Enhanced Recovery After Surgery and Its Effects on Patient Reported Outcomes.

Enhanced recovery programs were developed as a means for improving patient recovery after surgery with a multifaceted approach including several interventions in the perioperative period. There is now sufficient evidence in the literature that enhanced recovery programs have actually shortened hospital length of stay after colorectal surgery. Nonetheless, the impact of these successful programs on patient-reported outcomes like functional recovery and return to baseline quality of life is not known.

Curcumin: An age-old anti-inflammatory and anti-neoplastic agent.

Curcumin is a natural anti-inflammatory agent that has been used for treating medical conditions for many years. Several experimental and pharmacologic trials have demonstrated its efficacy in the role as an anti-inflammatory agent. Curcumin has been shown to be effective in treating chronic conditions like rheumatoid arthritis, inflammatory bowel disease, Alzheimer's and common malignancies like colon, stomach, lung, breast, and skin cancers. As treatments in medicine become more and more complex, the answer may be something simpler. This is a review article written with the objective to systematically analyze the wealth of information regarding the medical use of curcumin, the "curry spice", and to understand the existent gaps which have prevented its widespread application in the medical community.

Outcomes of salvage surgery for cure in patients with locally recurrent disease after local excision of rectal cancer.

BACKGROUND: Local excision for early rectal cancer has gained widespread interest. Currently available imaging modalities have low sensitivity to detect locoregional disease, which may result in understaging and a high risk of recurrence after local excision. OBJECTIVE: The purpose of this work was to study the morbidity, mortality, and long-term oncologic outcomes in a select cohort of patients undergoing salvage surgery for local recurrence after local excision of early rectal cancer. DESIGN: A retrospective review of patient charts was used to determine patterns of disease recurrence and outcomes as a single-institution case series. SETTINGS: The study was conducted at a tertiary care cancer center. PATIENTS: The study cohort included patients with early rectal cancer treated by local excision who then developed local recurrence for which a multimodal salvage surgery with curative intent was performed between 1997 and 2013 at our center. MAIN OUTCOME MEASURES: Log rank tests were used to measure overall and disease-free survival. RESULTS: Twenty-seven patients were identified, with a mean age of 66 ± 12 years. The median time to recurrence was 54 weeks (range, 7-326 weeks). Recurrent disease was luminal in 23 patients, regional (involving both mesorectal and pelvic lymph nodes) in 6 patients, and both luminal and nodal in 2 patients. For salvage surgery, neoadjuvant chemoradiation was used in 12 patients (44%), and radiation alone was used in 1 patient. Sphincter-preserving surgery was performed in 9 patients (33%). R0 resection was achieved in 25 patients (93%). Four patients received intraoperative radiation therapy. Five-year overall survival was 50% (95% CI, 30%-74%), and re-recurrence-free survival was 47% (95% CI, 25%-68%). LIMITATIONS: This study was limited by its retrospective nature, small patient cohort, referral bias, and selection bias. CONCLUSIONS: Even in highly selected patients who undergo surgery for local recurrence after transanal excision of early stage rectal cancer, oncologic outcomes are poor.

National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis.

BACKGROUND: Patients undergoing surgical treatment of chronic ulcerative colitis usually undergo a staged approach to IPAA. OBJECTIVE: The purpose of this work was to identify the national trends in approach to IPAA for chronic ulcerative colitis and to evaluate 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program. DESIGN: This was a retrospective review study SETTINGS: : This study was conducted at a tertiary care cancer center. PATIENTS: Patients with chronic ulcerative colitis who underwent IPAA from 2005 to 2011 were identified. Those who underwent colectomy with pouch procedure were placed in a 2-stage cohort, and those without simultaneous colectomy were part of a 3-stage cohort. Emergent operations were excluded. MAIN OUTCOME MEASURES: Trends in procedure mix, preoperative characteristics, and postoperative 30-day outcomes were compared. Multivariate analysis was used to identify independent risk factors for postoperative infection. RESULTS: Of 2002 patients who underwent IPAA, 1452 (72.5%) underwent 2-stage and 550 (27.5%) underwent 3-stage surgery. Since 2007, the distribution of 2- versus 3-stage procedures has not changed (p = 0.66). At the time of pouch surgery, patients who had undergone 3-stage surgery were less likely to have preoperative corticosteroid therapy, albumin <3 mg/dL, preoperative sepsis, and weight loss (all p < 0.05). Superficial surgical site infection was more common after 3-stage surgery (11.5% vs 7.3%; p < 0.01). After controlling for preoperative factors, wound classification was the only independent predictor of deep incisional or organ space infection (p < 0.01; OR, 1.76; 95% CI, 1.23-2.53). LIMITATIONS: This was a retrospective study. CONCLUSIONS: National trends of 2- versus 3-stage IPAA have remained stable over the last 5 years. Patients who underwent a 3-stage approach were healthier at the time of pouch surgery, with decreased corticosteroid use, hypoalbuminemia, and weight loss. Mixed results were seen for infectious complications with either approach. Prospective research is needed to determine the best approach to IPAA for chronic ulcerative colitis.

No benefit in staging fluorodeoxyglucose-positron emission tomography in clinically node-negative head and neck cutaneous melanoma.

BACKGROUND: Fluorodeoxyglucose-positron emission tomography (FDG-PET) has a high sensitivity for detecting metastasis from melanoma, but its application in early-stage melanomas is questionable. The purpose of this study was to determine if positron emission tomography (PET) is beneficial in staging of clinically node negative (cN0) head and neck melanoma. METHODS: After institutional review board approval, patients with head and neck melanoma treated at 2 cancer centers (between 2000 and 2010) were identified using International Classification of Disease (ICD)-9 codes. A retrospective medical chart review of cN0 patients was performed for the treatment course and outcomes. RESULTS: A total of 165 patients were treated; of these, 106 were node negative. FDG-PET was included in initial staging of 47 cN0 patients. None had true distant metastasis detected on PET. The imaging also failed to detect nodal metastasis in 2 patients who had disease on lymphatic sampling. CONCLUSION: FDG-PET did not alter the initial staging or treatment in patients with cN0 head and neck melanoma. Therefore, its routine use for staging is not warranted.

Repair of giant ventral hernias.

Repair of huge ventral hernias is technically challenging for the surgeon and a major operation for the patient and should be performed by experienced surgeons in centers that are used to caring for patients who are commonly massively obese with significant comorbidities. Preoperative medical optimization of patients is an important part in the overall management of these large hernias. Conventional component separation with retromuscular mesh repair is the workhorse operation, which successfully deals with many giant ventral hernias, but multiple alternative strategies must be available to address situations in which myofascial elements are completely deficient or there is significant loss of domain The complexity of this surgery is reflected by recurrence rates ranging from 10% to 30% and wound complication rates as high as 40% to 50% in experienced centers.

Ectopic bone in the abdominal cavity: a surgical nightmare.

INTRODUCTION: Heterotopic mesenteric ossification (HMO) is a rare clinical entity with less than 40 reported cases in the literature. Frequently associated with prior abdominal surgery or trauma, the precise etiology and optimal approach to its management remain undefined. CASE REPORT: The index patient is a 58-year-old male who originally presented with perforated diverticulitis. Following resection, the patient developed an enterocutaneous fistula. After a trial of conservative management, the patient underwent exploration and was found to have widespread intra-abdominal calcification. Sheets of calcific tissue were resected, and a diagnosis of HMO was confirmed via pathology. The patient had a postoperative course complicated by bleeding and redevelopment of enteric fistula. Following a prolonged hospital course requiring multiple operations, the fistula persists, and the patient remains on parenteral nutrition. DISCUSSION: The etiology of HMO is unknown. Diagnosis requires a high degree of clinical suspicion, as radiologic findings are often misleading. A review of 18 cases demonstrates significant morbidity associated with operative intervention. Nonsteroidals, in particular indomethacin, have been shown to decrease heterotopic ossification, but their role in mesenteric disease is not clearly defined. CONCLUSION: HMO is a rare but complicated pathologic process. A trial of conservative management with NSAIDs, bowel rest, and total parenteral nutrition is prudent, given the high rate of morbidity and mortality associated with operative intervention.

Effects of carotid artery stenting on arterial geometry.

BACKGROUND: The role of carotid artery stenting (CAS) for the treatment of carotid artery disease continues to evolve, despite higher stroke and restenosis risks for CAS compared with conventional open endarterectomy. Understanding the effects of CAS on arterial geometry, which strongly influence hemodynamics and wall mechanics, can assist in better stratifying the inherent risk of CAS to individual patients. STUDY DESIGN: Fifteen consecutive patients undergoing CAS had pre- and post-stenting CT angiograms. These images were used to reconstruct the 3-dimensional geometries of the bilateral carotid arteries from their origin to the skull base. Quantitative assessment of the carotid bifurcation angle, cross-sectional area, tortuosity and artery length, were compared pre- and post-stenting. Plaque volume and calcification were also measured. Mathematical models were devised to determine the mechanisms of CAS-induced geometric changes, and their mechanical and hemodynamic significances. RESULTS: Major and moderate changes in arterial tortuosity and elongation were seen in 5 (33%) patients. Characteristics most associated with the development of CAS-induced geometric changes were stenoses located in the internal carotid artery distal to the carotid bulb, circumferential distribution of plaque, and plaque calcification. Modeling did not demonstrate substantial alterations in wall shear stress due to geometric changes, but did show considerable increases in arterial wall axial stress. CONCLUSIONS: Carotid artery stenting can produce geometric changes to the artery that promote favorable conditions for complications and recurrent disease. Patients with circumferential, highly calcified plaques that are located relatively distal in the internal carotid artery are most likely to have post-stenting geometric changes.

Multiple pancreatic pseudocysts treated with endoscopic transpapillary drainage.

Management of a solitary pancreatic pseudocyst with endoscopic transpapillary stent drainage is a well recognized treatment modality. Endoscopic options are however limited in the presence of multiple pancreatic pseudocysts. Conventionally surgery has been the mainstay of treatment in this situation. In this case report, we present a patient with multiple pancreatic pseudocysts who was successfully treated via transpapillary placement of pancreatic duct stent.

Three-dimensional geometry of the human carotid artery.

Accurate characterization of carotid artery geometry is vital to our understanding of the pathogenesis of atherosclerosis. Three-dimensional computer reconstructions based on medical imaging are now ubiquitous; however, mean carotid artery geometry has not yet been comprehensively characterized. The goal of this work was to build and study such geometry based on data from 16 male patients with severe carotid artery disease. Results of computerized tomography angiography were used to analyze the cross-sectional images implementing a semiautomated segmentation algorithm. Extracted data were used to reconstruct the mean three-dimensional geometry and to determine average values and variability of bifurcation and planarity angles, diameters and cross-sectional areas. Contrary to simplified carotid geometry typically depicted and used, our mean artery was tortuous exhibiting nonplanarity and complex curvature and torsion variations. The bifurcation angle was 36 deg ± 11 deg if measured using arterial centerlines and 15 deg ± 14 deg if measured between the walls of the carotid bifurcation branches. The average planarity angle was 11 deg ± 10 deg. Both bifurcation and planarity angles were substantially smaller than values reported in most studies. Cross sections were elliptical, with an average ratio of semimajor to semiminor axes of 1.2. The cross-sectional area increased twofold in the bulb compared to the proximal common, but then decreased 1.5-fold for the combined area of distal internal and external carotid artery. Inter-patient variability was substantial, especially in the bulb region; however, some common geometrical features were observed in most patients. Obtained quantitative data on the mean carotid artery geometry and its variability among patients with severe carotid artery disease can be used by biomedical engineers and biomechanics vascular modelers in their studies of carotid pathophysiology, and by endovascular device and materials manufacturers interested in the mean geometrical features of the artery to target the broad patient population.

Surgical management of gallstone pancreatitis in children.

INTRODUCTION: Because of the low incidence of gallstone pancreatitis in children, we sought to examine effects of varied practice patterns on outcomes. SUBJECTS AND METHODS: A retrospective review was performed on all patients undergoing cholecystectomy for a diagnosis of gallstone pancreatitis from January 2000 to June 2011. Demographics, diagnostic strategies, operative approaches, length of stay, and morbidity were compared between Group 1, who had cholecystectomy performed during the admission of diagnosis, and Group 2, who underwent cholecystectomy subsequently. RESULTS: Cholecystectomy was performed for gallstone pancreatitis in 41 patients, of whom 29 (70.7%) patients were female. Ultrasound was performed in all cases, revealing cholelithiasis in 37 (90.2%). There were 22 patients in Group 1 and 19 in Group 2. Mean age and body mass index did not vary between groups. Endoscopic retrograde cholangiopancreatography was performed in 14 patients (8 in Group 1 and 6 in Group 2), of these procedures 11 were prior to cholecystectomy, 2 were after cholecystectomy, and 1 was both. Total number of hospital days attributed to the diagnosis of gallstone pancreatitis was 8.9 ± 6.5 in Group 1 compared with 14.0 ± 14.4 in Group 2 (P = .15). There were 7 patients (36.8%) in Group 2 who required readmission for recurrent pancreatitis prior to their operation. CONCLUSIONS: This represents the largest reported series of cholecystectomy for gallstone pancreatitis in children. Our results support the use of laparoscopic cholecystectomy during the initial hospitalization as is recommended in the adult literature, and this approach may decrease the total hospital stay.

Conservative management of traumatic lung hernia.

Traumatic lung hernia is a rare entity. The majority of cases reported in the literature have been treated surgically with early thoracotomy to prevent strangulation of pulmonary tissue. We report the case of a 63-year-old patient who experienced a 20-foot fall, causing multiple rib fractures with a lung hernia that was managed conservatively for 48 hours followed by spontaneous resolution of the herniated pulmonary segment. There is a need to review the indications for surgical versus conservative approach in the management of posttraumatic lung hernia.

A review: the role of high dose methylprednisolone in spinal cord trauma in children.

BACKGROUND: The use of steroids in traumatic spinal cord injury (SCI) in children is controversial. There is a paucity of literature on its usage. To help clarify recommendations on steroid use in children, we reviewed the current literature on the administration of high dose methylprednisolone (MP) use in traumatic spinal cord injuries with an emphasis in pediatric spinal cord trauma. METHODS: A retrospective review of the current literature on traumatic spinal cord injuries was conducted. Outcomes were critically reviewed from the National Acute Spinal Cord Injury Studies (NASCIS) II and III and Cochrane review; as well as, other randomized and retrospective studies. Papers describing objective neurological outcomes were only included. RESULTS: The outcomes of neurological improvement following steroid infusion have not been reproducible outside of the NASCIS and one single Japanese trial. High dose steroids significantly increase the risk of infections leading to prolonged hospital stay and ventilator dependence. CONCLUSION: Data from adult studies remains controversial with insufficient data to support administration of MP for treatment of traumatic spinal cord injuries. Randomized controlled trials are needed in the pediatric population to assess the advantages of steroid use after SCI in children. On the basis of the current evidence, the use of steroids in patients is associated with increased infectious risks and no neurological improvements.

Extracorporeal liver perfusion system for artificial liver support across a membrane.

BACKGROUND: An extracorporeal porcine liver perfusion (ECPLP) system circumvents the limitations of hepatocyte based bio-artificial liver, but its clinical application has been limited so far due to the potential risk of transmission of porcine endogenous retroviruses. The aim of this study was to develop an ECPLP model that can provide artificial hepatic support across a semi-permeable membrane, which has the potential to block porcine viruses due to its pore size. MATERIALS AND METHODS: Livers from white landrace pigs were perfused with normothermic oxygenated blood using Medtronic BP560 centrifugal pump (Medtronic, Inc., Minneapolis. MN). This ECPLP system was used to support a "surrogate" patient across the filter Evaclio-EC4A. Function of liver was measured by indocyanine green retention at 15 min (ICGR15). Clearance of galactose, ammonia, and para-aminobenzoic acid infused into the "surrogate" patient circulation was calculated to assess liver support across the membrane. The study was designed as test (n = 15) versus control (n = 5), with control experiments having no liver in the circuit. RESULTS: For the test experiments, we perfused 15 livers with mean hepatic artery pressure of 87 mm Hg and flows of 1.2 L/min. ICGR15 in test experiments was 11%. Ammonia clearance was 945 mg/min/kg, galactose metabolic rate was 111.7 mg/min/Kg, and the hippurate ratio was 91% in the test. In contrast, the control experiments did not show any significant change in the concentration of any of these compounds. CONCLUSION: Our ECPLP model was able to provide hepatic support in an experimental setting across a hollow fiber filter. Further work on an anhepatic animal is needed prior to application in human trials.

Giant ossifying malignant thymoma in a child.

We present the first reported case of an ossifying pediatric thymoma. Our patient was diagnosed with a massive thymoma replacing the whole of the left thoracic cavity. Percutaneous biopsy was attempted 3 times followed by an open incisional biopsy and adjuvant chemotherapy. Complete resection required a median sternotomy and a "trap door" thoracotomy after the tumor failed to respond to chemotherapy. Histology confirmed World Health Organization type B1 lymphocyte-rich thymoma, Masaoka stage I, with extensive osseous metaplasia.

Hepatic tuberculosis mimicking carcinoma gall bladder.

We report a 50-year-old man with tuberculosis of the liver with calculous cholecystitis. The diagnosis was made when the patient underwent cholecystectomy. He responded to antitubercular therapy.

Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy.

BACKGROUND: The new technique of circular stapler for the treatment of hemorrhoids has shown early promise in terms of minimal or no postoperative pain, early discharge from hospital, and quick return to work. This study was designed to compare stapled technique with the well-accepted conventional Milligan Morgan hemorrhoidectomy. METHODS: After fulfilling the selection criteria, 84 patients were randomly allocated to the stapled (n = 42) or open group (n = 42). All patients were operated on under spinal anesthesia. The 2 techniques were evaluated with respect to the operative time, pain scores, complications, day of discharge, return to work, and level of satisfaction. RESULTS: The mean age of patients was 46.02 years (SD, 12.33) in the stapled group and 48.64 years (14.57) in the open group. Grade III or IV hemorrhoids were more common in men (ie, 80.9% and 85.7% in the stapled and open group, respectively). The mean operative time was shorter in the stapled group 24.28 minutes (4.25) versus 45.21 minutes (5.36) in the Milligan-Morgan group (P < .001). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group. Mean hospital stay was 1.24 days (0.62) and 2.76 days (1.01) (P < .001) in the stapled and open group, respectively. The patients in the stapled group returned to work or routine activities earlier (ie, within 8.12 days [2.48]) as compared with 17.62 (5.59) in the open group. Only 88.1% of patients were satisfied by the open method compared with 97.6% after the stapled technique. The median follow-up period was 11 months with a maximum follow-up of 19 months (range 2-19 months). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective day-care procedure for the treatment of grade III and grade IV hemorrhoids. It ensures lesser postoperative pain, early discharge, less time off work, complications similar to the open technique, and in the end a more satisfied patient with no perianal wound. However, more such randomized trials are essential to deny any long-term complication.