the province of Quebec, Canada, where, during the 2004 to 2005 winter, 30 hospitals reported rates over 15 per 10,000 patient-days, at least 5 times higher than historical rates.3–5 In Sherbrooke, Quebec, the incidence of CDAD among individuals aged 65 years or more increased 10-fold between 1991 and 2003, and a recent study showed that the excess mortality that could be attributed to nosocomial CDAD in 2003 to 2004 was 16.7%.6,7 This coincided with the emergence of a hypervirulent toxinotype III NAP1/027 strain of C. difficile, which produces levels of toxins A and B that are 16 to 23 times higher than historical strains, most of which were toxinotype 0.8 The same hypervirulent strain has also been found in the United Kingdom, the Netherlands, and Belgium.9–12 It used to be uncommon for patients with CDAD to require admission into an intensive care unit (ICU), but many hospitals in Quebec have noted a dramatic increase in the number of such cases since 2003.13 In that context, intensive care physicians have been frequently seeking a surgical opinion for the most severe cases, and many patients have undergone an emergency colectomy. Such a decision is largely empirical given the absence of evidence supporting a surgical approach. To improve the surgical decision-making process for patients critically ill with CDAD, we undertook a retrospective study of all patients with CDAD who, between January 1, 2003 and June 30, 2005, required admission into an ICU in 2 tertiary care hospitals of Quebec.

Clinical and Economic Validation of the International Study Group of Pancreatic Fistula (ISGPF) Classification Scheme

Abstract: Pancreatic fistula is widely regarded as the most ominous of complications following pancreatic resection. Its clinical impact and sequelae have been previously described and shown to contribute to the development of other morbid complications and high rates of mortality.1–4 Despite refinements in operative technique and advancements in postoperative management, fistulas still occur with a frequency of 5% to 30%.5–12 Efforts to mitigate this problem have included technical considerations (modification of the pancreatico-jejunal anastomosis technique, reconstruction with pancreaticogastrostomy, and placement of pancreatic duct stents), perioperative infusion of somatostatin analogues, and use of adhesive sealants.9 However, the successes of these various techniques and pharmacologic adjuvants is frequently challenged, and dissension exists as to which methods are optimal for prevention and management of fistulas. The debate is further compounded by numerous and widely varying definitions of pancreatic fistula. Data from a recent analysis of 4 widely accepted definitions of fistula reported in the gastrointestinal surgical literature demonstrates that fistula rate depends largely upon the definition used.13 The lack of a universal definition of pancreatic fistula, therefore, precludes objective comparisons of surgical experiences with this complication. To address this problem and develop a consensus approach, an international consortium of 37 leading pancreatic surgeons from 15 countries, the International Study Group on Pancreatic Fistula (ISGPF), convened, reviewed the literature, and discussed their surgical experiences with fistulas.14 The result was a universal and applicable definition of pancreatic fistula and a grading system for fistula severity based on clinical impact on the patient. Appraisal of this grading system has yet to be accomplished, and to date, the ISGPF clinical classification scheme has not been rigorously tested or validated. The aims of this study, therefore, are: 1) to analyze our experience with pancreatic fistula by applying the ISGPF classification scheme in a high-volume pancreatico-biliary surgical specialty unit; 2) to demonstrate its value in examining outcomes in a large cohort of patients undergoing pancreaticoduodenectomy; and 3) to validate its application, clinically and economically, as a suitable alternative to current biochemical definitions of fistula.

Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis.

Abstract: Objective:A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence.Summary Background Data:Patient