Predicting Aggressive Behavior in Nonfunctional Pancreatic Neuroendocrine Tumors With Emphasis on Tumor Size Significance and Survival Trends: A Population-Based Analysis of 1787 Patients.

BACKGROUND: Nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) are rare tumors with continued controversies in management. This study aims to identify demographic and clinicopathologic characteristics associated with aggressive behavior and survival. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify patients with NF-PNETs from 1988 to 2012. Multivariate regression analysis and Cox proportional hazards modeling were used to assess the impact of patient, tumor, and treatment characteristics on tumor behavior and overall survival. RESULTS: In 1787 patients identified, size was a major determinant of aggressive behavior. The probability of aggressiveness increased 100% for tumor size ≥2 cm. For tumors ≥2 cm, every 1-cm increase in size was associated with an increase in probability of aggressive behavior by 11.3%. Patient age, tumor grade, and surgical resection were independent predictors of survival. Surgical resection was associated with improved survival but not grade I or II tumors with size <2 cm. DISCUSSION: Patient age, tumor size, and grade should be in the decision-making process around the surgical management of NF-PNETs. For tumors ≤2 cm with histologic grades of I or II, the probability of aggressive behavior is low, and surgical resection does not appear to afford survival benefit. Therefore, close observation could be justified.

Multidisciplinary Cancer Care Model: A Positive Association Between Oncology Nurse Navigation and Improved Outcomes for Patients With Cancer.

BACKGROUND: Patients with cancer often experience prominent deficiencies in cancer care in the immediate period following initial cancer diagnosis. OBJECTIVES: This article aims to determine whether the inclusion of a gastrointestinal (GI) oncology nurse navigator (ONN) on the multidisciplinary cancer care team is associated with improved quality of care for patients. METHODS: This retrospective study compared randomly selected patients with GI cancer with and without an ONN. Two endpoints, the time from diagnosis to treatment and the average number of missed appointments, were evaluated through a review of healthcare records using the Epic electronic health records system. FINDINGS: Patients with an ONN had a shorter time lapse between diagnosis and treatment commencement (p < 0.001). In this group, the average time spent between initial diagnosis and the start of treatment was 15.15 days, compared to 42.93 days for patients who were not part of the multidisciplinary cancer care model.

Extended Perioperative Antibiotic Coverage in Conjunction with Intraoperative Bile Cultures Decreases Infectious Complications after Pancreaticoduodenectomy.

Background. Bile contamination from the digestive tract is a well-known risk factor for postoperative complications. Despite the literature concerning prevalence of bacterobilia and fungobilia in patients with biliary pathologies, there are no specific recommendations for perioperative antimicrobial coverage for biliary/pancreatic procedures. We evaluated the effect of at least 72 hours of perioperative broad spectrum antibiotic coverage on outcomes of pancreaticoduodenectomy (PD). Materials and Methods. A retrospective review of all patients at Case Medical Center of Case Western Reserve University undergoing PD procedure, from 2006 to 2011, was performed (n = 122). Perioperative data including demographics, comorbidities, biliary instrumentation, antibiotic coverage, culture results, and postoperative outcomes were analyzed. Propensity score matching method was used to match the patients according to duration of antibiotic coverage into two groups: 72 hours (A72) and 24 hours (A24). Results. Longer broad spectrum antibiotic coverage in group A72 resulted in significantly less surgical site infections after PD, compared to routine 24 hours of perioperative antibiotics in group A24. This study did not reveal a statistically significant decrease in postoperative fungal infections in patients receiving preoperative antifungals. Conclusion. Prolonged perioperative antibiotic therapy in conjunction with intraoperative bile cultures decreases the short-term infectious complications of PD, with no significant increase in Clostridium difficile colitis incidence.

Surgical anatomy and morphologic variations of umbilical structures.

The umbilicus is the main access route to the abdominal cavity in laparoscopic surgeries. However, its anatomical configuration is rarely studied in the surgical and anatomical literature. With introduction of laparoendoscopic single-site surgery and considering the significant number of primary and postoperative umbilical hernias, we felt the necessity to comprehensively study the umbilical structures and analyze their protective function against hernias. Twenty-four embalmed cadavers were studied in the anatomy laboratory of Case Western Reserve University. Round hepatic, median and medial ligaments, umbilical ring, umbilical and umbilicovesicular fasciae, and pattern of attachment to the ring were dissected and measured. Mean age was 82.1 years, ranging between 56 and 96 years, with a male-to-female ratio of 1.4:1. Ninety-two per cent was white and 8 per cent black adults. According to shape and attachment pattern of ligaments, umbilical ring is classified into five types. Hernia incidence was 25 per cent. All hernia cases lacked the umbilical fascia and the round hepatic ligament was not attached to the inferior border of the ring. The umbilical ring and its morphologic relation with adjacent ligaments are described and classified into five types. In contrary to sparse existing literature, we propose that umbilical fascia is continuation and condensation of umbilicovesicular rather than transversalis fascia. It was absent in cadavers forming conjoined median and medial ligaments with a single insertion site to the ring. Round ligament insertion to the inferior border of the ring provides another protective factor. These two protective measures were absent in all the observed umbilical hernias.

Assessment of secondary cleft rhinoplasty using resorbable plates at the age of primary school.

BACKGROUND: Secondary rhinoplasty after a cleft lip repair remains a significant challenge. We have developed a technique in which resorbable plates are used to support the cleft alar cartilage to minimize relapse. There are few guidelines by which one can objectively assess the outcome of cleft rhinoplasty over time. This study attempts to demonstrate a means by which the symmetry and form of the proposed rhinoplasty technique can be evaluated. METHODS: Sixteen patients with unilateral cleft lip/palate repair had a secondary rhinoplasty performed at age 6 to 8 years, using a resorbable plate (resorption time, 2-3 years) placed between the nasal lining and cleft alar cartilage to simulate the shape of the noncleft cartilage. Photographs were taken preoperatively and postoperatively. Median follow-up was 9.6 +/- 2.8 months. Various angles and ratios were measured to demonstrate outcomes, comparing preoperative to postoperative measures, and symmetry between cleft and noncleft sides. RESULTS: Postoperatively, the angle between the horizontal axis, drawn across the alar base and tangent to the alar rim on both sides, was significantly altered (P < 0.001); both sides were closer to 60 degrees (mean, 56.28 degrees), approximating the angle of the aesthetic norm. A measure of the angle between the horizontal axis and a line drawn from midpoint of axis to nasal tip was significantly closer to 90 degrees (P < 0.05). The shape of the affected nostril became more oval and symmetric relative to the unaffected side (P < 0.05). Angle between the horizontal axis and a line drawn through the widest point of each nostril was close to zero. (P < 0.001). The difference in nostril height between the cleft and noncleft sides was significantly decreased (P < 0.001). CONCLUSION: We have objectively evaluated the outcomes of our technique of secondary cleft rhinoplasty using resorbable plates for alar support. A careful geometric evaluation of preoperative and postoperative photographs can help determine the symmetry and overall quality of the result. These measures may help to evaluate long-term outcomes of cleft rhinoplasty over time.