The American Journal of Surgery

Risk factors for surgical complications in distal pancreatectomy

2010-04-12

Abstract: Background: Pancreatic fistula (PF) represents a major complication after distal pancreatectomy. In a consecutive series of 110 patients, risk factors for the incidence of PF and surgical morbidity were identified.Methods: Patients having undergone distal pancreatectomy between 2003 and 2007 were identified. Clinicopathologic parameters as well as perioperative data were correlated with the incidence of PF and overall surgical morbidity using univariate and multivariate models.Results: In 72 patients (65%), malignant disease was present. Splenectomy and multivisceral resection were performed in 84 (76%) and 47 (42%) patients, respectively. Overall major surgical morbidity was 18%, and 12 patients (11%) developed PFs. A body mass index > 25 kg/m2 was the only independent significant predictive factor for PF. Malignancy, splenectomy, multivisceral resection, transfusion, comorbidity, and stapler use did not show statistical significance. For overall surgical morbidity, there was no significant indicator.Conclusions: A body mass index > 25 kg/m2 contributes to the incidence of PF after distal pancreatectomy. Other parameters did not show a significant influence on PF or on overall surgical morbidity.

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

2010-02-01

Abstract: Background: There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected.Methods: The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared.Results: Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group.Conclusions: The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.

Typical carcinoids and neuroendocrine carcinomas of the stomach: differing clinical courses and prognoses

2010-04-12

Abstract: Background: Gastric endocrine tumors are usually classified as 3 types of well-differentiated endocrine tumors (typical carcinoids or carcinoids) and poorly differentiated carcinomas (neuroendocrine carcinomas [NECs]).Methods: From 1993 to 2008, 97 patients (73 men and 24 women) were diagnosed with gastric neuroendocrine tumors at the Asan Medical Center.Results: Of the 45 patients with typical carcinoids, 37 underwent surgery (eg, endoscopic resection). Of the 52 patients with NECs, 43 underwent surgery (eg, radical gastrectomy). One patient died of recurrence of the typical carcinoids, whereas 26 patients with NECs died of related diseases (P < .05). The rates of survival and recurrence did not significantly differ by type of typical carcinoid (P > .05).Conclusions: Regardless of the type, carcinoids that are not yet advanced can be effectively treated with minimal endoscopic or laparoscopic surgery. However, all NECs and advanced carcinoids should be treated with radical gastrectomy.

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool

Sudip K. Sarker, M. Maciocco, A. Zaman, I. Kumar — 2010-06-24

Abstract: Aims: The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees.Methods: Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently.Results: Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann–Whitney for generic technical skills was significant for live and simulated operations, P ≤ .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann–Whitney P < .05, but not for supervised live operations, Mann–Whitney P > .05.Conclusions: The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.

Expressions of the anti-apoptotic genes Bag-1 and Bcl-2 in colon cancer and their relationship

Nianfeng Sun, Qingyi Meng, Ailing Tian — 2010-04-21

Abstract: Background: The aims of this study were to investigate the expressions and significance of the antiapoptotic genes Bag-1 and Bcl-2 in colon cancer and to evaluate their relationship.Methods: The expressions of Bag-1 and Bcl-2 were examined in 128 colon cancer and 20 normal colon tissue samples by reverse-transcription polymerase chain reaction and immunohistochemical technique (streptavidin-biotin-peroxidase complex method).Results: Bag-1 and Bcl-2 were expressed in colorectal cancer tissues but not in normal colorectal tissues by reverse-transcription polymerase chain reaction. The expression of Bag-1 in colon cancer was closely correlated with pathologic grade, distance metastasis, Duke stage, and prognosis, but it had no effect on the pathologic type, tumor diameter, depth of invasion, and lymphoid node metastasis of the cancer. By contrast, Bcl-2 had no significant correlation with all the clinical and pathologic factors. There was a positive correlation between Bag-1 and Bcl-2 in the development of colon cancer.Conclusions: High expressions of Bag-1 and Bcl-2 proteins in colon cancer were found. They might be regarded as biomarkers for the diagnosis of the early stage of colon cancer. In addition, they have significant relevance for the prognosis of colon cancer.

Isolated caudate lobe resection for hepatic tumor: surgical approaches and perioperative outcomes

Yi Wang, Lei Y. Zhang, Lei Yuan, Fu. Y. Sun, Tian G. Wei — 2010-04-22

Abstract: Background: Caudate lobe of the liver is relatively inaccessible because of its deep location and lying between the major vascular structures. Therefore, isolated caudate lobe resection (ICLR) is a much challengeable operation.Methods: Review of prospectively collected data from patients who underwent ICLR for hepatic tumor.Results: Forty-six patients (mean age 46.8 years) underwent ICLR for malignant (39 cases) and benign (7 cases) hepatic tumors. ICLRs were performed by 3 different approaches and in different ways of hepatic vascular control: without any vascular control in 7 patients, under Pringle maneuver in 26 patients, and under sequential inflow and outflow vascular occlusion in 13 patients. There were no perioperative deaths, and the postoperative complication rate was 8.7% (4/46). The mean operative time was 174.5 ± 44.3 minutes and the mean estimated intraoperative blood loss was 504.4 ± 356.2 mL.Conclusions: ICLR is a technically demanding but safe procedure. Choice of surgical approaches and ways of hepatic vascular control should be based on tumor location and surgeons'experience.

Prevention of seroma formation after mastectomy and axillary dissection by lymph vessel ligation and dead space closure: a randomized trial

2010-04-22

Abstract: Introduction: We aimed to reduce the incidence of seroma formation by altering surgical technique.Methods: Two hundred one breast cancer patients were randomly divided into 2 arms: arm 1 was operated on using an altered surgical technique, which is to ligate all of the tissue connecting axillary vein bundles to the specimen, to suture the anterior edge of the latissimus dorsi to the chest wall, and to fix the skin flap to the underlying muscle by subcutaneous sutures; arm 2 was operated on using the conventional technique.Results: The drainage volume, in the initial 3 days, for patients in arm 1 was significantly less than that for patients in arm 2 (P < .01). The duration of drainage in arm 1 was shorter than that in arm 2 (P < .01). The incidence of seroma formation in arm 1 (2%) was significantly less than that in arm 2 (14%) (P < .01).Conclusion: The modified operating technique is an effective approach to reducing the incidence of seroma formation after mastectomy and axillary dissection.

Post-appendectomy visits to the emergency department within the global period: a target for cost containment

2010-09-01

Abstract: Background: Postoperative visits to the emergency department (ED) instead of the surgeon's office consume enormous cost.Hypothesis: Postoperative ED visits can be avoided.Setting: Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine.Patients: Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period.Methods: Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson χ2 test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospital's billing department.Results: Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was $55,000 plus physician services.Conclusions: ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access.

The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy

2010-09-01

Abstract: Background: Laparoscopic surgery in pregnant women has become increasingly more common since the 1990s; however, the safety of laparoscopy in this population has been widely debated, particularly in emergent and urgent situations.Methods: A retrospective chart review of all pregnant women following a nonobstetric abdominal operation at a University hospital between 1993 and 2007. Perioperative morbidity and mortality for the mother and fetus were evaluated.Results: Ninety-four subjects were identified; 53 underwent laparoscopic procedures and 41 underwent open procedures. Cholecystectomy and appendectomy were performed in both groups with salpingectomy/ovarian cystectomy only in the laparoscopic group. No maternal deaths occurred, while fetal loss occurred in 3 cases within 7 days of the operation and in 1 case 7 weeks postoperatively. This and other perinatal complications occurred in 36.7% of the laparoscopic group and 41.7% of the open group.Conclusion: Laparoscopic appendectomy and cholecystectomy appear to be as safe as the respective open procedures in pregnant patients; however, this population in particular remains at risk for perinatal complications regardless of the method of abdominal access.

The clinical impact and outcomes of immunohistochemistry-only metastasis in breast cancer

2010-09-01

Abstract: Background: Modern surgical and pathological techniques can detect small-volume axillary metastases in breast cancer with unknown clinical significance.Methods: A retrospective database review from 1996 through 2004 identified all patients with immunohistochemical (IHC)-only sentinel node (IHC-SN) metastases and compared them with negative controls (Neg-SN).Results: When comparing the 232 IHC-SN patients with the 252 Neg-SN controls, the IHC-SN patients had larger tumors, more lobular histology, a higher grade, and more HER2/neu positivity. They also received more systemic therapy. With a median follow-up of 5 years, there were no differences in recurrence-free survival or overall survival. In 123 IHC-SN patients treated with axillary dissection (axillary lymph node dissection), 16% had positive non-SLNs. Patients with positive non-SLNs tended to have worse outcomes.Conclusions: IHC-only sentinel lymph node (SLN) metastases were associated with worse prognostic features and higher rates of systemic therapy. However, no outcomes differences were noted.

Diminishing morbidity with the increased use of sentinel node biopsy in breast carcinoma

Andrea Bafford, Michele Gadd, Xiangmei Gu, Stuart Lipsitz, Mehra Golshan — 2010-04-22

Abstract: Background: Sentinel lymph node biopsy has largely replaced axillary node dissection in the staging of women with clinically negative axillas. The aim of this study was to compare the morbidity of sentinel node biopsy only, sentinel node biopsy followed by axillary dissection, and axillary node dissection only.Methods: Retrospective review of a prospectively maintained database of patients who underwent sentinel lymph node biopsy, axillary lymph node dissection, or both between June 1996 and August 2008 was performed. The incidence of postoperative complications, including arm cellulitis, diminished shoulder range of motion, axillary hematoma, intercostal brachial nerve injury, pulmonary embolus or deep-vein thrombosis, lymphocele requiring aspiration, wound dehiscence, and wound infection, was compared among the 3 groups using Fisher's exact test.Results: Of the 6,847 axillary operations performed, 2,745 (40%) were sentinel node biopsy only, 1,825 (27%) were sentinel lymph node biopsy followed by completion axillary dissection, and 2,277 (33%) were axillary dissection only. The mean node retrieval was 2 for sentinel node biopsy, 13 for sentinel node biopsy and completion axillary dissection, and 14 for axillary dissection. The mean age was 58 years. The overall complication rate was higher during the first half of the study period than during the second half (9.9% vs 3.9%, P < .0001). Axillary dissection had the highest overall complication rate (11.1%), followed by sentinel node biopsy and completion axillary dissection (7.3%), followed by sentinel node biopsy alone (2.6%) (P < .0001). Significantly less shoulder range of motion limitation, axillary hematoma, and lymphocele requiring aspiration were seen after sentinel node biopsy alone than after sentinel node biopsy plus completion axillary dissection or axillary dissection alone (P < .0001). Wound infection was also significantly less common after sentinel node biopsy than after axillary dissection (P = .02). No difference was seen in incidence of postoperative pulmonary embolus or deep-vein thrombosis, arm cellulitis, intercostal brachial nerve injury, or wound dehiscence.Conclusions: Sentinel lymph node biopsy is less morbid than sentinel node biopsy followed by completion axillary dissection and axillary node dissection alone. The morbidity of axillary surgery has decreased over time.

The incidence of bariatric surgery has plateaued in the U.S.

Edward H. Livingston — 2010-04-22

Abstract: Background: Estimates of the procedure incidence for bariatric surgery have been derived primarily from surveys of bariatric surgeons or from inpatient data sources. New population-representative databases of outpatient surgery are available that enable accurate estimations of bariatric surgery case volumes.Methods: The 2006 National Hospital Discharge Survey, National Inpatient Sample, and National Survey of Ambulatory Surgery were assessed for bariatric surgery procedures. Data were compared with inpatient data from 1993 to 2007. Procedure costs were estimated.Results: The incidence of bariatric surgery has plateaued at approximately 113,000 cases per year. Open gastric bypass now constitutes only 3% of all cases but costs $4,800 less than laparoscopic procedures. Laparoscopic gastric banding is performed in 37% of all bariatric surgery cases and costs the same as laparoscopic gastric bypass to perform. Complication rates have fallen from 10.5% in 1993 to 7.6% of all cases in 2006. Bariatric surgery costs the health economy at least $1.5 billion annually.Conclusions: Despite predictions of continued growth of bariatric surgery, it appears that the annual incidence for these operations has remained stable since 2003. Most operations are performed laparoscopically, but open gastric bypass is substantially less costly than laparoscopic operations. Despite its simplicity, laparoscopic gastric banding costs the same as gastric bypass. There is no cost savings associated with ambulatory bariatric surgery.

Parenteral nutrition: a clear and present danger unabated by tight glucose control

2010-09-01

Abstract: Background: The infectious risks of parenteral nutrition (PN) in critical illness are well described, although most literature predates tight glucose control (TGC) practice. The authors hypothesized that PN-related complications are ameliorated by TGC and are equivalent to those in enteral nutrition (EN) patients.Methods: A prospective cohort study of patients admitted to the surgical intensive care unit was conducted, comparing PN and EN patients. TGC target was 80 to 110 mg/dL. Univariate and multivariate logistic regression was used to explore the association between infectious outcomes and PN use.Results: One hundred fifty-five patients were studied. Mean daily glucose values were lower for the PN group than for the EN patients (118.2 vs 125.6 mg/dL, P = .002). Nonetheless, the incidence of bloodstream infection and catheter-related bloodstream infection was significantly associated with the administration of PN. In a multivariate logistic regression model, PN was associated with a >4-fold increase in the odds of having a catheter-related bloodstream infection (odds ratio, 4.48; 95% confidence interval, 1.14–17.49; P = .03).Conclusions: Despite the successful implementation of TGC, PN is still a significant risk factor for infectious complications among surgical intensive care unit patients.

An expanding role for apolipoprotein E in sepsis and inflammation

Kelley Chuang, Erica L. Elford, Jill Tseng, Briana Leung, Hobart W. Harris — 2010-04-22

Abstract: Background: Apolipoprotein E (apoE), a component of plasma lipoproteins, plays an important, but poorly defined role in sepsis. We have shown that injecting apoE increases septic mortality in a rat model of gram-negative bacterial sepsis, with concomitant hepatic natural killer T (NKT) cell proliferation and activation. The presumed mechanism for this apoE-mediated mortality is that apoE can bind and traffic antigens, presumed to include lipopolysaccharide (LPS), and promote activation of dendritic cells (DC) with subsequent NKT activation and cytokine release. Thus, we sought to prove that LPS was the antigen responsible for the increased NKT activation enhanced by the presence of apoE.Methods: We isolated murine marrow-derived DCs, pulsed them with lipid antigen (LPS, and positive controls alpha-galactosylceramide [α-GalCer] and isoglobotrihexosylceramide 3 [iGb3]) with or without apoE, and then cocultured the DCs with hybridoma NKTs. NKT activation was measured by interleukin-2 (IL-2) supernatant levels using enzyme-linked immunosorbent assay (ELISA).Results: LPS at different concentrations was a weak stimulus for NKT activation regardless of apoE presence. When apoE was present, iGb3, an endogenous ligand analog, elicited more than a 2-fold increase in IL-2 response when compared with iGb3 alone (P < .05).Conclusions: These results indicate an endogenous ligand, not LPS, may be responsible for NKT activation. A molecular remnant similar to iGb3 could act as a damage-associated molecular pattern and play a prominent role in animal models of sepsis.

Epidermal growth factor receptor (EGFR) intron 1 polymorphism and clinical outcome in pancreatic adenocarcinoma

2010-04-22

Abstract: Background: Epidermal growth factor receptor (EGFR) intron 1 has a polymorphic region of CA repeats that is believed to be associated with increased EGFR expression, tumor aggressiveness, and worse survival in cancer patients.Methods: A large population of pancreatic adenocarcinoma patients was investigated to evaluate this polymorphism as a potential prognostic marker of clinical outcome. Deoxyribonucleic acid obtained from 50 resected pancreatic adenocarcinomas and from 85 diagnostic endoscopic ultrasound-guided fine-needle aspiration procedures corresponding to patients with unresectable tumors was included. The correlation between CA repeat length and EGFR messenger ribonucleic acid levels was also examined.Results: Analysis of the 135 patients revealed no correlation between EGFR intron 1 CA repeat length and tumor stage. There was no difference in overall patient survival when stratified by allele length. A correlation between EGFR intron 1 length and EGFR transcript and protein levels could not be established.Conclusions: The length of the EGFR intron 1 CA repeats does not correlate with levels of EGFR expression and cannot be used as marker of clinical prognosis in pancreatic cancer patients.

Biomechanical analysis of polypropylene prosthetic implants for hernia repair: an experimental study

2010-09-01

Abstract: Background: Although polypropylene (PP) is the most common biomaterial used for ventral and inguinal hernia repairs, its mechanical properties remain obscure.Methods: Retraction, solidity, and elasticity of 3 large pore-size monofilament PP prostheses, 1 heavy-weight PP (HWPP), a second low-weight PP, and a third coated with atelocollagen were evaluated in a rabbit incisional hernia model. A small pore-size multifilament PP implant (MPP) also was tested.Results: Unlike pore size, the weight of the prosthesis was not an influencing factor for retraction. Atelocollagen coating reduced retraction (P < .05). HWPP and MPP were less likely to rupture (P < .05). HWPP had comparatively better elasticity (P < .05), whereas MPP supported the greatest elastic force (P < .05). Nevertheless, the amount of shrinkage of MPP (30% of the original size) made this prosthesis unusable.Conclusions: In this study, HWPP presented the most advantageous biomechanical compromise for hernia surgery.

Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues

James Muntz — 2010-04-22

Abstract: Background: Venous thromboembolism (VTE) is a major cause of mortality and morbidity in patients after major surgery. The US Acting Surgeon General issued a “call to action” to reduce the number of VTE cases nationwide.Data sources: PubMed literature searches were performed to identify original studies.Results and conclusions: Noncompliance with VTE guidelines is common in clinical practice. Thromboprophylaxis is frequently stopped on discharge, not meeting recommendations for standard-duration prophylaxis (7–10 days) because of shorter hospital stays or for extended-duration prophylaxis (10–35 days). Appropriate pharmacologic prophylaxis options for orthopedic surgery patients include the low–molecular-weight heparins (LMWHs), fondaparinux, or warfarin (10–35 days). For patients undergoing abdominal surgery for cancer, the LMWHs are recommended beyond hospitalization (up to 28 days). Performance measures should help establish VTE-prevention policies that close the gap between guideline recommendations and clinical practice in a greater number of hospitals.

Invited commentary on “Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues” by Muntz

Ronald H. Clements — 2010-09-01

I read with great interest the article “Duration of deep vein thrombosis in the surgical patient and its relation to quality issues” by Dr. Muntz. It addresses the issue of inadequate venous thromboembolism (VTE) prophylaxis and encourages the use of quality improvement metrics to enhance compliance with published guidelines. The author is to be commended for drawing attention to our deficiencies that may be costly in terms of postoperative morbidity and mortality. I would urge the readers to thoughtfully consider the themes of this article.

Invited commentary on “Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues” by Muntz

Elliott R. Haut — 2010-04-22

The accompanying article by Dr Muntz is an excellent review of the evidence showing how poor a job American medicine as a whole does in the arena of prophylaxis for venous thromboembolism (VTE) in surgical patients. The article concisely summarizes the evidence-based guidelines that we should apply to patients undergoing major surgical procedures (with a significant focus on orthopedic surgery). The author then goes on to cite article after article showing that patients simply do not get the VTE prevention that they should. Some studies suggest that compliance with “best practice” may be low as 3% in certain patient subsets and hovers around the 50% range for many patient groups. When I first heard these statistics years ago, I was shocked; how could we be doing such a poor job when such good evidence exists? Clearly, I am not the only person appalled at these data. Samuel Z. Goldhaber, a national leader in VTE prevention efforts, has suggested that “the disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis.” The Agency for Healthcare Research and Quality has suggested that the #1 ranked opportunity for patient safety improvement is “appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.” The US Surgeon General's “Call to Action to Prevent Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)” also highlights the importance of getting this information more in the public eye. Educational efforts are clearly needed in this arena, yet education alone will not solve the problem.

Preoperative decision making for rectal cancer

2010-03-12

Abstract: Background: Rectal cancer treatment has become multimodal as a result of significant advances in imaging, staging, surgery, radiotherapy, and chemotherapy. Multidisciplinary teams can incorporate these developments into tailor-made treatment plans and offer state-of-the-art services for rectal cancer patients.Methods: We searched the MEDLINE and PubMed databases using the following keywords: “rectal cancer,” “total mesorectal excision,” “multidisciplinary treatment/team,” “radiotherapy,” “chemotherapy,” and their combinations. There were no language or publication year restrictions. References in published articles also were reviewed.Results: Total mesorectal excision surgery, high-resolution pelvic magnetic resonance imaging, preoperative chemoradiotherapy, and pathologic reports according to Quirke protocol are preconditions for the initiation of an effective multidisciplinary team. Common topics for discussion are the status of the circumferential margin, the type of radiotherapy and surgery required, and the chemotherapeutic agent to be used.Conclusions: This review focuses on this issue based on two main principles. First, the status of the circumferential margin dictates the use of preoperative chemoradiotherapy. Second, preoperative chemoradiotherapy is superior in terms of free circumferential resection margin rate, local recurrence rate, and toxicity.

Kirby I. Bland — 2010-07-01

Professor Seymour I. Schwartz, internationally renowned surgeon, physician-scientist, author, educator, cartographer, and art connoisseur, is perhaps best known for his monumental achievement as the founding editor of the Principles of Surgery, now in its 7th edition with over one-half million copies sold. As former Professor and Chairman of the Department of Surgery of the University of Rochester, he has held seminal roles in the leadership of American Surgery, including the American College of Surgeons, the American Board of Surgery, and the American Surgical Association.

A left circum-aortic renal vein aneurysm

2010-09-01

Abstract: A well-defined, slow-flowing vascular lesion was found incidentally by Doppler abdominal sonography in the left renal hilar region of a 36-year-old Taiwanese woman. Clinically, the physical examination and laboratory screening were unremarkable. A magnetic resonance angiography of the area near the renal hilum showed a saccular mass (3.5 × 3.1 × 2.5 cm) embracing the aorta by the anterior and posterior branch of the aneurysm originating from the left renal vein to the inferior vena cava. However, the patient refused further invasive intervention and has since been examined periodically by ultrasonography for 18 months without increasing size or symptoms.

Florid papillomatosis of the male nipple

Massimiliano Tuveri, Pietro Giorgio Calò, Cristina Mocci, Angelo Nicolosi — 2010-04-22

Abstract: The authors present a case of an adenoma of the nipple in a 61-year-old man who reported a 6-month history of nodularity and itching at his left nipple. Examination revealed a firm, well-defined, vascularized tumor measuring .8 cm that altered the normal anatomy of the nipple. A total excision of the nipple and areola was performed. The histological diagnosis was adenoma of the nipple. No recurrent tumor has been observed during 4 years of postoperative follow-up. An adequate excision of the lesion is curative without any risk of recurrence or development of malignancy.

Intravenous leiomyomatosis: diagnosis and follow-up with multislice computed tomography

2010-04-22

Abstract: Intravenous leiomyomatosis is a rare disease, which appears histologically benign but is clinically aggressive. It is characterized by the intraluminal growth of leiomyomas in the intrauterine and systemic veins. Intravenous leiomyomatosis was reported to have originated in the uterus and extended into the right ventricle via the inferior vena cava (IVC). In these circumstances, it is fatal. Multislice compute tomography (MSCT) allows an early and accurate preoperative diagnosis, resulting in a higher rate of surgical resection and improved survival. The authors present 3 cases of intravenous leiomyomatosis with a history of uterine leiomyoma and hysterectomy. The lesions were found to have extended through the IVC into the right cardiac cavities and were confirmed to be intravenous leiomyomatosis by surgery.

Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery

Antonio V. Sterpetti — 2010-09-01

Abstract: The author presents a technique for endarterectomy and reconstruction of the carotid bifurcation in difficult cases when the plaque extends high into the internal carotid artery. The technique combines the aspects of the 2 most commonly performed procedures: carotid endarterectomy after a longitudinal arteriotomy extending from the common carotid artery into the internal carotid artery and eversion endarterectomy in which the plaque is removed from the internal carotid artery sectioned from the common carotid artery and everted. The author suggests applying this technique selectively in patients in whom the atherosclerotic plaque extends very high into the internal carotid artery. The technique offers the advantages of removing the plaque into the common carotid artery under direct vision and leaving the original dimensions and geometry of the internal carotid artery, theoretically decreasing the probability of early thrombosis and recurrent carotid disease. For routine cases, the author prefers and recommends standard carotid bifurcation endarterectomy with patch closure when the size of the arteries is reduced like in women and selected male patients.

2010-09-01

The American Journal of Surgery

Risk factors for surgical complications in distal pancreatectomy

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

Typical carcinoids and neuroendocrine carcinomas of the stomach: differing clinical courses and prognoses

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool

Expressions of the anti-apoptotic genes Bag-1 and Bcl-2 in colon cancer and their relationship

Isolated caudate lobe resection for hepatic tumor: surgical approaches and perioperative outcomes

Prevention of seroma formation after mastectomy and axillary dissection by lymph vessel ligation and dead space closure: a randomized trial

Post-appendectomy visits to the emergency department within the global period: a target for cost containment

The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy

The clinical impact and outcomes of immunohistochemistry-only metastasis in breast cancer

Diminishing morbidity with the increased use of sentinel node biopsy in breast carcinoma

The incidence of bariatric surgery has plateaued in the U.S.

Parenteral nutrition: a clear and present danger unabated by tight glucose control

An expanding role for apolipoprotein E in sepsis and inflammation

Epidermal growth factor receptor (EGFR) intron 1 polymorphism and clinical outcome in pancreatic adenocarcinoma

Biomechanical analysis of polypropylene prosthetic implants for hernia repair: an experimental study

Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues

Invited commentary on “Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues” by Muntz

Invited commentary on “Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues” by Muntz

Preoperative decision making for rectal cancer

A left circum-aortic renal vein aneurysm

Florid papillomatosis of the male nipple

Intravenous leiomyomatosis: diagnosis and follow-up with multislice computed tomography

Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery

Table of Contents