Local versus Radical Excision of Early Distal Rectal Cancers: A National Cancer Database Analysis.

BACKGROUND: Local excision (LE) has been proposed as an alternative to radical resection for early distal rectal cancer, for which the optimal oncologic treatment remains unclear. OBJECTIVE: The goal of this study was to compare the overall survival of rectal cancer patients with early distal tumors who underwent LE versus abdominoperineal resection (APR) using a large contemporary database. METHODS: The National Cancer Database (2004-2013) was used to identify patients with early T-stage rectal adenocarcinoma who underwent LE or APR. Patients were split into groups based on T stage and type of surgery (LE vs. APR). The primary outcome measure was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival. RESULTS: Overall, there were 2084 patients with T1 tumors and 912 patients with T2 tumors. For patients with T1 disease, after adjusting for age, sex, income level, race, Charlson score, insurance payor, and tumor size, there was no significant difference in survival between the LE and APR groups (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.65-1.22; P = 0.49). For patients with T2 disease, after adjusting for age, Charlson score, and tumor size, there was no significant difference in survival between patients undergoing LE + chemoradiation therapy (CRT) and APR (HR 1.11, 95% CI 0.84-1.45; P = 0.47). CONCLUSIONS: Patients with early distal rectal adenocarcinoma who underwent LE had similar survival to patients who underwent APR. LE is an acceptable oncologic treatment strategy for patients with T1 rectal cancers, and LE with CRT is an acceptable oncologic treatment for patients with T2 distal rectal cancers.

Early results of a surgeon-led, perioperative surgical home.

BACKGROUND: The Perioperative Surgical Home is a novel care model designed to provide patient-centered, high-quality surgical care. In 2013, we implemented POSH, a pilot Peri-Operative Surgical Home at Phoenix Indian Medical Center (PIMC), an Indian Health Service hospital, as a quality improvement project. After 2 y, we sought to quantify the impact of POSH on the quality of surgical care at PIMC. MATERIALS AND METHODS: We conducted a retrospective review of 33 surgical patients who underwent surgery at PIMC through the POSH process between 2013 and 2015 matched to 64 historical controls with similar operations. Study patients underwent surgery via the POSH treatment process. Primary outcomes were composite measures of (1) care standards and (2) care goals. Success was defined as meeting seven of nine care standards and six of eight care goals. RESULTS AND DISCUSSION: The mean number of care standards met was 8.1 ± 1.0 versus 4.2 ± 1.4 (P < 0.001) and the mean number of care goals met was 6.7 ± 0.8 versus 6.1 ± 1.1 (P = 0.005) for POSH patients and historical controls, respectively. Patients participating in the POSH model were 8.6 (95% confidence interval: 3.5-22.3) and 1.5 (95% confidence interval: 1.2-1.9) times more likely to meet the minimum number of care standards and goals, respectively. Fourteen of the study patients (42%) would not have been offered surgery at PIMC before POSH due to elevated surgical risk. CONCLUSIONS: POSH may have improved quality of surgical care at PIMC while expanding services to more complex patients. POSH may present an opportunity for improved surgical quality in resource-constrained environments.

Colloidal gold: a novel nanoparticle for targeted cancer therapeutics.

Since their initial description in 1857, gold nanoparticles have been used extensively in the fields of diagnostics and therapeutics. Now, gold nanoparticles are engineered to target the delivery of potent anti-cancer therapeutics to solid tumors to improve either their safety or efficacy or both. Described in this chapter is the development of one such nanotherapeutic, termed CYT-6091, that targets the delivery of tumor necrosis factor alpha (TNF) to solid tumors. Outlined in the presentation is a discussion of nanoparticles and specifically colloidal gold, an historical review on the biology of TNF and its limited use in the clinic when administered systemically, and finally, how gold nanoparticles bound with TNF may improve the safety and efficacy profiles of TNF.

Reoperation for parathyroid adenoma: a contemporary experience.

BACKGROUND: We reviewed reoperations for persistent or recurrent sporadic parathyroid adenoma to evaluate and compare our current results and outcomes to our previous experience. METHODS: From 1996 to 2008, 237 patients with persistent or recurrent hyperparathyroidism after failed operation underwent reoperation. Patients were re-explored with the assistance of non-invasive and sometimes invasive imaging. RESULTS: A missed adenoma was suspected pre-operatively in 163 patients. Reoperation resulted in long-term resolution of hypercalcemia in 92%. Adenomas were in entopic locations in 32%; the most frequent ectopic location was the thymus (20%). Sestamibi scanning and ultrasonography were the most successful non-invasive imaging studies (96% positive predictive value (PPV) and 84% PPV respectively). Forty-four percent of patients had a reoperation based solely on non-invasive imaging. Of the invasive procedures performed, arteriography resulted in the best localization (92% PPV). Permanent recurrent laryngeal nerve injury occurred in 1.8%. CONCLUSION: Compared to our prior experience (1982-1995), outcomes remained similar (92% resolution of hypercalcemia and 1.8% recurrent nerve injury currently versus 96% and 1.3% previously). Fewer patients received invasive studies for pre-operative localization (56% vs 73%, respectively). The decreased use of invasive imaging is due to technical improvements and greater confidence in the combination of ultrasonography and sestamibi scanning.

Recapitulation of pancreatic neuroendocrine tumors in human multiple endocrine neoplasia type I syndrome via Pdx1-directed inactivation of Men1.

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal syndrome caused by mutations in the MEN1 tumor suppressor gene. Whereas the protein product of MEN1, menin, is ubiquitously expressed, somatic loss of the remaining wild-type MEN1 allele results in tumors primarily in parathyroid, pituitary, and endocrine pancreas. To understand the endocrine specificity of the MEN1 syndrome, we evaluated biallelic loss of Men1 by inactivating Men1 in pancreatic progenitor cells using the Cre-lox system. Men1 deletion in progenitor cells that differentiate into exocrine and endocrine pancreas did not affect normal pancreas morphogenesis and development. However, mice having homozygous inactivation of the Men1 in pancreas developed endocrine tumors with no exocrine tumor manifestation, recapitulating phenotypes seen in the MEN1 patients. In the absence of menin, the endocrine pancreas showed increase in cell proliferation, vascularity, and abnormal vascular structures; such changes were lacking in exocrine pancreas. Further analysis revealed that these endocrine manifestations were associated with up-regulation in vascular endothelial growth factor expression in both human and mouse MEN1 pancreatic endocrine tumors. Together, these data suggest the presence of cell-specific factors for menin and a permissive endocrine environment for MEN1 tumorigenesis in endocrine pancreas. Based on our analysis, we propose that menin's ability to maintain cellular and microenvironment integrity might explain the endocrine- restrictive nature of the MEN1 syndrome.

Results of a national survey of surgical resident interest in international experience, electives, and volunteerism.

BACKGROUND: Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. STUDY DESIGN: A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. RESULTS: Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried >or=$100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). CONCLUSIONS: American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

The utility of routine transcervical thymectomy for multiple endocrine neoplasia 1-related hyperparathyroidism.

BACKGROUND: Operation for multiple endocrine neoplasia (MEN)1-related hyperparathyroidism (HPT) includes a neck exploration with resection of 3.5 or 4 parathyroid glands and transcervical thymectomy (TCT). We reviewed our experience with initial operation for primary HPT to determine the outcome and utility of routine TCT. METHODS: All patients with MEN1 who underwent initial neck exploration from 1993 to 2007 under an institutional review board-approved protocol were reviewed. RESULTS: We identified 66 patients with initial operation for HPT in MEN1. In 34 patients, 4 glands were found; in 32 patients, <4 glands were found. In 2 of the 34 (6%) and 17 of the 32 (53%), intrathymic parathyroid tissue was found on permanent pathology. No thymic carcinoid tissue was found in any specimen. CONCLUSION: These data highlight the importance of performing TCT when <4 entopic parathyroid glands are found at first operation.

Operative management of Cushing syndrome secondary to micronodular adrenal hyperplasia.

BACKGROUND: We reviewed our experience with micronodular adrenal hyperplasia (MAH), its pigmented variant primary pigmented nodular adrenocortical disease (PPNAD), and the association with Carney's complex (CNC) to better characterize these disorders. METHODS: This retrospective study analyzes clinical data and operative reports of 34 patients identified with MAH and/or PPNAD who underwent resection between 1969 and 2006 at the Clinical Research Center, an inpatient research hospital at the National Institutes of Health. Symptoms and anthropometric and biochemical data were used to evaluate effect of resection. RESULTS: Fifteen patients (44%) presented as adults and 19 (56%) as children. Twenty-five patients (74%) presented with noncyclic Cushing syndrome and 9 patients (26%) presented with cyclic Cushing syndrome. Thirty-one patients underwent bilateral resection; this was curative biochemically in 30 patients. Fourteen operations were performed laparoscopically (41%), and 20 were performed as open resections (59%). There was 1 postoperative complication in the laparoscopic group (7%) and 6 complications in the open group (30%; P = .20). Follow-up was available for 25 patients (74%). Statistically significant improvements in anthropometrics were observed for both adults and children. The most frequent manifestation of CNC requiring additional operation was cardiac myxoma, which was associated strongly with an atypical (cyclic) presentation of Cushing syndrome (P = .009). CONCLUSION: Cushing syndrome due to MAH and PPNAD may be cured by bilateral adrenal resection. All patients should be screened for manifestations of CNC at the time of adrenal diagnosis with particular attention to cardiac disease.

Nonfunctioning pancreatic endocrine neoplasm presenting as asymptomatic, isolated pancreatic duct stricture: a case report and review of the literature.

Morphologic irregularities of the pancreatic duct are often noted on abdominal imaging studies obtained for unrelated symptoms or conditions. We report the case of a patient who was found to have an incidental, isolated pancreatic duct dilatation on multiple imaging studies and who was found to have a nonfunctioning pancreatic endocrine neoplasm at resection. His prognosis is excellent based on the histology of the lesion and a curative resection. This case highlights the importance of fully investigating incidental pancreatic duct abnormalities regardless of the setting in which they are found.

Insulinoma and gastrinoma syndromes from a single intrapancreatic neuroendocrine tumor.

CONTEXT: The insulinoma syndrome is marked by fasting hypoglycemia and inappropriate elevations of insulin. The gastrinoma syndrome is characterized by hypergastrinemia, ulcer disease, and/or diarrhea. Rarely, insulinoma and gastrinoma coexist in the same patient simultaneously. OBJECTIVE: Our objective was to determine the cause of a patient's hypoglycemic episodes and peptic ulcer disease. DESIGN AND SETTING: This is a clinical case report from the Clinical Research Center of the National Institutes of Health. PATIENT AND INTERVENTION: One patient with hypoglycemic episodes and peptic ulcer disease had a surgical resection of neuroendocrine tumor. RESULTS: The patient was found to have a single tumor cosecreting both insulin and gastrin. Resection of this single tumor was curative. CONCLUSIONS: A single pancreatic neuroendocrine tumor may lead to the expression of both the hyperinsulinemic and hypergastrinemic syndromes.

International experience, electives, and volunteerism in surgical training: a survey of resident interest.

BACKGROUND: Sustainable international surgery expertise is more frequently being discussed in the US surgical community. At the resident level, there is discussion about incorporating international experience into residency training, but current opportunities for residents are limited and often require personal funding and use of vacation time. This study analyzed resident interest in acquiring international experience. STUDY DESIGN: A structured questionnaire was administered anonymously to all New York University general surgery residents. The questionnaire elicited demographic information and information about interest in an international surgery elective and future volunteerism. Descriptive statistics and chi-square analyses were performed for the completed data. RESULTS: Fifty-two of 63 residents (82.5%) completed surveys. Fifty-one residents (98%) were interested in an international elective, and 38 residents (73%) would prioritize such an elective over all other electives. Twenty-three (44%) and 25 (48%) residents would be willing to use vacation and finance the elective, respectively. The most frequent expectations of international training were acquiring technical and clinical skills (94% of residents) and cultural skills (88%). Residents believed financial difficulties and scheduling conflicts were the most significant barriers to international training (82% and 53%, respectively). Thirty-two residents (62%) planned to incorporate volunteer work into their future practice. Chi-square analyses revealed a significant relationship between residents who would prioritize international training and those who planned to incorporate volunteerism into their future practice (p<0.01). CONCLUSIONS: International training represents an opportunity for US surgical education to provide residents with broader clinical expertise and increased cultural awareness. Our data suggest that surgical residents at NYU are strongly interested in acquiring this experience and that international training may provide an opportunity to encourage lifelong volunteerism. National study of US residents and faculty is warranted to further investigate these conclusions.

Left renal vein reconstruction after right nephrectomy and inadvertent left renal vein ligation: a case report and review of the literature.

Left renal vein ligation has been used as a technical aid to gain exposure to the perirenal aorta and to control bleeding in abdominal aortic operations. Left renal vein ligation is considered to be well tolerated in patients with 2 functioning kidneys, but has rarely been described in the setting of concomitant right nephrectomy and presents a management challenge. Some reports suggest recovery of renal function may be possible after left renal vein ligation during right nephrectomy, but other suggest that a delay in revascularizing the left renal venous drainage may result in irreversible nephropathy. This article reports the inadvertent division of the left renal vein during right nephrectomy. Renal failure ensued postoperatively. The left renal vein was reconstructed, and renal function was recovered. The inability to reliably predict which patients will have adverse outcome after left renal vein ligation in the setting of a right nephrectomy may necessitate preemptive intervention.

Trends in general surgery workforce data.

BACKGROUND: During the past 25 years, there has been much debate about general surgical workforce supply and demand. In the late 1970s and early 1980s, concern was raised by the Study on Surgical Services for the United States and the Graduate Medical Education National Advisory Council that there would be a gross oversupply of total physicians and surgeons by the years 1990 and 2000. DATA SOURCES: In a 1990 report sponsored by the Council on Graduate Medical Education, reevaluation of the workforce data showed no surplus at that time and instead predicted a deficit of surgeons by 2010. Studies by other investigators in the mid-1990s supported these conclusions. Furthermore, a new workforce model published in 2002 predicted a significant overall deficit of physicians by 2020. The discrepancies in the projected and the actual data have been explained by a variety of factors including an aging population with increased surgical needs, an increasing number of outpatient surgical procedures, subspecialization within the field of general surgery, and decreasing interest in the field by United States medical students. CONCLUSIONS: Although it is difficult to compare data among studies, and there are many confounding factors in the data, review of the workforce data does support a future deficit of surgeons, a prediction that warrants further investigation.