Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs.

BACKGROUND: There is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC. METHODS: Sequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL. RESULTS: Of 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62-1.37), oncologic treatment (CR 0.66, 95% CI 0.32-1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77-1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16-0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens. CONCLUSIONS: SDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Long-term outcomes of combined endoscopic/laparoscopic intragastric enucleation of presumed gastric stromal tumors.

PURPOSE: Definitive surgical treatment of gastric myogenic neoplasms such as gastrointestinal stromal tumors (GISTs) typically involves full-thickness resection of the lesion with normal gastric wall as the margin. This is not readily possible with proximal gastric lesions near the gastroesophageal junction, nor necessary for small incidental lesions. We have employed a combined endoscopic/laparoscopic intraluminal enucleation technique for selected patients and report long-term surveillance following this novel technique. METHODS: Retrospective review of patients who have undergone intraluminal laparoscopic resection from 1994 to 2008. RESULTS: Fifteen patients who underwent intraluminal enucleation were followed up for a median of 61 months. There were eight men and seven women with a mean age of 62.1 ± 3.38 years. Eight patients (53 %) underwent endoscopy for gastrointestinal bleeding, six for dyspepsia (40 %), six for anemia (40 %), and four for abdominal pain (27 %). Eight lesions (53 %) were located in the fundus/cardia: six (40 %) in the body and two (13 %) in the antrum. The mean tumor size was 3.5 ± 0.45 (1.5-7.0) cm. GIST lesions with benign histologic features predominated. All operations were successfully completed, including full-thickness resections with no conversion to open procedure, major morbidity, or mortality. Complete endoscopic and endosonographic surveillance was accomplished in 14 patients with no local or distant recurrence and no symptomatic follow-up in any patient. CONCLUSION: Enucleation of intact gastrointestinal stromal tumors can be accomplished with low risk of recurrence when done with a combined endoscopic/laparoscopic intraluminal technique. It should be the preferred approach considered for small, proximal, intraluminal tumors.

Preoperative risk factors and radiographic findings predictive of laparoscopic conversion to open procedures in Crohn's disease.

INTRODUCTION: Laparoscopy is accepted as a standard surgical approach for Crohn's disease. However, the rate of conversion is high, ranging from 15 to 70 % depending on the population. There are also concerns that conversion results in worsened outcomes versus an initial open procedure. METHODS: This study evaluated preoperative radiographic findings to determine who is at increased risk of conversion and may therefore benefit from an initial open approach. A case-matched study included patients from 2004 to 2013 with preoperative CTE/MRE who underwent laparoscopic surgery converted to an open approach, and compared them to laparoscopically completed controls with similar age, same surgeon, and number of previous abdominal operations. Studies were reviewed by two blinded radiologists. Variables included abdominal AP diameter, amount of subcutaneous fat, peritoneal versus pelvic location of disease (greater or lesser hemipelvis or abdomen), intestinal location of disease (colon, TI, ileum, jejunum), and presence, length, and location of strictures, simple or complex fistula, phlegmon, or abscess. Conditional logistic regression evaluated relationships between radiographic variables and conversion. Twenty-seven patients meeting study criteria were compared with 81 controls. RESULTS: A negative association between conversion and disease in the left lesser pelvis was found (p = 0.019) and neared significance for left abdomen (p = 0.08). Positive correlations were found with pelvic fistulas (p = 0.003), complex fistulas (p = 0.017), and pelvic abscesses (p = 0.009) and neared significance for Society of Abdominal Radiology classification (p = 0.058). CONCLUSION: Preoperative imaging in patients with Crohn's disease can help in selecting the most suitable cases to approach laparoscopically and reduce conversion rates and should be evaluated in conjunction with other preoperative factors.

Line-associated thrombosis as the major cause of hospital-acquired deep vein thromboses: an analysis from National Surgical Quality Improvement Program data and a call to reassess prophylaxis strategies.

BACKGROUND: Quality improvement has mitigated the occurrence of postoperative deep vein thromboses (DVTs); however, despite adherence to protocols, they continue to occur. This study aimed to characterize their rate and distribution at our institution, and appropriate use of thromboprophylaxis. METHODS: Local American College of Surgeons National Surgical Quality Improvement Program data were queried for general surgery cases complicated by DVT from 2009 to 2011. Medical records were evaluated to ascertain the following: classify DVTs by site, ascertain if appropriate prophylactic measures were instituted, evaluate treatment instituted, evaluate the occurrence of a PE if the DVT was line-associated, and if so, the indication for the central line. RESULTS: Of 1,857 patients, 39 had postoperative DVTs (2.1%). Fourteen lower-extremity (35.9%) DVTs, 4 central (10%) DVTs, and 21 upper-extremity (53.8%) DVTs (UEDVTs) were captured. All but 2 had appropriate thromboprophylaxis. All but one UEDVT was line-associated. Diagnoses were prompted by symptoms in 72% of the patients. Pulmonary emboli developed in 3 of 39 patients. CONCLUSIONS: An unexpected finding was that line-associated UEDVTs comprised over half of all DVTs, mostly in patients without cancer. This analysis highlights the need for more selective central-line use; choosing peripheral access may reduce DVT rates further. Improved pharmacoprophylaxis protocols would likely benefit this population.

Diffuse malignant epithelioid mesothelioma in a background of benign multicystic peritoneal mesothelioma: a case report and review of the literature.

Peritoneal mesotheliomas are unusual entities with diverse origins and outcomes. Both benign and malignant variants exist. Benign multicystic peritoneal mesotheliomas (BMPMs), also known as multiple or multilocular peritoneal inclusion cysts, are extremely rare tumours arising from the peritoneal mesothelium covering the abdominal serous cavity. Even though these entities are considered benign tumours, BMPMs tend to recur after surgical resection, and in two cases have been reported to undergo malignant transformation. In contrast, diffuse malignant peritoneal mesotheliomas, while also quite rare, are the second most common form of malignant mesothelioma after the pleural variety with extremely high mortality and poor response to many treatments to date. We present a rare case of diffuse malignant peritoneal mesothelioma within a large component of a BMPM in a young man admitted to our service.

Mechanical evaluation of balloon-type gastrostomy devices.

Purpose is to evaluate the durability of two commonly used gastrostomy devices. The performance of balloon-type gastrostomy devices was evaluated in an accelerated aging failure mode as well as a feeding tube interlock pullout failure mode. Two commonly used devices were tested: MINI (Applied Medical Technology Inc.) and MIC-Key (Kimberly Clark/Ballard Medical). In the aging test, devices (n = 20) from each manufacturer were pressurized and subjected to controlled pH and temperature conditions to evaluate the product life. In the pullout failure test, devices were subjected to controlled mechanical loading to evaluate the force at which each plastic interlock pulls out of the rubber that encapsulates it. In the aging testing, the MIC-Key devices had a lifespan of 98 ± 34 h and the MINI survived for 1187 ± 422 h. The difference was statistically significant (p < 1 × 10-9). In the pullout testing, the MIC-Key failed at 183 ± 24 N whereas the MINI failed at 202 ± 26 N (p < 0.04). Pullout strength for both devices appears adequate in view of estimated in vivo loads during normal use of the device with the MINI requiring a statistically significantly greater pullout strength. Although the aging tests were performed using an accelerated protocol, the aging tests suggest that the in vivo lifespan and failure mode of the MINI may be superior to the MIC-Key.

Trends and disparities in education between specialties in thyroid and parathyroid surgery: An analysis of 55,402 NSQIP patients.

PURPOSE: To determine practice patterns/outcomes and educational opportunities in endocrine surgery by resident involvement in general surgery (GS) and otolaryngology (ENT). METHODS: We queried the American College of Surgeon National Surgical Quality Improvement Program for thyroid/parathyroid operations. Resident involvement was categorized by postgraduate year (PGY) and specialty. RESULTS: Of 38,257 thyroid patients, attendings alone performed 28% in GS versus 65% in ENT, and of 17,145 parathyroid patients, 22.1% vs 66.5%. Of GS cases done with housestaff, the percentages with junior residents (PGY1-3), senior residents (PGY4,5), and fellows were 42%, 50%, and 7%, respectively, whereas for ENT operations, the percentages were 35%, 46%, and 16%. For parathyroidectomies, the percentages were 41.1%/46.8%/12.1% vs 38.7%/45.9%/15.5%. Operative time was less for GS (115 minutes) versus ENT (123 minutes). Time in the operating room increased with increasing PGY in ENT, but not in GS. Case complexity and outcomes were similar. Duration of hospital stay was greater in ENT. CONCLUSION: No differences exist in case complexity between specialties. More thyroid/parathyroid operations are performed with residents in GS; junior residents in GS perform a large percentage of these cases (∼40%), indicating early exposure to endocrine surgery and balanced experience between resident levels with minimal effect of fellows. Although junior residents receive exposure in ENT, a greater proportion is performed by fellows. Outcomes were similar by resident level, except operative time, which was greater for ENT at all levels. Ultimately, equal outcomes but lesser operating times and durations of hospital stay are seen with GS residents than their ENT counterparts.

Antimesenteric jejunal diverticulosis after a remote history of necrotising enterocolitis: a case report.

Jejunal diverticulosis is a rare, acquired pathology of the small bowel. While most patients are asymptomatic, the condition is difficult to diagnose. It may present with chronic abdominal pain, diarrhoea, bloating and complications including malabsorption, diverticulitis, bleeding, intestinal obstruction or perforation. This is a case presentation of a 27-year-old woman with a history of necrotising enterocolitis (NEC) requiring surgical resection as a premature newborn who presented with recurrent abdominal pain and was found to have several small bowel diverticula intraoperatively. She underwent resection with complete resolution of symptoms over a 2-year follow-up. This is the first case report to suggest that small bowel diverticular disease as a long-term complication of NEC may result in chronic morbidity in long-term survivors.

Food allergy among low birthweight children in a national survey.

The aim of this paper was to investigate the association between birthweight and prevalence of food allergies using a national sample of US children. Adult report of birthweight and child food allergies were obtained for years 2005-2009 from the National Health Interview Survey (NHIS), a cross-sectional household survey of the US population. A total of 51,748 children aged 0-17 years were included in the analyses representing over 73 million children. Multivariable logistic regression analyses examined associations between birthweight categories and food allergies stratified by age and gender; accounting for the complex design of NHIS. Children aged 6-12 years who were born very low birthweight (500-1,499 g) were more likely to have reported food allergy compared to referent (3,000-3,499 g), OR = 1.72; 95% CI: 1.02-2.91. However, there was no clear trend of an association between birthweight and food allergy with increasing or decreasing birthweight across all ages. Estimates were generally stronger in younger male children as compared to estimates in females of the same age group. Marginal associations for respiratory allergy (OR = 1.52; 95% CI: 1.02-2.29) and hay fever (OR = 1.54; 95% CI: 0.93-2.54) were observed among very low birthweight children aged 0-5 years. There was limited evidence for a clear association between birthweight and food allergy. Marginal associations observed in children weighing 500-1,499 g at birth support efforts to minimize preterm births and very low birthweight given the increase in pediatric food allergies and the large number of children born low birthweight each year in the US.