Showing papers in "Annals of Surgery in 2011"

Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis.

Abstract: Objective: To examine the long-term oncological impact of anastomotic leakage (AL) after restorative surgery for colorectal cancer using meta-analytical methods. Outcomes evaluated were local recurrence, distant recurrence, and survival. Background: Recurrence after potentially curative surgery for colorectal cancer remains a significant clinical problem and has a poor prognosis. AL may be a risk factor for disease recurrence, however available studies have been conflicting. A meta-analysis was conducted to investigate the impact of AL on disease recurrence and long-term survival. Methods: Studies published between 1965 and 2009 evaluating the long-term oncological impact of AL were identified by an electronic literature search. Outcomes evaluated included local recurrence, distant recurrence, and cancer specific survival. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute odds ratio and 95% confidence intervals. Study heterogeneity was evaluated using Q statistics and I2 and publication bias assessed with funnel plots and Egger's test. Results: Twenty-one studies comprising 13 prospective nonrandomized studies, 1 prospective randomized, and 7 retrospective studies met the inclusion criteria, yielding a total of 21,902 patients. For rectal anastomoses, the odd ratios (OR) of developing a local recurrence when there was AL was 2.05 (95% CI = 1.51-2.8; P = 0.0001). For studies describing both colon and rectal anastomoses, the OR of local recurrence when there was an AL was 2.9 (95% CI = 1.78-4.71; P Conclusions: AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted. No association between AL and distant recurrence was found.

Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery A Randomized Clinical Trial (LAFA-study)

Abstract: Objective:To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer.Summary Background Data:Important developments in elective colorectal surgery

A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria.

Abstract: Objective:To compare the long-term outcomes of surgical resection and radiofrequency ablation for the treatment of small hepatocellular carcinoma (HCC).Summary Background Data:Radiofrequency ablation (RFA) is a promising, emerging therapy for small HCC. Whether it is as effective as surgical resecti

First Report from the American College of Surgeons -- Bariatric Surgery Center Network: Laparoscopic Sleeve Gastrectomy has Morbidity and Effectiveness Positioned Between the Band and the Bypass

Abstract: Objective:To assess the safety and effectiveness of the laparoscopic sleeve gastrectomy (LSG) as compared to the laparoscopic adjustable gastric band (LAGB), the laparoscopic Roux-en-Y gastric bypass (LRYGB) and the open Roux-en-Y gastric bypass (ORYGB) for the treatment of obesity and obesity-relat

Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study.

Abstract: Objective: To assess local recurrence, disease-free survival, and overall survival in magnetic resonance imaging (MRI)-predicted good prognosis tumors treated by surgery alone. Background: The MERCURY study reported that high-resolution MRI can accurately stage rectal cancer. The routine policy in most centers involved in the MERCURY study was primary surgery alone in MRI-predicted stage II or less and in MRI "good prognosis" stage III with selective avoidance of neoadjuvant therapy. Patients and Methods: Data were collected prospectively on all patients included in the MERCURY study who were staged as MRI-defined "good" prognosis tumors. "Good" prognosis included MRI-predicted safe circumferential resection margins, with MRI-predicted T2/T3a/T3b (less than 5 mm spread from muscularis propria), regardless of MRI N stage. None received preoperative or postoperative radiotherapy. Overall survival, disease-free survival, and local recurrence were calculated. Results: Of 374 patients followed up in the MERCURY study, 122 (33%) were defined as "good prognosis" stage III or less on MRI. Overall and disease-free survival for all patients with MRI "good prognosis" stage I, II and III disease at 5 years was 68% and 85%, respectively. The local recurrence rate for this series of patients predicted to have a good prognosis tumor on MRI was 3%. Conclusions: The preoperative identification of good prognosis tumors using MRI will allow stratification of patients and better targeting of preoperative therapy. This study confirms the ability of MRI to select patients who are likely to have a good outcome with primary surgery alone.

Preoperative High-resolution Magnetic Resonance Imaging Can Identify Good Prognosis Stage I, II, and III Rectal Cancer Best Managed by Surgery Alone: A Prospective, Multicenter, European Study That Recruited Consecutive Patients With Rectal Cancer.

Abstract: OBJECTIVE:: To assess local recurrence, disease-free survival, and overall survival in magnetic resonance imaging (MRI)-predicted good prognosis tumors treated by surgery alone. BACKGROUND:: The MERCURY study reported that high-resolution MRI can accurately stage rectal cancer. The routine policy in most centers involved in the MERCURY study was primary surgery alone in MRI-predicted stage II or less and in MRI "good prognosis" stage III with selective avoidance of neoadjuvant therapy. PATIENTS AND METHODS:: Data were collected prospectively on all patients included in the MERCURY study who were staged as MRI-defined "good" prognosis tumors. "Good" prognosis included MRI-predicted safe circumferential resection margins, with MRI-predicted T2/T3a/T3b (less than 5 mm spread from muscularis propria), regardless of MRI N stage. None received preoperative or postoperative radiotherapy. Overall survival, disease-free survival, and local recurrence were calculated. RESULTS:: Of 374 patients followed up in the MERCURY study, 122 (33%) were defined as "good prognosis" stage III or less on MRI. Overall and disease-free survival for all patients with MRI "good prognosis" stage I, II and III disease at 5 years was 68% and 85%, respectively. The local recurrence rate for this series of patients predicted to have a good prognosis tumor on MRI was 3%. CONCLUSIONS:: The preoperative identification of good prognosis tumors using MRI will allow stratification of patients and better targeting of preoperative therapy. This study confirms the ability of MRI to select patients who are likely to have a good outcome with primary surgery alone.

A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients.

Abstract: OBJECTIVE To investigate the association between markers of acute endothelial glycocalyx degradation, inflammation, coagulopathy, and mortality after trauma. BACKGROUND Hyperinflammation and acute coagulopathy of trauma predict increased mortality. High catecholamine levels can directly damage the endothelium and may be associated with enhanced endothelial glycocalyx degradation, evidenced by high circulating syndecan-1. METHODS Prospective cohort study of trauma patients admitted to a Level 1 Trauma Centre in 2003 to 2005. Seventy-five patients were selected blindly post hoc from 3 predefined injury severity score (ISS) groups ( 27). In all patients, we measured 17 markers of glycocalyx degradation, inflammation, tissue and endothelial damage, natural anticoagulation, and fibrinolysis (syndecan-1, IL-6, IL-10, histone-complexed DNA fragments, high-mobility group box 1 (HMGB1), thrombomodulin, von Willebrand factor, intercellular adhesion molecule-1, E-selectin, protein C, tissue factor pathway inhibitor (TFPI), antithrombin, D-dimer, tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), soluble uPA receptor, and plasminogen activator inhibitor-1), hematology, coagulation, catecholamines, and assessed 30-day mortality. Variables were compared in patients stratified according to syndecan-1 median. RESULTS Patients with high circulating syndecan-1 had higher catecholamines, IL-6, IL-10, histone-complexed DNA fragments, HMGB1, thrombomodulin, D-dimer, tPA, uPA (all P < 0.05), and 3-fold increased mortality (42% vs. 14%, P = 0.006) despite comparable ISS (P = 0.351). Only in patients with high glycocalyx degradation was higher ISS correlated with higher adrenaline, IL-6, histone-complexed DNA fragments, HMGB1, thrombomodulin, and APTT, lower protein C (all P < 0.05), unchanged TFPI and blunted D-dimer response (P < 0.001) because D-dimer was profoundly increased even at low ISS. After adjusting for age and ISS, syndecan-1 was an independent predictor of mortality (OR: 1.01 [95%CI, 1.00-1.02]; P = 0.043). CONCLUSIONS In trauma patients, high circulating syndecan-1, a marker of endothelial glycocalyx degradation, is associated with inflammation, coagulopathy and increased mortality.

Is there still a glass ceiling for women in academic surgery

Abstract: Despite the dramatically increased entry of women into general surgery and surgical subspecialties, traditionally male-dominated fields, there remains a gross under-representation of women in the leadership positions of these departments. Women begin their careers with fewer academic resources and tend to progress through the ranks slower than men. Female surgeons also receive significantly lower salaries than their male counterparts and are more vulnerable to discrimination, both obvious and covert. Although some argue that female surgeons tend to choose their families over careers, studies have actually shown that women are as eager as men to assume leadership positions, are equally qualified for these positions as men, and are as good as men at leadership tasks.Three major constraints contribute to the glass-ceiling phenomenon: traditional gender roles, manifestations of sexism in the medical environment, and lack of effective mentors. Gender roles contribute to unconscious assumptions that have little to do with actual knowledge and abilities of an individuals and they negatively influence decision-making when it comes to promotions. Sexism has many forms, from subtle to explicit forms, and some studies show that far more women report being discriminately against than do men. There is a lack of same-sex mentors and role models for women in academic surgery, thereby isolating female academicians further. This review summarizes the manifestation of the glass-ceiling phenomenon, identifies some causes of these inequalities, and proposes different strategies for continuing the advancement of women in academic surgery and to shatter the glass ceiling.

Arterial Resection During Pancreatectomy for Pancreatic Cancer: A Systematic Review and Meta-Analysis

Abstract: Background:The majority of pancreatic cancers are diagnosed at an advanced stage. As surgical resection remains the only hope for cure, more aggressive surgical approaches have been advocated to increase resection rates. Institutions have begun to release data on their experience with pancreatectomy

Hepatocellular carcinoma: current management and perspectives for the future.

Abstract: Objective: To review the literature on current management of hepatocellular carcinoma (HCC). Background: Hepatocellular carcinoma represents one of the most common malignancies worldwide with a rising incidence in western countries. There have been substantial advances in the surgical and medical treatment of HCC within the past 2 decades. Methods: A literature review was performed in the MEDLINE database to identify studies on the management of HCC. On the basis of the available evidence recommendations for practice were graded using the Oxford Centre for Evidence-based Medicine classification. Results: Advances in surgical technique and perioperative care have established surgical resection and orthotopic liver transplantation (OLT) as primary curative therapy for HCC in noncirrhotic and cirrhotic patients, respectively. Primary resection and salvage OLT may be indicated in cirrhotics with preserved liver function. Selection criteria for OLT remain debated, as slight expansion of the Milan criteria may not worsen prognosis but is limited by organ shortage and prolonged waiting time with less favorable outcome on intention-to-treat analyses. Strategies of neoadjuvant treatment before OLT require evaluation within prospective trials. Transarterial chemoembolization is the primary therapy in patients with inoperable HCC and compensated liver function. Although systemic chemotherapy is not effective in patients with advanced HCC, there is recent evidence that these patients benefit from new molecular targeted therapies. If these agents are also effective in the neoadjuvant and adjuvant setting is currently being investigated. Furthermore, selective intra-arterial radiation therapy represents a promising new approach for treatment of unresectable HCC. Conclusions: Recent developments in the surgical and medical therapy have significantly improved outcome of patients with operable and advanced HCC. A multidisciplinary approach seems essential to further improve patients' prognosis.

The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients.

Abstract: Objective To assess the impact of postoperative complications on full in-hospital costs per case. Background Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear. Patients and methods Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders. Results This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery. Conclusion This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.

Microvascular invasion is a better predictor of tumor recurrence and overall survival following surgical resection for hepatocellular carcinoma compared to the Milan criteria.

Abstract: Objective:To compare microvascular invasion (McVI) with parameters defined by the Milan criteria in predicting tumor recurrence and overall survival (OS) in patients with surgical resection (SR) for hepatocellular carcinoma (HCC).Summary Background Data:Although the Milan criteria is discriminatory

A Lethally Irradiated Allogeneic Granulocyte-Macrophage Colony Stimulating Factor-Secreting Tumor Vaccine for Pancreatic Adenocarcinoma: A Phase II Trial of Safety, Efficacy, and Immune Activation

Abstract: Pancreatic cancer remains the fourth leading cause of cancer related death in the United States.1 Surgical resection provides the only possibility of cure. However, the historical 5-year survival postresection remains approximately 15% to 20%, with 1 and 2-year survival of 63% and 42% respectively.2 A standard adjuvant treatment approach for patients with resected disease has not yet been determined.2–11 We developed irradiated GM-CSF transfected allogeneic whole cell tumor lines for pancreas ductal adenocarcinoma immunotherapy.12 We previously reported that this immunotherapy treatment administered intradermally in sequence with chemoradiotherapy to patients with resected pancreatic adenocarcinoma induced posttreatment delayed type hypersensitivity (DTH) responses to autologous tumor cells in 1 of 3 participants receiving 1 × 108 cells and in 2 of 5 participants receiving 5 × 108 vaccine cells. The 3 DTH responders are the only participants who remain disease-free at 10+ years. Importantly, immunized lymphocytes from the DTH-responders were used to screen a number of differentially expressed genes in pancreatic cancer. All 3 DTH responders demonstrated a postimmunotherapy T cell response to mesothelin, a glycosyl-phosphatidylinositol (GPI)-linked cell surface protein that likely serves as an adhesion molecule that promotes metastases.13–16 We now report the results of a single institution 60 patient phase II study testing the highest immunotherapy dose of GM-CSF secreting pancreatic tumor cells found to be safe and bioactive in phase I testing. This study was designed to estimate the disease-free and overall survival rates and the prevalence of mesothelin-specific T cell responses that are associated with immunotherapy treatment.

Are There Better Guidelines for Allocation in Liver Transplantation? A Novel Score Targeting Justice and Utility in the Model for End-Stage Liver Disease Era

Abstract: Objectives:To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.Background:The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).

Pancreatic cancer surgery in the new millennium: better prediction of outcome.

Abstract: Background:Surgery is the only therapy with potentially curative intention in pancreatic cancer. This analysis aimed to determine prognostic parameters in a patient cohort with resected pancreatic adenocarcinoma with a special focus on the revised R1-definition.Methods:Between October 2001 and Augus

Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center.

Abstract: Liver transplantation remains the standard treatment for patients with end-stage liver disease. Over the years there have been significant improvements in liver transplant outcomes due to improved surgical techniques, organ preservation, immunosuppression, and anti-infective therapies. This success has resulted in more patients being listed for transplantation out of proportion to the number of available organs. Thus, the donor organ shortage remains a significant obstacle to increasing the number of liver transplants. In an attempt to combat the donor organ shortage, more liver transplant centers are using livers from donation after cardiac death (DCD) donors. Based on the Scientific Registry of Transplant Recipients (SRTR) 2007 Annual Report, there has been a seven-fold increase in the number of liver transplant programs performing DCD liver transplants over the last seven years. In addition the number of DCD liver transplants performed at centers in the United States increased from 39 in 2000 to 277 in 2007 (2007 OPTN/SRTR Annual Report. HHS/HRSA/HSB/DOT; UNOS; Arbor Research Collaborative for Health). Despite this increase in DCD liver utilization, there remains reluctance among many centers to aggressively use these organs. This unwillingness is based on both national database and single-center studies reporting inferior patient and graft survival rates when compared to liver transplants from donation after brain death donors (DBD).1,2,3,4 Another important concern with the use of DCD livers is the development of biliary complications. The incidence of biliary complications after DCD liver transplantation ranges between 25–60%, 3,5,6,7,8 compared to 10–30% seen in DBD whole liver transplantation.9,10,11,12 The most critical biliary complication that frequently requires retransplantation is the development of ischemic-type biliary strictures or ischemic cholangiopathy. Ischemic cholangiopathy (IC) is defined as intra-hepatic or non-anastomotic, extra-hepatic biliary strictures in the presence of a patent hepatic artery. The incidence of IC in DCD liver transplantation ranges between 10–50% in published series.13,5,6,8,14 Although not all patients with IC require retransplantation, this complication can result in considerable patient morbidity including biliary sepsis, prolonged antibiotic therapy, and the requirement for multiple endoscopic or percutaneous biliary procedures. In addition, most patients with IC maintain excellent hepatocellular function despite biliary damage and dysfunction and therefore have relatively low Model for End-Stage Liver Disease (MELD) scores when being considered for retransplantation. In many cases requests for a MELD exception are made to the regional review boards in order to obtain a sufficient MELD score for re transplantation. The granting of these exceptions is quite variable across the country and not standardized in the current liver allocation process. This prolonged waiting time may result in recurrent biliary sepsis, the development of multi-resistant organisms, and patient debilitation that could potentially exclude them from retransplantation. Previous analyses utilizing the United Network for Organ Sharing/Organ Procurement and Transplantation Network Liver Transplantation Registry have identified potential risk factors that are predictive of graft survival after DCD liver transplantation.15,16 However, the risk factors for the development biliary complications were not analyzed in these studies. The objectives of this analysis were (1) to compare the long-term outcomes of DCD and DBD liver transplants with 15 year follow-up, (2) to compare the incidence of biliary complications between DCD and DBD liver transplant recipients, and (3) to identify potential risk factors for the development of biliary complications in DCD liver transplant recipients at the University of Wisconsin.

Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients.

Abstract: OBJECTIVE To determine if implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival.

The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism.

Abstract: Objective:To compare the results of minimally invasive parathyroidectomy (MIP) and conventional parathyroid surgery.Background:Primary hyperparathyroidism is a common endocrine disorder often treated by surgical intervention. Outpatient MIP, employing image-directed focused exploration under cervica

Continuous improvement of survival outcomes of resection of hepatocellular carcinoma: a 20-year experience.

Abstract: Objective:To investigate the trend of the posthepatectomy survival outcomes of hepatocellular carcinoma (HCC) patients by analysis of a prospective cohort of 1198 patients over a 20-year period.Background:The hospital mortality rate of hepatectomy for HCC has improved but the long-term survival rate

Updated Recommendations for Control of Surgical Site Infections

Abstract: Objective: The objective of this study is to provide updated guidelines for the prevention of surgical wound infections based upon review and interpretation of the current and past literature. Background: The development and treatment of surgical wound infections hasalwaysbeenalimitingfactortothesuccessofsurgicaltreatment.Although continuous improvements have been made, surgical site infections continue to occur at an unacceptable rate, annually costing billions of dollars in economic loss caused by associated morbidity and mortality. Methods: The Centers for Disease Control (CDC) provided extensive recommendations for the control of surgical infections in 1999. Review of the current literature with interpretation of the findings has been done to update the recommendations. Results: New and sometimes conflicting studies indicate that coordination and application of techniques and procedures to decrease wound infections will be highly successful, even in patients with very high risks. Conclusions: This review suggests that uniform adherence to the proposed guidelines for the prevention of surgical infections could reduce wound infections significantly; namely to a target of less than 0.5% in clean wounds, less than 1% in clean contaminated wounds and less than 2% in highly contaminated wounds and decrease related costs to less than one-half of the current

Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla.

Abstract: Objective:Systematic evidence synthesis of ultrasound-guided needle biopsy (UNB) of axillary nodes in breast cancer.Summary Background Data:Women affected by invasive breast cancer undergo initial staging with sentinel node biopsy, generally progressing to axillary node dissection (AND) if metastase

Diverting Loop Ileostomy and Colonic Lavage: An Alternative to Total Abdominal Colectomy for the Treatment of Severe, Complicated Clostridium difficile Associated Disease

Abstract: Objective:To determine whether a minimally invasive, colon-preserving approach could serve as an alternative to total colectomy in the treatment of severe, complicated Clostridium difficile–associated disease (CDAD).Background:C. difficile is a significant cause of morbidity and mortality worldwide.

Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial.

Abstract: Objective:To evaluate a mastery learning, simulation-based curriculum for laparoscopic, totally extraperitoneal (TEP) inguinal hernia repair.Background:Clinically relevant benefits from improvements in operative performance, time, and errors after simulation-based training are not clearly establishe

Optimal timing of surgery after chemoradiation for advanced rectal cancer: preliminary results of a multicenter, nonrandomized phase II prospective trial.

Abstract: Objective To determine whether extending the interval between chemoradiation (CRT) and surgery, and administering additional chemotherapy during the waiting period has an impact on tumor response, CRT-related toxicity and surgical complications in patients with advanced rectal cancer.

Ischemic cholangiopathy after controlled donation after cardiac death liver transplantation: a meta-analysis.

Abstract: US: United StatesDCD: Donation after Cardiac DeathHRSA: Health Resources and Services AdministrationCMS: Centers for Medicare and Medicaid ServicesDBD: Donation after Brain DeathIC: Ischemic CholangiopathyLOS: Length of StayUNOS: United Network for Organ SharingSRTR: Scientific Registry of Transplan

Surgical Site Infection Prevention: Time to Move Beyond the Surgical Care Improvement Program

Abstract: Objectives:The objective of this study was to evaluate whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates using national data at the patient level for both SCIP adherence and SSI occurrence.Background:The SCIP was established in 2006 with the goal of re

Long-term prevention of mortality in morbid obesity through bariatric surgery. a systematic review and meta-analysis of trials performed with gastric banding and gastric bypass.

Abstract: Background:Bariatric surgery has been reported to reduce long-term mortality in operated participants in comparison with nonoperated participants.Methods:We performed a systematic review and meta-analysis of clinical trials published as full articles dealing with cardiovascular (CV) mortality, all-c

Wait times for cancer surgery in the United States: Trends and predictors of delays

Abstract: Background:Patients frequently voice concerns regarding wait times for cancer treatment; however, little is known about the length of wait times from diagnosis to surgery in the United States. Our objectives were (1) to assess changes in wait times over the past decade and (2) to identify patient, t

Out-of-hospital Hypertonic Resuscitation After Traumatic Hypovolemic Shock: A Randomized, Placebo Controlled Trial

Abstract: Objective:Todeterminewhetherout-of-hospitaladministrationofhypertonic fluids would improve survival after severe injury with hemorrhagic shock. Background: Hypertonic fluids have potential benefit in the resuscitation of severely injured patients because of rapid restoration of tissue perfusion, with a smaller volume, and modulation of the inflammatory response, to reduce subsequent organ injury. Methods:Multicenter,randomized,blindedclinicaltrial,May2006toAugust 2008, 114 emergency medical services agencies in North America within the Resuscitation Outcomes Consortium. Inclusion criteria: injured patients, age ≥ 15 years with hypovolemic shock (systolic blood pressure ≤ 70 mm Hg or systolic blood pressure 71‐90 mm Hg with heart rate ≥108 beats per minute). Initial resuscitation fluid, 250 mL of either 7.5% saline per 6% dextran 70 (hypertonic saline/dextran, HSD), 7.5% saline (hypertonic saline, HS), or 0.9% saline (normal saline, NS) administered by out-of-hospital providers. Primary outcome was 28-day survival. On the recommendation of the data and safety monitoring board, the study was stopped early (23% of proposed sample size) for futility and potential safety concern. Results:A total of 853 treated patients were enrolled, among whom 62% were with blunt trauma, 38% with penetrating. There was no difference in 28-day survival—HSD: 74.5% (0.1; 95% confidence interval [CI], −7.5 to 7.8); HS: 73.0% (−1.4; 95% CI, −8.7‐6.0); and NS: 74.4%, P = 0.91. There was a higher mortality for the postrandomization subgroup of patients who did not receive blood transfusions in the first 24 hours, who received hypertonic fluids compared to NS [28-day mortality—HSD: 10% (5.2; 95% CI, 0.4‐10.1); HS: 12.2% (7.4; 95% CI, 2.5‐12.2); and NS: 4.8%, P < 0.01].

Significance of histopathological tumor regression after neoadjuvant chemotherapy in gastric adenocarcinomas: a summary of 480 cases.

Abstract: Objective:An increasing number of patients with locally advanced gastric carcinomas (GC) are being treated with preoperative chemotherapy before surgery.Background:Histopathological tumor regression may have an important prognostic impact in addition to the UICC-TNM classification system.Methods:We