Pancreatoduodenectomy using a no-touch isolation technique

Background

Pancreatoduodenectomy is the only effective treatment for cancers of the periampullary region. Because surgeons usually grasp tumors during pancreatoduodenectomy, this procedure may increase the risk of squeezing and shedding the cancer cells into the portal vein, retroperitoneum, and/or peritoneal cavity. In an effort to overcome these problems, we have developed a surgical technique for no-touch pancreatoduodenectomy.

Methods

From March 2005 through May 2008, 42 patients have been operated on following this technique. Resected margins were microscopically analyzed.

Results

We describe a technique for pancreatoduodenectomy using a no-touch isolation technique. We resect cancers with wrapping them within Gerota's fascia and transect the retroperitoneal margin along the right surface of the superior mesenteric artery and abdominal aorta without grasping tumors.

Conclusions

No-touch pancreatoduodenectomy has many potential advantages that merit further investigation in future randomized controlled trials.     

Clinicopathologic characteristics and prognosis of synchronous multifocal gastric carcinomas

Background

We sought to define differences between multifocal and solitary gastric carcinoma to decrease the risk of missing a cancer while resecting another more evident carcinoma.

Methods

We retrospectively examined clinicopathologic characteristics of multifocal gastric carcinoma including anatomic distribution and postoperative survival.

Results

Multifocal gastric carcinoma was seen more frequently when patients were older and when the largest tumor was small and at an early stage. More than half of accessory lesions were located near the main tumor. No significant difference in postoperative survival was seen between patients with multifocal and solitary carcinoma, whether early or advanced.

Conclusions

The entire stomach should be examined carefully before and during resection, especially when local or endoscopic surgery is performed.     

Wrong-site sinus surgery in otolaryngology

Objective

To determine the scope of wrong-site sinus surgery.

Study Design

Electronic mail survey.

Setting

E-mailed via the American Academy of Otolaryngology-Head and Neck Surgery's weekly newsletter.

Subjects and Methods

Members were asked about wrong-site sinus surgery in an 11-item survey.

Results

A total of 455 members responded (response rate 19.8%). Forty-two (9.3%) have heard of a case of wrong-site sinus surgery occurring. Twenty-one cases were analyzed; of these, 10 (48%) implicated radiographic error, and the Universal Protocol was followed in one third. In seventeen reports (81%), there was disclosure to the family, one case with delayed disclosure; there was no disclosure in three cases. Sixty-one percent (n = 266) are concerned about operating on the wrong sinus or side. Forty-nine percent (n = 216) routinely use a checklist preoperatively. There is large variation in site marking for sinus surgery. Sixty-five percent (n = 282) routinely review the computed tomography scan prior to surgery.

Conclusion

Approximately 10 percent of survey respondents know of a case of wrong-site sinus surgery occurring; the majority of respondents are concerned about a wrong-sinus or wrong-sided surgery occurring in their practice. Otolaryngologists should be vigilant regarding the potential for inverted computed tomography images; there should be national efforts to address this latent systems defect. Surgeons should be trained in understanding the role of and engaging in disclosure and in other techniques that are of greatest support to the patient. Consideration of sinus-specific checklists should be led by the societies representing sinus surgeons.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Postdischarge unplanned admission in ambulatory surgery—a prospective study

Background

Postdischarge recovery continues at home and some patients will need admission if complications occur.

Objective

To analyze the postdischarge unplanned admission rate in a hospital-based ambulatory surgery unit.

Method

Prospective non-comparative study. Patients admitted in the first 30 days postdischarge were included.Univariate analysis was performed to identify independent predictive factors for these admissions.

Results

The postdischarge unplanned admission rate was 1%. Urology, gynaecology and general surgery, patients 90 years or older and epidural anaesthesia were significant risk factors for postdischarge unplanned admission.

Conclusion

The postdischarge unplanned admission rate was very low.     

The use of vacuum assisted closure therapy in the management of Fournier's gangrene

Background

Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) has been used to successfully treat a variety of complex wounds. This technique was investigated for use in managing Fournier's gangrene following initial debridement.

Methods

Ten patients with Fournier's gangrene were treated in this study. After initial surgical debridement, 5 were treated using conventional therapy and 5 were treated with VAC at each dressing change. The effectiveness and cost of VAC for this indication were assessed; patient and physician satisfaction were also determined.

Results

Conventional and VAC treatment were equally effective in healing the wounds. The total costs of each treatment were similar. With the use of VAC, patients had fewer dressing changes, less pain, fewer skipped meals, and greater mobility. Hands-on treatment time was decreased for physicians using VAC.

Conclusions

VAC therapy is an effective and economical way to manage Fournier's gangrene. Patients and physicians were more satisfied with VAC therapy than with conventional treatment.     

The ratio between metastatic and examined lymph nodes is an independent prognostic factor for patients with resectable middle and distal bile duct carcinoma

Background

The lymph node ratio, defined as the ratio between the number of lymph node metastasis and the total number of lymph nodes examined, has been reported to be an important prognostic factor in other gastrointestinal carcinomas except middle and distal bile duct carcinomas.

Methods

Between 1991 and 2004, 62 consecutive patients who underwent surgery for middle and distal bile duct carcinoma were retrospectively analyzed concerning prognostic factors.

Results

The median number of lymph nodes examined was 12 (range 5 to 38). The overall 5-year survival rates of patients with lymph node ratio of 0, lymph node ratio of 0 to .2, and lymph node ratio >.2 were 62%, 41%, and 0%, respectively. A multivariate analysis revealed that a lymph node ratio >.2 and perineural invasion were independent predictive factors for survival.

Conclusions

Lymph node ratio >.2 is an important factor to predict survival after resected middle and distal bile duct carcinoma.     

Surgical treatment of pectus excavatum: 30 years 398 patients of experiences

Purpose

The aim of the study is to review the surgical experiences with pectus excavatum (PE) chest deformities at the Department of Pediatric Surgery, West China Hospital of Sichuan University (Sichuan, PR China), during a 30-year period.

Method

Records of 398 PE patients (396 congenital, 2 acquired) who underwent surgical repair between 1975 and 2005 were reviewed. Modified sternal elevation was applied in all patients. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a metal strut for 1 year. Five technical details were strictly followed for each case. Three hundred twelve patients (78.39%) were followed up from 1 to 16 years.

Result

There were no deaths. Normal contour of the costal cage was constructed postoperatively in 98.74% (393/398) of the patients. Exercise tolerance was improved, and cardiac function recovered to the healthy level of same age. But pulmonary function recovered slowly after surgery.

Conclusions

The 5 technical details are key principles for sternal elevation. Normal appearance of chest wall can be recovered; normal cardiopulmonary function can be restored by the modified sternal elevation with excellent long-term physiologic, cosmetic results and low rate of complications.     

Preliminary NSQIP results: A tool for quality improvement

Objective

To utilize National Surgical Quality Improvement Program (NSQIP) data to evaluate patient outcomes in otolaryngology-head and neck surgery.

Study Design

Retrospective medical chart abstraction of patients undergoing major surgical procedures in the inpatient and outpatient setting.

Setting

Academic/teaching hospitals with more than 500 beds.

Subjects and Methods

The American College of Surgeons NSQIP collects data on 135 variables including preoperative risk factors, intraoperative variables, and 30-day-postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in the inpatient and outpatient setting. As of August 2008, there are currently 47 hospitals submitting data for otolaryngology-head and neck surgery.

Results

Opportunities for improvement were identified in respiratory, wound, and venothromboembolic (VTE) occurrences. Implementation of a standardized VTE and perioperative protocol resulted in a decreased length of stay and observed-to-expected (O/E) morbidity and mortality for all surgical services.

Conclusion

NSQIP reports form the basis for quality improvement with targeted interventions in areas of concern that result in changes in patient care processes. The reports are composed of outcomes-based, risk-adjusted data that are submitted by participating hospitals and have recently included data for otolaryngology-head and neck surgery. Actions taken based on NSQIP data demonstrate improvements in patient morbidity and mortality, decreased length of stay, and decreased hospital costs. In a time of increased scrutiny of health care costs and outcomes, NSQIP is an important tool for surgeons to improve quality and decrease costs.     

Loss of Raf-1 kinase inhibitor protein expression is associated with lymph node metastasis in papillary thyroid cancer

Objective

Raf-1 kinase inhibitor protein has potential as a molecular determinant of tumor metastasis and may serve as a prognostic marker. The aim of this study is to analyze the correlation between Raf-1 kinase inhibitor protein expression and the clinicopathologic characteristics of papillary thyroid cancer.

Study Design

Immunohistochemical analysis.

Setting

Tertiary care teaching hospital.

Subjects and Methods

Fifty-nine patients with papillary thyroid cancer underwent total thyroidectomy and central neck dissection. Using specimens from total thyroidectomy and central neck dissection, we performed immunohistochemistry for Raf-1 kinase inhibitor protein and evaluated associations between Raf-1 kinase inhibitor protein expression and lymph node metastasis, tumor size, number of tumors, extrathyroidal invasion, angiolymphatic invasion, and status of the tumor border.

Results

We found significantly low Raf-1 kinase inhibitor protein expression in papillary thyroid cancer with lymph node metastasis. However, Raf-1 kinase inhibitor protein expression was not associated with tumor size, multifocality, extrathyroidal invasion, or status of the tumor border.

Conclusion

The loss of Raf-1 kinase inhibitor protein expression is associated with lymph node metastasis of papillary thyroid cancer but not with the progression of primary tumors.     

Does the duration of surgery affect outcomes in patients undergoing coronary artery bypass grafting?

Background

Numerous predictors of coronary artery bypass grafting (CABG) outcomes have been identified. We aimed to determine whether the duration of surgery independently predicts outcome in patients undergoing CABG.

Methods

We retrospectively reviewed data from 337 patients (mean age 62 ± 7 years) who underwent CABG consecutively at our institution between January 2005 and December 2006.

Results

Duration of surgery correlated positively with length of both surgical intensive care unit (SICU) stay (r = .147, P = .004) and ventilator support (r = .097, P = .038) in univariate analysis, but only with length of SICU stay (P = .01) in a multivariate logistic regression after confounding factors were controlled for in the model. The regression coefficient was .006; every additional 30 minutes of surgery time was associated with 4.32 more hours of SICU stay. Duration of surgery was not associated with survival (P > .05).

Conclusions

Although duration of surgery did not affect short-term survival after CABG, surgical duration independently predicted length of SICU stays. Efforts to reduce the length of operations may promote more efficient use of hospital resources.     

Intraoperative myocardial acidosis as a risk for hospital readmission after cardiac surgery

Background

This study elucidates the relationship between intraoperative myocardial acidosis/ischemia and the risk of unplanned hospital readmissions within 30 days and 6 months after cardiac surgery.

Methods

Myocardial tissue pH (corrected to 37°C: pH_37C) was monitored in 221 patients during cardiac surgery. Regional myocardial acidosis was defined in terms of specific pH thresholds.

Results

Fourteen percent and 27% of the patients were readmitted within 30 days and 6 months postoperatively, respectively. The mean number of readmissions was 1.67 ± 1.24; pH_37C <6.85 at the end of cardiopulmonary bypass (CPB) was identified as the threshold most significantly associated with readmission. This threshold was associated with a 6-fold increased risk of readmission within 30 days and a 5-fold increased risk within 6 months.

Conclusions

Persistent regional myocardial acidosis after weaning from CPB independently determines unplanned readmission rates up to 6 months postoperatively. This study underscores the importance of avoiding myocardial tissue acidosis during cardiac surgery.     

The lung primordium an outpouching from the foregut! Evidence-based dogma or myth?

Background/Purpose

This study examines and challenges the “evidence-based legitimacy” of the theory, “the lung primordium is an outpouching from the foregut.”

Method

A literature review was undertaken using computer database, journals, and relevant anatomical and embryological texts.

Results

The independent path of development taken by the tracheobronchial system and the oesophagus once identified as separate entities; the lack of morphologic, molecular, biological, and genetic supportive evidence for the “common-origin” theory; the distinct longitudinal line of demarcation between the nonsegmented muscles of the esophagus and the highly segmented cartilaginous structure of the tracheobronchial tree; the absence of a tracheoesophageal septum in the process of separation; the differences in epithelial lining; and the diametrically opposed mucociliary cascade of the upper airway vs the mucociliary escalator of the tracheobronchial tree all seriously challenge the authenticity of a common origin to these 2 entities.

Conclusion

To the extent that the foregut is seen as consisting of 2 separate semitubular splanchnopleuric entities ventrodorsally juxtaposed, it is true that the lung primordium as an outpouching of, and not from, the foregut. This must never be confused with the notion that the esophagus and tracheobronchial tree have a common origin. In fact, they develop from 2 completely separate segments of the trilaminar germ disk, but because of head fold development are brought together to create a common tracheoesophageal chamber that is later separated, facilitated by the prochordal membrane diverticulum.     

Extended criteria for living donor liver transplantation in patients with advanced hepatocellular carcinoma

Background

The purpose of this study was to evaluate the possibility of expanding the selection criteria in living donor liver transplantation (LDLT) to treat hepatocellular carcinoma (HCC).

Methods

From October 2000 to December 2010, we retrospectively analyzed 71 patients who had undergone LDLT beyond the Milan criteria (MC), among the entire cohort of 199 HCC patients. We evaluated the tumor biology as well as overall and disease-free survival (DFS), seeking to identify risk factors for recurrence. The median follow-up was 37 months (range 5-124).

Results

Among the 71 patients beyond the MC were 18 recurrences and 30 deaths. Their 5-year overall and DFS rates were 52.3% and 67.7%, respectively. On multivariate analysis, tumor diameter, tumor number, and E-S grade significantly influenced overall and DFS. According to our new criteria (size ≤7 cm, number ≤7), 86% of our patients would be included compared with 64% using MC. Five-year DFS and overall survival rates according to our criteria were comparable with the MC: 86.8% and 72.3% versus 86.8% and 73.4%, respectively.

Conclusion

Our criteria appear to achieve useful cut-off values beyond the MC.     

Impaired expression of myogenic regulatory molecules in the pelvic floor muscles of murine embryos with anorectal malformations

Background/Purpose

Recent biological studies have elucidated the molecular mechanism of muscle development, in which various regulatory factors (myogenic regulatory factors [MRFs]) play key roles during embryogenesis. To investigate the development of anorectal malformations (ARMs), we studied MRF expressions in myogenic cells in the pelvic floor using murine embryos affected with ARM.

Methods

Anorectal malformation embryos were obtained from the 10.5th embryonal day (E10.5) to the 7.0th postnatal day (D7.0) in a natural mutant strain (Sd/+, RSV/Le). Serial frozen sections were prepared for immunohistochemistry using specific antibodies to M-cadherin, myoD, Myogenin, myosin heavy chain, and alfa-actin molecule.

Results

In normal mice, embryonal caudal somites differentiated into myogenic stem cells and migrated to the pelvic floor between E11.0 and E14.0. In the ARM mice, however, caudal somites were irregularly arranged and MRF expressions in myogenic cells were markedly decreased in the dorsocaudal region at E11.5 to E13.0, leading to hypoplastic pelvic floor muscles.

Conclusions

The maldevelopment of pelvic floor muscles in ARM is derived from a deficient supply of myogenic stem cells, with impaired MRF expression. These results suggest that myogenic stem cells, available from bone marrow contents, may be used for postnatal muscle regeneration to reinforce the pelvic floor muscle function in children with ARM.     

Extent of small bowel resection does not influence the magnitude of intestinal adaptation in the mouse

Purpose

The magnitude of intestinal adaptation is considered to correlate with the extent of small bowel resection (SBR). However, this association has never been tested in mice. We sought to test the hypothesis that a greater SBR will induce a greater adaptation response.

Methods

C57/B6 mice underwent 50% SBR, 75% SBR, or sham operation and were killed on postoperative day 7. The magnitude of adaptation was compared between 50% SBR and 75% SBR as changes in villus height, crypt depth, as well as rates of apoptosis and proliferation.

Results

Seventy-five percent SBR led to decreased survival and increased weight loss compared with 50% SBR. The remnant ileum of both 50% SBR and 75% SBR displayed similar crypt expansion, enhanced villi, and increased apoptotic indices. Proliferation rates increased after 50% and 75% SBR equally.

Conclusion

Models of resection greater than 50% in mice result in greater morbidity and mortality and do not magnify the adaptation response to massive SBR. The use of more extreme resection models does not appear to provide added benefit for investigating mechanisms of intestinal adaptation.     

Psychosocial liaison-consultation for the children who have undergone repair of imperforate anus and Hirschsprung disease

Objective

The aim of this study was to investigate the psychological status of Japanese children with congenital anorectal malformation and their mothers to develop appropriate psychiatric interventions.

Method

The subjects comprised 50 children with congenital anorectal malformation aged 0 to 16 years and their mothers. The psychology of children aged 7 to 16 years was investigated by Kovacs' Children's Depression Inventory (CDI). The psychology of their mothers was assessed by Spielberger's State-Trait Anxiety Index (STAI) and Zung's Self-rating Depression Scale (SDS).

Results

Depression was more marked in the children aged 12 to 16 years than in those aged 7 to 11 years according to the CDI. The mothers of preschool children showed higher levels of anxiety and depression than those of school-aged children, according to the STAI and SDS. Significant correlations between the CDI score of the children and the STAI or SDS score of the mothers were observed only among children aged 7 to 11 years.

Conclusions

The frequency of depression and anxiety among children with congenital anorectal malformation and that among their mothers was associated with the age of the child. Long-term postoperative psychosocial support for the children and their mothers may be required, taking into account the age of the child.     

Dynamic Splinting for the Stiff Hand after Trauma: Predictors of Contracture Resolution

Study Design

Prospective cohort.

Introduction

Many variables are believed to influence the success of dynamic splinting, yet their relationship with contracture resolution is unclear.

Purpose of the Study

To identify the predictors of outcome with dynamic splinting of the stiff hand after trauma.

Methods

Forty-six participants (56 joints) completed eight weeks of dynamic splinting, and the relationship between 13 clinical variables and outcome was explored.

Results

Improvement in passive range of motion, active range of motion (AROM), and torque range of motion averaged 21.8°, 20.0°, and 13.0°, respectively (average daily total end range time, 7.96 hours). Significant predictors included joint stiffness (modified Weeks Test), time since injury, diagnosis, and deficit (flexion/extension). For every degree change in ROM on the modified Weeks Test, AROM improved 1.09° (standard error, 0.2). Test-retest reliability of the modified Weeks Test was high (intraclass correlation coefficient [2, 1] = 0.78).

Conclusions

Better progress with dynamic splinting may be expected in joints with less pretreatment stiffness, shorter time since injury (<12 weeks), and in flexion rather than extension deficits. Further research is needed to determine the accuracy with which the modified Weeks Test may predict contracture resolution.

Level of Evidence

2b.     

Marked increase in incidence of Achromobacter xylosoxidans infections caused by sporadic acquisition from the environment

Background

An increased incidence of Achromobacter xylosoxidans infections has been observed at the Cystic Fibrosis Centre at Aarhus University Hospital, as the proportion of patients colonised with A. xylosoxidans increased from 6 to 10% from 2005 to 2009.

Methods

Pulsed field gel electrophoresis (PFGE) was used to type isolates of A. xylosoxidans.

Results

Four patients infected for 2-7 years were part of a larger epidemic spread involving both Danish CF centres, while 11 patients carried strains with unique genotypes. Longitudinal analysis of isolates from ten patients with multiple preserved isolates showed that each patient persistently carried isolates of a single genotype. Following lung transplantation, two patients showed re-colonisation of the lung grafts with the pre-transplant A. xylosoxidans strain.

Conclusions

A. xylosoxidans has been transmitted between patients from our clinic, but the recent increase in incidence is not caused by cross infections.