bluuebunny/crossref_metadata_2025 huggingface dataset:
The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?
Authors: Postlewait Lauren M. , Ethun Cecilia G. , Mcinnis Mia R. , Merchant Nipun , Parikh Alexander , Idrees Kamran , Isom Chelsea A. , Hawkins William , Fields Ryan C. , Strand Matthew , Weber Sharon M. , Cho Clifford S. , Salem Ahmed , Martin Robert C.G. , Scoggins Charles , Bentrem David , Kim Hong J. , Carr Jacquelyn , Ahmad Syed , Abbott Daniel , Wilson Gregory C. , Kooby David A. , Maithel Shishir K.
Published: June 2020

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000–2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.
Longer Time Intervals from Diagnosis to Surgical Treatment in Breast Cancer: Associated Factors and Survival Impact
Authors: Mariella Margaret , Kimbrough Charles W. , Mcmasters Kelly M. , Ajkay Nicolas
Published: June 2020

Time interval (TI) from breast cancer diagnosis to definitive surgery is increasing, but the impact on outcomes is not well understood. TI longer than 30 days is associated with a greater chance of delay of chemotherapy, which may impact survival. We sought to identify factors associated with longer TI and the influence on outcome measures. Methods: We examined TI for stage 0-III breast cancer patients treated between 2006 and 2015 at a university-based cancer center. Univariate and multivariate analyses were used to study factors associated with TI <30, 30 to 60, and >60 days. Kaplan–Meier plots were used to examine the effect of different TI on overall survival, disease-specific survival, and recurrence-free survival. Results: 1589 patients were included with a median follow-up of 47 months. Median TI was 32 days. Median TI increased in patients from 2011 to 2015 compared with those from 2006 to 2010 (35 vs 30 days, P < 0.001). On multivariate analysis, mastectomy (with or without reconstruction), MRI use, and increasing age were independent predictors of TI >30 days. There were no significant differences in overall survival, disease-specific survival, or recurrence-free survival. There was no association between TI >30 days and a subsequent delay >60 days to adjuvant chemotherapy (OR 1.04, 95% CI 0.72–1.52). Conclusions: TI has increased in the last five years. Patient characteristics, tumor biology, and stage do not influence TI, whereas age, mastectomy, and MRI use were all associated with longer TI. Longer TI does not appear to significantly delay adjuvant chemotherapy or influence short-term outcomes.
Academic versus Clinical Productivity of Cardiac Surgeons in the State of New York: Who Publishes More and Who Operates More
Authors: Rosati Carlo Maria , Gaudino Mario , Vardas Panos N. , Weber Daniel J. , Blitzer David , Hameedi Fawad , Koniaris Leonidas G. , Girardi Leonard N.
Published: June 2020

We investigated whether/how cardiac surgeons can be productive both academically and clinically. Using online resources (New York State Adult Cardiac Surgery database, SCOPUS), we collected individual clinical volumes (operations performed/year), academic metrics (ongoing publications, role as author), practice setting, and seniority for all cardiac surgeons in the State of New York from 1994 to 2011. Over time, individual clinical volumes decreased (median operations/year: 193 in 1995 vs 126 in 2010; P < 0.001), whereas academic productivity remained unchanged (median publications/year: 0.7 vs 0.3; P = 0.55). There was no correlation (Spearman's correlation coefficient: -0.061; P = 0.08) between the number of new publications and operations/year for the whole population. More operations/year (median: 155 vs 144; P = 0.03) were performed by surgeons without versus with publications during that same year. Who published more worked at hospitals with higher clinical volumes (Spearman's correlation coefficient: 0.16; P < 0.001) and was more likely affiliated with thoracic surgery fellowship programs (median publications/year: 1.7 for affiliated vs 0 for nonaffiliated surgeons; P < 0.001). Cardiac surgeons could be classified into four categories: ∼40 per cent clinically busy, but not publishing at all; ∼45 per cent operating less, but publishing a little; ∼15 per cent clinically very productive (operating as much as the non-publishers) and publishing a lot; and ∼1 per cent operating the least, but publishing the most.
Rationale for Mastectomy after Neoadjuvant Chemotherapy
Authors: Gusic Lejla Hadzikadic , Walsh Kendall , Flippo-Morton Teresa , Sarantou Terry , Boselli Danielle , White Richard L.
Published: June 2020

Neoadjuvant chemotherapy (NAC) reduces tumor size, facilitating the use of breast conservation surgery (BCS). However, mastectomy remains the surgical outcome for certain women. The goal of this study was to determine the rationale for mastectomy after NAC, particularly in women eligible for BCS. Retrospective data were reviewed on patients who received NAC between February 2006 and August 2010 at our institution. Demographics and tumor characteristics were compared between patients who received BCS and mastectomy after NAC. Of 149 patients meeting inclusion criteria, 102 (68%) underwent BCS and 47 (32%) underwent mastectomy. Patient preference was the most common rationale for mastectomy ( n = 19; 40%), followed by extent of disease ( n = 13; 28%), presence of a breast cancer susceptibility gene (BRCA) mutation ( n = 9; 19%), persistent positive margins ( n = 5; 11%), and wound complications ( n = 1; 2%). Of the 47 patients who underwent mastectomy, 37 (79%) were eligible for BCS after NAC. Larger pathologic tumor size (2.05 vs 1.25 cm, P = 0.04) and lobular histology [invasive lobular carcinomas, n = 12/17 (70%) vs invasive ductal carcinomas, n = 36/133 (27%); P < 0.01] were associated with increased rate of mastectomy. After NAC, patient preference, extent of disease, and the presence of a BRCA mutation account for the vast majority of mastectomies. Interestingly, most of these patients were shown to be candidates for breast conservation. This highlights the importance of educating patients about their surgical choice and the lack of evidence, showing a benefit to more extensive surgery.
Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography
Authors: Rosemurgy Alexander , Downs Darrell , Luberice Kenneth , Rodriguez Christian , Swaid Forat , Patel Krishen , Toomey Paul , Ross Sharona
Published: June 2020

This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller myotomy with anterior fundoplication.
Building a Single-Site Robotic Cholecystectomy Program in a Public Teaching Hospital: Is It Safe for Patients and Feasible for Residents to Participate?
Authors: O'Leary Michael P. , Ayabe Reed I. , Dauphine Christine E. , Hari Danielle M. , Ozao-Choy Junko J.
Published: June 2020

Single-site robotic cholecystectomy (SSRC) accounts for most of the robotic surgery cases performed by general surgeons at our institution since acquiring the da Vinci Si Surgical SystemTM (Intuitive Surgical, Inc., Sunnyvale, CA) in 2014. We sought to determine whether a SSRC program is safe to start in a public teaching hospital and to determine whether resident participation in this procedure is feasible. Data on age, gender, race, BMI, total operative time, length of stay, comorbidities, and conversion from laparoscopic to open surgery were examined for elective SSRC and laparoscopic cholecystectomies (LCs) performed by two faculty surgeons between February 2015 and August 2015. Thirty-eight patients underwent elective SSRC, whereas 27 patients underwent LC. Residents participated as operating surgeons for some portion of the case in 15 SSRC cases and in all LC cases. There were no significant differences in operative time, length of stay, or 30-day readmission rates, regardless of resident involvement. Patients in the SSRC group had a significantly lower BMI (25.8 vs 33.7, P = 0.008). This study suggests that resident participation does not increase complications or total operative time and that SSRC is a safe procedure to start in a public teaching hospital after proper faculty and resident training.
Short- and Long-Term Results of Laparoscopic Parenchyma-Sparing Hepatectomy for Small-Sized Hepatocellular Carcinoma: A Comparative Study Using Propensity Score Matching Analysis
Authors: Inoue Yoshihiro , Suzuki Yusuke , Ota Masato , Fujii Kensuke , Kawaguchi Nao , Hirokawa Fumitoshi , Hayashi Michihiro , Uchiyama Kazuhisa
Published: June 2020

The aim of this study was to evaluate the degree of invasiveness and the clinical outcomes of laparoscopic parenchyma-sparing hepatectomy (LPSH) for a maximum hepatocellular carcinoma (HCC) size ≤5 cm. Sixty-one LPSHs and 175 open parenchyma-sparing hepatectomies (OPSHs) for small-sized HCC were analyzed using a propensity score matching analysis. The median operative time was significantly shorter in the LPSH group (194 min) than in the OPSH group (275 minutes) ( P < 0.0001). The estimated blood loss was significantly lower in the LPSH group (100 mL) than in the OPSH group (380 mL) ( P < 0.0001). The incidences of superficial incisional surgical site infections and respiratory complications were significantly lower in the LPSH group than in the OPSH group ( P = 0.0161 and 0.0285, respectively). During the postoperative course, the white blood cell counts and C-reactive protein levels were significantly lower in the LPSH group. There were no differences in overall survival and disease-free survival ( P = 0.1293 and 0.4039, respectively), and no significant differences in terms of type of recurrence and site of intrahepatic recurrence ( P = 0.1410). The data from the present series suggest the lesser invasiveness and safety of LPSH even for small-sized HCC patients.
Weight Loss and Glycemic Control after Sleeve Gastrectomy: Results from a Middle Eastern Center of Excellence
Authors: Khalifa Khalid Al , Ansari Ahmed Al , Showaiter May
Published: June 2020

Obesity and its associated metabolic disorders are strongly linked to both morbidity and mortality. Sleeve gastrectomy (SG) has been established as an effective means of weight loss for obese patients as well as a treatment for type 2 diabetes mellitus (T2DM). This study was designed to examine the short- and midterm outcomes of patients who underwent SG in a Middle Eastern Center of Excellence, a military training teaching hospital. The clinical outcomes of 59 patients with impaired glucose tolerance and T2DM who underwent SG between 2011 and 2014 with at least one and up to four years of follow-up were studied. Data were collected and compared, including the pre- and post-surgery measures of weight, body mass index, glycosylated hemoglobin (HbA1c), and fasting blood glucose. Complete remission was defined as a fasting blood glucose level ≤100 mg/dL, an HbA1c ≤6 mg/dL, without use of antidiabetic medications. All patients showed significant reduction in body mass index following SG. Tight glycemic control was achieved among both diabetic and prediabetic patients. In this study, 88.14 per cent of all patients (diabetic and prediabetic) achieved complete resolution from their impaired glucose tolerance and T2DM and maintained normal blood glucose and HbA1C levels from one to four years post-operatively. SG is beneficial both in terms of short- and midterm weight loss and glucose control in both diabetic and prediabetic obese patients.
A Cost-Benefit Analysis of Reducing Surgical Site Infections
Authors: Rosemurgy Alexander , Whitaker Jacqueline , Luberice Kenneth , Rodriguez Christian , Downs Darrell , Ross Sharona
Published: June 2020

Surgical Site Infections (SSI) represent an onerous burden on our health-care system. This study was undertaken to determine the impact of a protocol aimed at reducing SSIs on the frequency and cost of SSIs after abdominal surgery. Beginning in 2013, 811 patients undergoing gastrointestinal operations were prospectively followed. In 2014, we initiated a protocol to reduce SSIs. SSIs were monitored before and after protocol implementation, and differences in SSI incidence and associated costs were determined. Before protocol initiation, standardized operative preparation cost was $40.85 to $126.94 per patient depending on the results of methicillin-resistant Staphylococcus aureus screen; after protocol initiation, the cost was $43.85 per patient, saving up to $83.09 per patient. With the protocol in place, SSI rate was reduced from 4.9 to 3.4 per cent (13 of 379) representing a potential prevention of eight infections that would have cost payers $166,280 ($20,785 per infection). Notably, the SSI rate after pancreatectomy was reduced by 63 per cent ( P = 0.04). With preparation and diligence, SSI rate can be meaningfully reduced and potential cost savings can be achieved. In particular, SSI rate reduction for major abdominal operations and especially pancreatic resections can be achieved. A protocol to reduce SSI is a “win-win” for all stakeholders and should be encouraged with thoughtful and active participation from all hospital disciplines.
Substernal Goiter: Correlation between Grade and Surgical Approach
Authors: Tostado Karla V. ChÁVez , VelÁZquez-Fernandez David , Chapa MÓNica , Pantoja MillÁN Juan P. , Salazar Mauricio S. , Herrera Miguel F.
Published: June 2020

Substernal goiter is defined as a thyroid growth beyond the thoracic inlet. Using the cross-section imaging CT system, it can be classified into three grades. The aim of the study was to validate the surgical approach and the occurrence of postoperative complications with substernal goiter extension in our patient population. From a total of 1145 patients who underwent thyroid surgery at our institution in a 15-year period, 60 patients with substernal goiter were included. Clinical features and demographics, degree of extension, surgical details, and complications were analyzed. Mean ± SD age of the patients was 58 ± 14.7 years and 88 per cent were females. According to the cross-section imaging CT system 61.7 per cent were grade I,23.3 per cent grade II, and 15 per cent grade III. Total thyroidectomy was performed in 78.3 per cent of the patients, subtotal thyroidectomy in 18.3 per cent, and lobectomy in 3.3 per cent. The cervical approach was sufficient to perform 96.7 per cent of the thyroidectomies, requiring partial sternotomy in only two patients with grade III substernal goiter. Patients with grade III substernal goiter had a higher risk for postoperative dysphonia (OR = 14.29, IC95% 1.14-178.9, P = 0.03), which occurred in three patients (two transient and one permanent). Transitory hypoparathyroidism was present in 20 patients (33.3%) and did not correlate with goiter extension. Most substernal goiters can be resected through a cervical approach, with relatively low morbidity. Postoperative dysphonia was directly related to the extension of the goiter. Few cases with grade III goiters require a partial sternotomy.
Supervisor, Colleague, or Assistant: General Surgery Resident Perceptions of Advanced Practitioners
Authors: Clark Clancy J. , Hildreth Amy , Migaly John , Sieren Leah , Carter Jeffrey , Stewart John H.
Published: June 2020

Integration of advanced practitioners (APs) into academic medical centers can improve processes of care and decrease physician workload but may adversely impact general surgery residency training. The aim of the present study was to characterize general surgery resident perceptions of APs and their impact on resident training. We conducted an institutional review board–approved survey covering five topic areas: knowledge of AP training, interaction with APs, scope-of-practice of APs, role of APs in the health-care team, and impact of APs on physician training. The survey was administered to general surgery residents at six large academic medical centers. One hundred eighteen general surgery residents completed the survey. The majority (43.6%) of respondents were junior residents. All respondents had interactions with APs with 90.7 per cent having worked directly with an AP in the last month. Residents reported minimal formal educational involvement by APs with 6.8 per cent reporting participation in didactics and 22.2 per cent teaching operative techniques. Almost half (44.1%) of the respondents reported that APs played an important role in their education, and 42.4 per cent of respondents disagreed or strongly disagreed that the role of the AP is well defined in their hospital. Today's general surgery residents work closely with APs who seem to positively impact resident education. Although residents perceive significant benefit with integration of APs, well-defined roles are lacking.
Outcomes after Falls Continue to Worsen Despite Trauma and Geriatric Care Advancements
Authors: Charles Eric J. , Napoli Nicholas J. , Johnston Lily E. , Foster Carrie A. , Goode Deirdre A. , Parker Trevor B. , Sharp Eleanor A. , Barnes Laura , Young Jeffrey S.
Published: June 2020

The most common mechanism of traumatic injury is ground-level fall. The objective of this study was to understand how patients sustaining falls and their outcomes have evolved. An institutional trauma database was used to identify adult patients who suffered a fall and were admitted to a Level I trauma center during two distinct time periods: 1998 to 2003 (past) and 2008 to 2013 (current). Data on anticoagulant use and comorbidities was gathered by retrospective chart review of patients treated during 2003 and 2013. Univariable analyses and multivariable regression were used to evaluate demographics and outcomes. A total of 6116 patients were identified, with a 24 per cent increase in number of falls between groups. Current fall patients are older (70 vs 66 years, P < 0.001), more often admitted to intensive care (28 vs 12%, P < 0.001), have longer lengths of stay (5 vs 4 days, P < 0.001), are frequently discharged to skilled nursing facilities (24 vs 8%, P < 0.001), and have higher mortality (5 vs 3%, P = 0.002). The adjusted odds of mortality for patients treated during 2003 and 2013 was associated with age, gender, injury severity score, and Glasgow Coma Scale score. Current fall patients use more health care resources and have worse outcomes, despite advances in trauma and geriatric care.
Evaluation of Drain Amylase Level after Pancreaticoduodenectomy with Special Reference to Delayed Pancreatic Fistula
Authors: Maeda Takashi , Kayashima Hiroto , Imai Daisuke , Takeishi Kazuki , Harada Noboru , Tsujita Eiji , Tsutsui Shinichi , Matsuda Hiroyuki
Published: June 2020

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMYon postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases ( P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMYon POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.
Endoscopic Pneumatic Dilation for Esophageal Achalasia
Authors: Markar Sheraz , Zaninotto Giovanni
Published: June 2020

Pneumatic dilation is a well-established treatment modality that has withstood the test of time. Prospective and randomized trials have shown that in expert hands, it provides results similar to a laparoscopic Heller myotomy with fundoplication. In addition, it should be considered the primary form of treatment in patients who experience recurrence of symptoms after a surgical myotomy.
Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence?
Authors: Rebecchi Fabrizio , Allaix Marco E. , Schlottmann Francisco , Patti Marco G. , Morino Mario
Published: June 2020

There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon's experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.
Laparoscopic Heller Myotomy versus Per Oral Endoscopic Myotomy: Evidence-Based Approach to the Treatment of Esophageal Achalasia
Authors: Schlottmann Francisco , Patti Marco G.
Published: June 2020

Esophageal achalasia is a rare disorder characterized by a failure of the lower esophageal sphincter to relax during swallowing, combined with aperistalsis of the esophageal body. Treatment is not curative, but aims to eliminate the outflow resistance caused by the nonrelaxing lower esophageal sphincter. Current evidence suggests that both laparoscopic Heller myotomy and per oral endoscopic myotomy (POEM) are very effectiveinthe reliefof symptoms in patients with achalasia. Specifically, for type III achalasia, POEM may achieve higher success rates. However, POEM is associated to a very high incidence of pathologic reflux, with the risk of exchanging one disease–achalasia–with another–gastroesophageal reflux.
A New Approach to an Old Technique—The S.U.T.R. First Technique
Authors: Jones Frank , Lewis Catherine , Knight Darryl , Bacon Louise , Patel Vijay , Moore Carolyn
Published: June 2020

Ventral and incisional hernias of the abdominal wall are common problems treated by surgeons around the globe. Incisional hernias are common postoperative complications of abdominal laparotomies with a reported incidence of up to 20 per cent. The increasing use of prosthetic mesh in open ventral hernia repairs necessitated the development of different operative techniques used in the repairs. It also required that surgeons become facile with placement of the mesh in different anatomical positions on the abdominal wall. One of the most common locations is placement of the mesh in the underlay position. Many surgeons who use the underlay technique have expressed significant concerns. Among these are fear of an inadvertent bowel injury while placing the mesh, poor visualization during mesh placement, and the inability to use the underlay technique for difficult hernias. We present a very useful, if not, novel technique of open hernia repair using mesh in the underlay position that helps to 1) prevent complications, 2) facilitate easier mesh fixation, 3) simplify open repair of atypical ventral hernias, and 4) reduce total operative time while still adhering to the important fundamental principles of a tension-free hernia repair. This technique as we describe it has been compared with the old parachute technique, but we think this is a significant improvement of that seldom used technique. We believe the use of this technique for the underlay position makes open ventral hernia repair safer, faster, and easier; however, our goal for this article is to describe the procedure in detail. In addition, we recently have started using this technique to fix the mesh when doing the retrorectus approach as well.
Single-Incision Laparoscopic Colectomy for Colon Cancer: Experiences with 308 Consecutive Cases
Authors: Hirano Yasumitsu , Hattori Masakazu , Douden Kenji , Hiranuma Chikashi , Hashizume Yasuo , Taniguchi Keizo
Published: June 2020

Single-incision laparoscopic surgery (SILS) has been developed with the aim to further reduce the invasiveness of conventional laparoscopy. Our experiences with more than 300 consecutive patients with SILS for colon cancer are reviewed, and its outcomes are evaluated to determine the midterm clinical and oncologic safety of SILS for colon cancer in a community hospital. A single surgeon's consecutive experience of SILS for colon cancer is presented. Three hundred and eight patients were treated with the SILS procedure for colon cancer between December 2010 and March 2015. Data were analyzed according to intention to treat. Of these 308 patients, 19 (6.2%) were converted to laparotomy. Intraoperative injury occurred in five patients. Postoperative complications occurred in 19 patients (6.2%). The 2-year relapse-free survival rates of patients with Stage I, Stage II, and Stage III were 97.8, 92.2, and 80.4 per cent, respectively, and the 2-year overall survival rates of patients with Stage I, Stage II, Stage III, and Stage IV were 100, 95.7, 93.0, and 74.4 per cent, respectively. Our initial experiences showed that SILS colectomy for cancer can be performed safely and with good short-term oncologic outcomes by a skilled surgeon.
Nongastrointestinal Stromal Tumor Spindle Cell Sarcomas of the Colon or Rectum
Authors: Ikoma Naruhiko , Roland Christina L. , Cormier Janice N. , Chiang Yi-Ju , Torres Keila E. , Hunt Kelly K. , You Y. Nancy , Feig Barry W.
Published: June 2020

Because of the low incidence of nongastrointestinal stromal tumor (non-GIST) spindle cell sarcomas of the colon or rectum, the clinical behavior and ideal surgical treatment of these tumors and patient outcomes are poorly defined. The purpose of this study was to characterize these tumors and to determine the best surgical approach. We identified 1056 patients with non-GIST spindle cell sarcomas of the colon or rectum (1998–2010) in the National Cancer Database and collected data for each patient that included patient and tumor characteristics, tumor site (colon vs rectum), surgery type, and outcomes. The median overall survival was significantly longer in patients with rectal tumors than in those with colon tumors ( P < 0.01). Patients with colon tumors who underwent anatomic surgical resection showed a trend toward longer median survival than those with no surgical treatment [hazard ratio (HR), 1.94; P = 0.09] or who underwent local excision (HR, 1.74; P = 0.09). Patients with rectal tumors did not benefit from anatomic surgical resection, but there was a trend favoring local excision (HR, 0.55; P = 0.06). Local sphincter-sparing procedures should be considered for rectal non-GIST tumors whenever technically feasible.
Understanding Disparities in Breast Cancer Care in Memphis, Tennessee
Authors: Lamb Elena P. , Pritchard F. Elizabeth , Nouer Simonne S. , Tolley Elizabeth A. , Boyd Brandon S. , Davidson Jesse T. , Munene Gitonga , Fleming Martin D.
Published: June 2020

Although significant progress has been made in improving breast cancer survival, disparities among racial, ethnic, and underserved groups still exist. The goal of this investigation is to quantify racial disparities in the context of breast cancer care, examining the outcomes of recurrence and mortality in the city of Memphis. Patients with a biopsy-proven diagnosis of breast cancer from January 1, 2002, through December 31, 2012, were obtained from the tumor registry. Black patients were more likely to have advanced (II, III, or IV) clinical stage of breast cancer at diagnosis versus white patients. Black breast cancer patients had a two times higher odds of recurrence (95% confidence interval: 1.4, 3.0) after adjusting for race and clinical stage. Black breast cancer patients were 1.5 times more likely to die (95% confidence interval: 1.2, 1.8), after adjusting for race; age at diagnosis; clinical stage; ER, PR, HER2 status; and recurrence. Black women with stages 0, I, II, and III breast cancer all had a statistically significant longer median time from diagnosis to surgery than white women. Black patients were more likely to have advanced clinical stages of breast cancer at diagnosis versus white patients on a citywide level in Memphis. Black breast cancer patients have higher odds of recurrence and mortality when compared with white breast cancer patients, after adjusting for appropriate demographic and clinical attributes. More work is needed to develop, evaluate, and disseminate interventions to decrease inequities in timeliness of care for breast cancer patients.
Frailty Predicts Morbidity and Mortality after Colectomy for Clostridium difficile Colitis
Authors: Venkat Raghunandan , Pandit Viraj , Telemi Edwin , Trofymenko Oleksandr , Pandian Twinkle K. , Nfonsam Valentine N.
Published: June 2020

Frailty has been noted as a powerful predictive preoperative tool for 30-day postoperative complications. We sought to evaluate the association between frailty and postoperative outcomes after colectomy for Clostridium difficile colitis. The National Surgical Quality and Improvement Program cross-institutional database was used for this study. Data from 470 patients with a diagnosis of C. difficile colitis were used in the study. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with the National Surgical Quality and Improvement Program to assess frailty. Outcome measures included serious morbidity, overall morbidity, and Clavien IV (requiring ICU) and Clavien V (mortality) complications. The median age was 70 years and body mass index was 26.9 kg/m2. 55.6 per cent of patients were females. 98.5 per cent of patients were assigned American Society of Anesthesiologists Class III or higher. The median mFI was 0.27 (0–0.63). Because mFI increased from 0 (non-frail) to 0.55 and above, the overall morbidity increased from 53.3 per cent to 84.4 per cent and serious morbidity increased from 43.3 per cent to 78.1 per cent. The Clavien IV complication rate increased from 30.0 per cent to 75.0 per cent. The mortality rate increased from 6.7 per cent to 56.2 per cent. On a multivariate analysis, mFI was an independent predictor ofoverall morbidity (AOR: 13.0; P < 0.05), mortality (AOR: 8.8; P = 0.018), cardiopulmonary complications (AOR: 6.8; P = 0.026), and prolonged length of hospital stay (AOR: 6.6; P = 0.045). Frailty is associated with increased risk of complications in C. difficile colitis patients undergoing colectomy. mFI is an easy-to-use tool and can play an important role in the risk stratification of these patients who generally have significant morbidity and mortality to begin with.
Too Much of a Good Thing: Radioactive Iodine Ablation Use for Micropapillary Thyroid Carcinoma
Authors: Chae Andrew W. , Martinez Steve R.
Published: June 2020

Radioactive iodine (RAI) is not routinely recommended for the adjuvant treatment of micro-papillary thyroid carcinoma (MPTC). We aimed to report on clinical and pathologic factors associated with the use of RAI in these patients. We queried the Surveillance, Epidemiology, and End Results database for patients who underwent surgery for MPTC (tumor size ≤1 cm) from 1988 to 2009. We excluded patients without a biopsy-proven diagnosis, those diagnosed at autopsy, and patients with documented extra-thyroidal extension. Multivariate logistic regression models predicted the use of RAI based on patient, tumor, and treatment-related factors. We identified 24,076 patients with MPTC that were eligible for study inclusion. Of these, 6,172 (25.6%) received RAI. Lymph node metastases were present in 23.8 per cent of those for whom lymph node status was known. On multivariate analysis, an increasing number of positive nodes, increasing tumor size, Asian race, and male gender predicted the use of RAI. RAI use was less likely in those with advancing age, an increasing number of lymph nodes examined and patients that received less than a total thyroidectomy. Among node-negative patients, Asian race and increasing tumor size predicted the use of RAI. Factors predicting decreased use of RAI were an increasing number of lymph nodes examined, unknown race, less than a total thyroidectomy, and advancing age. A significant number of MPTC patients receive potentially unnecessary RAI.
Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study
Authors: Guerrier Jean B. , Mehaffey James H. , Schirmer Bruce D. , Hallowell Peter T.
Published: June 2020

Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m22. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis ( P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intra-operative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.
Is Hepatopancreatoduodenectomy an Acceptable Operation for Biliary Cancer?
Authors: Lee Eung Chang , Han Sung-Sik , Lee Seung Duk , Park Sang-Jae
Published: June 2020

Hepatopancreatoduodenectomy (HPD) is usually indicated for the resection of locally advanced bile duct (BD) cancer or gallbladder (GB) cancer. Previous studies have demonstrated a favorable survival rate in BD cancer patients after HPD if R0 resection is achieved. By contrast, the benefit of HPD for GB cancer remains controversial. This study aimed to analyze the outcomes of GB and BD cancer after HPD. Between January 2004 and December 2013, a total of 22 patients underwent HPD for BD (n = 14) or GB cancer (n = 8). We analyzed the survival, mortality, morbidity, and prognostic factors. After HPD, the mortality rate was 4.5 per cent and the morbidity rate was 68.2 per cent. Pancreatic fistula occurred in 50.0 per cent of the patients (grade A, 40.9%; grade B, 9.1%). Liver failure did not occur. The 1-, 3-, and 5-year survival rates for BD cancer patients were 57.1, 17.9, and 17.9 per cent and those for GB cancer patients were 62.5, 25.0, and 25.0 per cent, respectively ( P = 0.768). In BD cancer, significant prognostic factors were tumor size, portal vein invasion, multiple lymph node metastases, and operation time. Furthermore, BD cancer patients with three or more of risk factors showed poorer survival than those with fewer than three risk factors. HPD for GB and BD cancer can be performed with acceptable mortality and morbidity rates. GB cancer patients who underwent HPD showed comparable survival rates compared with BD cancer patients. Long-term survival can be achieved in selected patients with BD cancer.
Efficacy of Laparoscopic Percutaneous Extraperitoneal Closure for Unilateral Inguinal Hernia in Children and Significance of Simple Exploration Maneuver for Contralateral Patent Processus Vaginalis: A Retrospective Study
Authors: Kangwen Cheng , Guihe Wang
Published: June 2020

To evaluate the efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) for unilateral inguinal hernia in children and effect of intraoperative laparoscopic exploration for finding contralateral patent processus vaginalis (CPPV) on prevention of the metachronous contralateral hernia (MCH). We retrospectively analyzed unilateral inguinal hernia ligation in children, which can be diveded into two groups: a total of 252 cases with open surgical ligation from January 2010 to December 2012 (open group), a total of 184 cases underwent laparoscopic percutaneous peritoneal hernia sac high ligation LPEC from January 2013 to March 2015 (LPEC group). Then, we observed postoperative complications, recurrence of hernia, and the postoperative MCH in the two groups and analyzed the influence factors of the MCH. In Open groups and LPEC groups, the complication incidences, respectively, were 4.4 and 1.6 per cent, having statistical difference ( P > 0.05), the average postoperative follow-up duration, respectively, were 42 months and 22 months, whereas the overall incidence of MCH, respectively, were 5.2 and 0.5 per cent ( P < 0.05). In the first 24 months follow-up time, the overall incidence of MCH, respectively, were 3.6 and 0 per cent. Laparoscopic evaluation was positive for CPPV in 67 cases. We found the prevalence of 56.1 per cent of CPPV in LPEC groups aged 0.6 to 2 years old, finding the incidence gradually decline with the increase of age, until 14.3 per cent to 10 to 12 years old group. Our study shows LPEC has proven efficacy in treatment of unilateral inguinal hernia in children, and routine laparoscopic exploration with this simple maneuver should be actively performed to observe CPPV in all chidren.
The Use of Standardized Measures to Predict and Assess Quality of Life after Laparoscopic Hiatal Hernia Repair
Authors: Shapiro Mark , Lee Benjamin E. , Rutledge John R. , Korst Robert J.
Published: June 2020

The literature regarding laparoscopic hiatal hernia repair is difficult to interpret because of inconsistencies in describing hernia characteristics and outcome measures. This study was performed to evaluate risk factors for an unsatisfactory outcome after repair using objective definitions of hernia size and a clinically relevant outcome instrument. A retrospective review of a prospectively maintained database was conducted over a seven-year period. Data collected included patient demographics and hernia-related variables. Outcomes were defined using a validated quality of life (QOL) instrument. Postoperatively, the mean total QOL score decreased from 22.9 to 5.8 (P < 0.001). In all, 13.8 per cent of patients had unsatisfactory QOL scores postoperatively. Multivariate analysis showed that high gastroesophageal (GE) junction position (P = 0.03) and female gender (P = 0.02) were the only significant factors associated with an unsatisfactory postoperative QOL. Laparoscopic hiatal hernia repair significantly improves QOL. With respect to predicting clinically relevant outcomes, hernias are best characterized by the position of the GE junction. Females with high GE junction position are at the highest risk for an unsatisfactory outcome.
Correlation between Ki-67 Expression and Hemodynamics of Contrast-Enhanced Ultrasound in Patients with Breast Infiltrative Ductal Carcinoma
Authors: Du Rui , Zhang Hao , Shu Weiwei , Chen Baoding , Li Yuefeng , Zhang Xin , Wu Xincai , Wang Zhongqun
Published: June 2020

Breast cancer causes great threats to public health worldwide. The aim of this study was to investigate the correlation between Ki-67 expression and the hemodynamics of contrast-enhanced ultrasound (CEUS) in patients with infiltrative ductal carcinoma (IDC). CEUS was performed on 109 masses in 85 IDC cases before resection. Based on the immunohistochemical staining on the antigen Ki-67, the masses were divided into negative group, weakly positive group, positive group, and strong-positive group. Significant statistical differences were noticed in time to peak, arrive intensity, and peak intensity in the positive groups compared with the negative group. Compared with the positive groups, the negative group showed significant statistical differences in arrive intensity and peak intensity. The antigen Ki-67 was positively correlated with arrived intensity, intensity changes, and rising curve's slope. In contrast, it was negatively correlated with arrived time, time to peak, and continuous time. The hemodynamic parameters of CEUS were correlated with the expression of antigen Ki-67. On this basis, Ki-67 is an effective supplement to the diagnosis of IDC.
Delirium in Postoperative Patients Admitted to the Intensive Care Unit
Authors: Romanauski Timothy R. , Martin Erin E. , Sprung Juraj , Martin David P. , Schroeder Darrell R. , Weingarten Toby N.
Published: June 2020

Postoperative delirium (POD) is common among surgical patients admitted to the intensive care unit (ICU) and is associated with increased resource utilization, morbidity, and death. Our primary aim was to compare rates of POD using administrative International Classification of Diseases, Ninth Revision, records and automated interrogation of electronic health records from Confusion Assessment Method for the ICU (CAM-ICU) screening. The secondary aim was to assess POD risk associated with patient and perioperative characteristics. Electronic health records of surgical patients admitted to the ICU during 2011 through 2014 were abstracted for POD assessment by CAM-ICU and by administrative codes, Charlson comorbidity index, surgical characteristics, and Acute Physiology, Age, Chronic Health Evaluation III scores. Of 6338 patients, CAM-ICU identified 606 (9.6%) and administrative records identified 55 (0.9%) POD cases, with agreement on 50 cases. In multivariable logistic regression based on POD identified with CAM-ICU, preexisting dementia had the strongest association with POD (odds ratio [95% confidence interval], 6.47 [3.68–11.37]; P < 0.001). Other associations found were older age, congestive heart failure, chronic pulmonary disease, increased surgical duration, emergency cases, blood transfusions, postoperative ventilation, and higher Acute Physiology, Age, Chronic Health Evaluation III scores (all P ≤ 0.01). POD cases had lengthier ICU and hospital stays and a higher mortality rate (all P < 0.001). CAM-ICU scores identified higher rates of POD than a search for POD based on administrative codes. Preoperative presence of dementia and major comorbidities were associated with POD. Delirium in surgical patients is associated with worse outcomes.