The Role of Angioembolization in Hepatic Trauma.

The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.

Identifying patients with AAA with the highest risk following endovascular repair.

INTRODUCTION: It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair. METHODS: We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression. RESULTS: A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups. CONCLUSIONS: Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.

Malignant potential in incidental pancreatic cysts.

Although pancreatic cysts are being diagnosed with greater frequency, a uniform agreement on management is still lacking. This is mainly because accurate and reliable preoperative determination of the exact pathology of a pancreatic cyst remains elusive. Although ultrasound-guided fine needle aspiration represents a significant advancement in our ability to characterize pancreatic cysts preoperatively, significant limitations persist. In this article, we review the roles of clinical characteristics, imaging features and biochemical markers in the correct classification of incidental pancreatic cysts. The correct diagnosis and management of these cysts still hinges, to a large extent, on clinical experience and multidisciplinary cooperation.

Re-evaluation of a scoring system to predict nonsentinel-node metastasis and prognosis in melanoma patients.

BACKGROUND: We previously developed a scoring system based on patient age and total sentinel node (SN) tumor size to predict nonsentinel node (NSN) metastasis. The score relied on the cutoff values of 55 years for age and 5 mm total SN tumor size to stratify SN-positive patients into 3 categories. Its validity, however, remains in doubt given that it was developed by retrospective review of a single, relatively small cohort of SN-positive melanoma patients. The purpose of this study was to validate this scoring system and to determine its value in predicting patient survival. STUDY DESIGN: A review of melanoma patients who had undergone sentinel node biopsy and completion lymph node dissection (CLND) at the Melanoma Institute Australia from June 1992 until April 2009 was undertaken. The significance of the correlation of each of the score variables (age and total SN tumor size) with NSN metastasis, melanoma-specific survival, and overall survival was tested. Cox logistic regression analysis was used to determine the degree of correlation of the score system to each of the 3 outcomes. RESULTS: Six hundred six SN-positive patients were identified and included in this study. The score system did not significantly correlate with NSN metastasis (p = 0.1049). However, it did significantly correlate with both overall survival (p < 0.0001) and disease-specific survival (p = 0.0014). CONCLUSIONS: Our results revealed that the previously developed scoring system does not predict NSN metastasis; however, it was found to be a powerful predictive tool for overall and disease-free survival in SN-positive melanoma patients.

Total sentinel lymph node tumor size predicts nonsentinel node metastasis and survival in patients with melanoma.

INTRODUCTION: In patients with a primary melanoma ≥1.0mm in Breslow thickness, the rate of metastasis to regional lymph nodes, as determined by sentinel node biopsy (SLNB), is approximately 20%. Among the patients with a positive SLNB result, however, only approximately 20% have tumor identified in additional non-SLNs. Therefore, many melanoma patients are still subjected to the morbidity of a complete lymph node dissection (CLND) without obvious benefit. In the current study, we analyzed the clinical and pathologic features of melanoma patients with positive SLNBs treated at the Melanoma Institute Australia. The aim was to correlate clinical and pathologic features of both the primary melanoma and the SLN metastases, including total SLN metastasis, with non-SN metastasis and (disease specific and overall) survival. METHODS: Total SLN tumor size was obtained by adding the largest diameters of all individual metastatic deposits within the SLN. Clinicopathological variables analyzed included patient age at the time of diagnosis, primary tumor characteristics (histologic type, Breslow thickness, ulceration, mitotic rate, site of primary tumor), and SLNB characteristics (date of SLNB procedure, location of LN field, number of draining LN fields, number of SLNs harvested, number of positive SLNs, size of largest metastatic deposit, total metastatic deposit size, location of metastasis within the SLN, extra nodal extension (ENE), and number of metastatic deposits within the SLN). The correlation between each of the predictor variables and outcome was determined by univariate analysis. The predictor variables that correlated with NSLN metastasis with a p value < 0.10 on univariate analysis were then entered into a multivariate model. RESULTS: There were 606 patients with a positive SNSNB result who proceeded to a CLND. The median number of NSNs in CLND specimens was 18 and the median number of positive NSLNs was 2.68. Of the patients with SN metastasis, 23.5% also had NSLN metastasis on CLND. Total SLN tumor size was significantly correlated to NSLN metastasis, melanoma-specific survival and overall survival on both univariate and multivariate analyses. CONCLUSION: Total SN tumor size predicts the likelihood of non-SLN metastasis, and also predicts survival outcome.

Predictors of sentinel lymph node metastasis in melanoma.

BACKGROUND: Several studies have examined the correlation between patient and tumour characteristics and sentinel lymph node (SLN) metastasis in patients with melanoma. Although most studies have identified Breslow thickness as an important factor, results for other variables have been conflicting. Much of this variability is probably because of differences in measurement techniques and reporting practices at different institutions. We sought to identify the predictors of SLN melanoma metastasis in our institution and patient population. METHODS: We performed a retrospective chart review of 348 patients with malignant melanoma who underwent SLN biopsy at a single institution from January 1999 to April 2007. We compared multiple variables related to patient demographics, primary tumour characteristics and SLN characteristics between patients in the positive and negative SLN groups. RESULTS: Breslow thickness and nodular tumour type were independent factors significantly correlated with a positive SLN biopsy result in our study. Head and neck tumour location correlated with a lower likelihood of positive SLN status in univariate but not multivariate analyses. CONCLUSION: This study confirms the status of Breslow thickness as a reproducible predictor of positive SLN status. We also found that nodular type was predictive of positive SLN status, an outcome that has not been reported by others.

Validation of a scoring system to predict non-sentinel lymph node metastasis in melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has been widely accepted as the lymph node sampling procedure of choice for melanoma patients. Current standards of practice suggest completion lymph node dissection (CLND) for patients with a positive SLNB result. The rationale for SLNB+/-CLND is for staging and prognosis as well as local control and possibly survival improvement. CLND, however, entails significant morbidity. In addition, most patients (approximately 80%) will have no further melanoma metastases in non-sentinel nodes and these patients may not benefit from the additional dissection. We had previously developed a score (based on patient age and the total size of metastasis within the SLN) that predicted which SLN-positive patients would have a positive CLND. Utilization of this scoring system would spare a significant number of melanoma patients the risks associated with CLND. The purpose of this study was to validate this score using different melanoma populations. METHODS: A retrospective chart review of all patients that had undergone SLNB for melanoma at four different Canadian centers was undertaken. Data from the Calgary Foothills Medical Center, the Winnipeg Health Sciences Center, and the Toronto Sunnybrook Health Sciences Center from January 1999 to present was collected. In addition, we identified all patients from April 2007 to present at the Misericordia Hospital in Edmonton for this study. This patient information had not been utilized when we were developing this score. The collected variables included patient age, Breslow thickness, result of SLNB, total size of SLN metastasis, largest size of SLN metastasis, and results of CLND. Logistic regression was used to test the significance of a score system's correlation (based on cutoff age of 55 years and cutoff total SLN metastasis of 5 mm) with the CLND results. We also used logistic regression to test the correlation of cutoff values of total SLN metastasis with non-sentinel lymph node (NSLN) metastasis. RESULTS: Data were collected on 599 patients across the four centers. Breslow thickness significantly correlated with SLN metastasis. The risk score system (based on patient age and total SLN metastasis) was significantly predictive of the CLND result in SLNB-positive patients. However, the age became non-significant on multivariate analysis. Total SLN metastasis emerged as the variable that is most predictive of NSLN metastasis. Patients with total SLN metastasis less than 2 mm had a 3.6% risk of NSLN metastasis, those with SLN metastasis from 2-5 mm had a 12.5% risk of NSLN metastasis, whereas those with total SLN metastasis of 5 mm or greater had a 30% risk of NSLN metastasis. CONCLUSION: Using cutoff values of 2 and 5 mm for total SLN metastasis, prediction of NSLN metastasis can be made in melanoma patients. Patients with less than 2 mm of total SLN metastasis are unlikely (<3.67% likelihood) to harbor NSLN metastasis; these patients may not benefit from additional nodal dissection beyond SLNB.

Survival in cystic neoplasms of the pancreas.

BACKGROUND: The natural history of pancreatic cystic neoplasms remains poorly understood despite growing evidence on the subject. Pancreatic cysts display a wide spectrum of pathological phenotypes, each associated with a different prognostic implication. Many pancreatic cysts are of undetermined malignant potential at presentation and remain so until surgically resected. While the survival rates of patients with malignant cysts are known to be poor, survival rates in patients with undetermined pancreatic cysts are unknown. OBJECTIVE: To identify the factors associated with survival in a group of patients diagnosed with a pancreatic cyst(s). METHODS: The present study was a retrospective multicentre review of pancreatic cystic neoplasms. All patients with a diagnosis of a neoplastic pancreatic cyst from 1994 to 2003 were identified at five different institutions in Edmonton, Alberta. The data collected included patient age, sex, imaging modality, cyst location, cyst size, number of cysts, comorbid illnesses, history of upper abdominal surgery, previous cancer, previous or concurrent metastases, symptoms (pain, upper gastrointestinal bleeding, signs of biliary obstruction, nausea/vomiting), remarkable radiological features, elevated amylase or lipase, type of pancreatic surgery, final pathology (benign or malignant) and overall survival. Survival models were used to assess whether any covariates were predictors of the survival time. Patient data were plotted using the Kaplan-Meier method. The resulting plot was used to calculate survival in the cohort. RESULTS: In total, 64 patients were identified as having neoplastic pancreatic cysts from 1994 to 2003 at the five institutions. The median overall patient survival time was 86 months. The median age at diagnosis for the patient population was 73 years, with 40 patients being women. Univariate analysis revealed that the risk of death was associated with patient age, sex and history of major comorbid illness. Multivariate models identified increased patient age and male sex as the factors that correlated most strongly with decreased overall survival. CONCLUSION: Overall survival in patients with neoplastic pancreatic cysts is determined by patient factors (ie, age and sex) rather than factors descriptive of the cyst such as size and morphology. No conclusions could be made regarding the relationship between cyst pathology and patient survival.

Prediction of nonsentinel lymph node metastasis in malignant melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is the standard at many institutions caring for melanoma patients. Patients with positive SLNB results are currently offered completion lymph node dissection (CLND) of the affected lymph node basin. This procedure entails considerable morbidity and is often applied to patients with shortened life expectancies. Because 80% of CLNDs yield no additional positive nodes and there is no proof that CLND leads to survival improvement, criteria are needed to limit this procedure to those most likely to harbor nonsentinel lymph node (SLN) metastases. METHODS: A retrospective review of 349 cases of melanoma from January 1999 to April 2007 that underwent sentinel lymph node biopsy at a single institution was done. Statistical analysis was used to compare two subgroups of patients: a positive CLND group and a negative CLND group. These two groups were compared with regards to multiple variables related to patient demographics, primary tumor characteristics, and SLN tumor burden. RESULTS: Age and total size of SLN tumor deposit were the factors with the strongest correlation with CLND positivity. By applying a risk score model that uses the cutoff values of age 55 y and SLN tumor deposit of 5 mm, it is possible to predict CLND positivity in SLN-positive melanoma patients. CONCLUSION: The likelihood of CLND positivity in SLN-positive melanoma patients can be predicted from two criteria readily available: size of SLN tumor deposit and patient age.

Can surgeon familiarization with current evidence lead to a change in practice? A prospective study.

BACKGROUND: Despite evidence against its utility, many surgeons continue to employ prophylactic nasogastric decompression in elective colonic resection. This study aimed to establish whether an easy and practical intervention, mailing out a summary of current evidence to surgeons, can change surgeons practice to bring it more in line with current evidence. METHODS: The use of prophylactic nasogastric (NG) decompression in elective colonic resections was documented for the 2 consecutive months of October and November, 2004 at the Royal Alexandra Hospital (RAH). A one page summary of recent evidence concerning this practice was then mailed to all general surgeons at that institution. A similar second review was carried out for the months of January and February, 2005. The two periods were compared with regards to prophylactic NG use. RESULTS: Twenty two patients underwent elective colonic resections during the months of October and November, 2004. Twenty one patients underwent such procedures in January and February, 2005. Seven out of the 22 cases in the first group (the pre-intervention block) received prophylactic NG decompression. Five out of the 21 cases in the second group (the post-intervention block) received prophylactic NG decompression. The difference in prophylactic NG use between the two groups was not statistically significant. CONCLUSIONS: This study has shown that mailing out a summary of current evidence to surgeons concerning a certain issue is not sufficient to lead to a change in practice.

Complications of splenectomy.

Surgical removal of the spleen, splenectomy, is a procedure that has significantly decreased in frequency as our understanding of the infectious complications of the asplenic state increased. The full spectrum and details of splenic function, however, have yet to be fully outlined. As a result, our comprehension of the long-term consequences of splenectomy remains incomplete. We review the evidence relating to the effects of splenectomy on infection, malignancy, thrombosis, and transplantation. Perhaps the best-defined and most widely understood complication of splenectomy is the asplenic patient's susceptibility to infection. In response to this concern, novel techniques have emerged to attempt to preserve splenic function in those patients for whom surgical therapy of the spleen is necessary. The efficacy of these techniques in preserving splenic function and staving off the complications associated with splenectomy is also reviewed in this article.