Keith Millikan

Local regional recurrence (LRR) remains the primary cause of treatment failure in solid tumors despite advancements in cancer therapies. Canady Helios Cold Plasma (CHCP) is a novel Cold Atmospheric Plasma device that generates an Electromagnetic Field and Reactive Oxygen and Nitrogen Species to induce cancer cell death. In the first FDA-approved Phase I trial (March 2020–April 2021), 20 patients with stage IV or recurrent solid tumors underwent surgical resection combined with intra-operative CHCP treatment. Safety was the primary endpoint; secondary endpoints were non-LRR, survival, cancer cell death, and the preservation of surrounding healthy tissue. CHCP did not impact intraoperative physiological data (p > 0.05) or cause any related adverse events. Overall response rates at 26 months for R0 and R0 with microscopic positive margin (R0-MPM) patients were 69% (95% CI, 19–40%) and 100% (95% CI, 100–100.0%), respectively. Survival rates for R0 (n = 7), R0-MPM (n = 5), R1 (n = 6),...

Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.

While adding chemotherapy to radiation for the treatment of esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control remains problematic. The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatment of of esophageal cancer and to assess the impact of this approach on regional control and survival. Twenty-five patients with esophageal cancer were treated in a phase I pilot protocol consisting of initial esophagectomy with gastroesophagostomy and subsequent combined chemotherapy and radiation. Chemotherapy consisted of cisplatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuous infusion. Radiation therapy was administered in varying fractionation schedules of once or twice daily concomitantly with the chemotherapy. Treatment was repeated every other week for two to four cycles. Median follow-up was 42 months. Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in four of 10 patients, (two lethal). Control of local disease for all patients was excellent with only two known and two possible local recurrences (16%) but distant metastases were common (46%). Disease-free survival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 and 32% at 1 and 2 years, respectively (median survival, 19 months). The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and radiation given prior to surgery. A dose-fractionation schedule of < 2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse effects. The role of surgery will be defined by randomized studies. Better systemic therapy is needed to impact on systemic failure.

While adding chemotherapy to radiation for the treatment of esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control remains problematic. The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatment of of esophageal cancer and to assess the impact of this approach on regional control and survival. Twenty-five patients with esophageal cancer were treated in a phase I pilot protocol consisting of initial esophagectomy with gastroesophagostomy and subsequent combined chemotherapy and radiation. Chemotherapy consisted of cisplatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuous infusion. Radiation therapy was administered in varying fractionation schedules of once or twice daily concomitantly with the chemotherapy. Treatment was repeated every other week for two to four cycles. Median follow-up was 42 months. Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in four of 10 patients, (two lethal). Control of local disease for all patients was excellent with only two known and two possible local recurrences (16%) but distant metastases were common (46%). Disease-free survival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 and 32% at 1 and 2 years, respectively (median survival, 19 months). The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and radiation given prior to surgery. A dose-fractionation schedule of < 2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse effects. The role of surgery will be defined by randomized studies. Better systemic therapy is needed to impact on systemic failure.

To evaluate the effect of surgical approach and adjuvant therapy on patients with carcinoma of the esophagus and/or cardia. Retrospective analysis of 157 consecutive patients who underwent esophagectomy. A private university medical center and its affiliated community hospital. One hundred twenty men and 37 women (mean age, 61.7 years) with carcinoma of the esophagus and/or cardia that was surgically treated between 1978 and 1993. Three approaches were used for resection: Transhiatal esophagectomy (THE) (n = 67), transthoracic esophagectomy (TTE) (n = 71), and abdominal-only esophagectomy (AOE) (n = 19). Sixty-five patients received adjuvant radiotherapy and chemotherapy. Surgical mortality, morbidity, and survival and the effect of adjuvant therapy. The overall surgical mortality rate was 7.6%: 12.7% with the TTE, 4.5% with the THE, and 0% with the AOE approach. A significantly increased incidence of adult respiratory distress syndrome (P < .001) and empyema (P < .001) was seen with the TTE approach. The average intraoperative blood loss (P = .08) and the median intensive care unit stay (P = .26) and hospital stay (P = .40) were decreased with the THE and AOE approaches when compared with the TTE approach without significance. The overall median survival time was 17 months, with a 5-year survival rate of 21%. There was no significant difference in survival by pathologic stage between approaches. The addition of adjuvant therapy did not affect the overall median survival time or the 5-year survival rate. Node-positive patients did benefit from adjuvant radiotherapy and chemotherapy, with increased median survival times from 7 to 15 months and a 5-year survival rate from 0% to 15% (P = .01). The THE and AOE approaches have fewer early complications than does TTE. Both THE and TTE have equal long-term survival rates. Adjuvant therapy provides increased survival to node-positive patients with carcinoma of the esophagus and/or cardia.

Mucin Hypersecreting Intraductal Papillary Neoplasm is a rare neoplasm that arises from ductal epithelial cells. This entity is distinct from the more commonly known Mucinous Cystadenoma or Mucinous Cystadenocarcinoma. Despite this distinction, it has been erroneously categorized with these more common cystic neoplasms. Characteristic clinical presentation, radiographic, and endoscopic findings help distinguish this neoplasm from the cystadenomas and cystadenocarcinomas. Histopathologic identification is not crucial to the preoperative diagnosis. This neoplasm is considered to represent a premalignant condition and, therefore, surgical resection is warranted. Prognosis, following resection, is felt to be curative for the majority of patients. We present two cases of Mucin Hypersecreting Intraductal Papillary Neoplasm and discuss their diagnosis and surgical therapy.

This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases. The records of 131 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resection was performed in 107 of these patients. Thirty-one experienced recurrences confined to the liver. Thirteen (13 of 107, 12%) of them underwent resection and make up the study population. The eight men (62%) and five women (38%) had a median age of 60 years (range, 32 to 75 years). In 30% of patients recurrence developed near the original resection site. In 70% the recurrences were remote from the original site. The patients underwent a total of six wedge resections, two left lateral segmentectomies, three right lobectomies, and two trisegmentectomies. Average blood loss was 2995 cc; average hospital stay was 17.2 days. Morbidity was 23% (3 of 13); mortality was 8% (1 of 13). Four patients died of recurrent disease, with a mean disease-free survival of 9.7 months (median, 7.5 months; range, 3 to 21 months) and mean total survival of 39 months (median, 24 months; range, 8 to 99 months). One of these patients had a second recurrence resected at month 21 and lived an additional 78 months. Seven patients were alive with no evidence of disease, with a mean follow-up time of 34.9 months (median, 14 months; range, 1 to 186 months). Actual 5-year survival was 23% (3 of 13). Actual disease-free 5-year survival was 15% (2 of 13). In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection.

This study was conducted to identify the range and nature of surgical clerkship experiences in three different hospital settings-university, community, and public. An instrument was developed to track the location and type of learning experience, patient demographics, surgical content, and clinical experience of students on their surgical clerkship. Twenty-three students used the instrument to record the events of their surgical clerkship. Data were analyzed to describe the frequency of tasks performed, the nature and location of learning experience, exposure to surgical topics, and patient demographics. Students were involved in an average of 245 common surgical tasks over their 8-week clerkship. Of their exposure to common tasks, students had the opportunity to observe 25% and perform 70% of those tasks. Sixty-six percent of task work occurred on the patient floor and 23% occurred in the operating room. Students were exposed to a broad range of surgical topics, 71% of which were general surgery topics. Only 25% of these experiences were auditory, whereas 39% involved exposure to a patient, and 36% included participation in an operation. Patient load and characteristics tended to vary across hospital settings, and on average, students worked with 164 patients during their clerkship. The smallest patient load (m = 113) occurred in the university hospital and the largest patient load (m = 251) occurred in the public hospital. Although surgical services and hospital settings may offer students different clerkship experiences, the common clinical and didactic components of a surgical clerkship can balance a student's exposure to surgical topics and practice of clinical skills. Tracking surgical clerkship experiences is valuable in identifying the range and nature of medical students' didactic, clinical, and operative experiences.

This article describes a case of superior mesenteric and portal vein thrombosis following laparoscopic-assisted right hemicolectomy. A retrospective case review was performed. Data continue to grow regarding safety and technical feasibility of laparoscopic-assisted colectomy. As this minimally invasive alternative to open colonic resection becomes more popular, it is inevitable that information on benefits and complications associated with it will continue to expand. We report a case of superior mesenteric and portal vein thrombosis following laparoscopic-assisted colon resection. To our knowledge, this represents a complication of laparoscopic colon resection not previously reported in literature. Careful patient selection for this procedure is important. Additionally, the incision for extracorporeal resection and anastomosis in laparoscopic-assisted colectomy must be planned appropriately and carefully monitored intraoperatively to avoid potential complication of vascular trauma leading to mesenteric vein thrombosis.

Percutaneous angioplasty would provide a durable alternative to surgical revision in the treatment of infrainguinal vein graft stenosis. Outcome analysis of the results of percutaneous angioplasty of infrainguinal vein graft stenosis. Academic vascular surgical practice in a university-affiliated community hospital. All patients undergoing percutaneous intervention for infrainguinal vein graft stenosis from January 1, 1995, to May 31, 2002, were enrolled in the study. Lower extremity arterial reconstruction was performed by one of us. Proximal and distal sites of graft placement were identified, as well as the conduit used. Percutaneous angioplasty was performed on grafts by 1 of 4 interventional radiologists. Criteria for intervention and the anatomic location of intervention were noted. Morbidity from percutaneous intervention was also determined. Success and durability of percutaneous angioplasty were determined by clinical follow-up, duplex surveillance, and arteriography. Failure was defined as duplex ultrasonographic or arteriographic documentation of stenosis of 75% or greater. Kaplan-Meier life table analysis was applied to all grafts in the study. Ninety-four patients with 101 grafts were included in the study. Nearly 35% of angioplasties had failed at 6 months, 53.6% had failed at 12 months, 60.6% had failed at 24 months, and 75.1% had failed at 36 months. Comorbid disease, use of anticoagulant medications, criteria for intervention, or anatomic location of percutaneous intervention did not affect patency. Eight angioplasties (7.9%) were associated with significant complications. Percutaneous angioplasty does not provide a durable solution to the problem of infrainguinal vein graft stenosis. Because of the high rate of complications, its routine use cannot be advocated.

Previous gastric resection complicates alimentary tract reconstruction after esophagectomy. Colonic interposition is the standard conduit in this circumstance, but has substantial mortality and morbidity, especially important when treatment goals are to provide effective alimentation and minimize hospital stay. This report details the technique of a transabdominal, intrathoracic, stapled esophagojejunostomy created without a pursestring suture, which was used to reconstruct the esophagus in 3 patients who had previously undergone partial gastrectomy. This technique avoids both colon interposition and thoracotomy, thereby minimizing the associated complications.

During laparoscopic ventral hernia repair (LVHR), it is not always possible to reduce incarcerated omentum through a tight defect and it may tear or require transection within the abdomen. This leaves an ischemic mass of tissue within the hernia sac which can cause pain, infection, or the appearance of hernia recurrence postoperatively. We describe a technique which allows extraction of any retained omentum within the hernia sac, mesh insertion, and laparoscopic completion of the procedure using only 5 mm trocars. After obtaining access to the abdomen with a 5 mm optical trocar in select patients, lysis of adhesions is performed as needed. When incarcerated omentum that cannot be safely reduced is discovered, it is transected at the level of the abdominal wall using electrocoagulation or ultrasonic dissection. At this point, we make a 2-3 cm skin incision overlying the retained omentum, open the hernia sac, and remove the amputated omentum. The rolled up piece of mesh utilized for the repair is then inserted through this opening. The hernia sac is closed with absorbable suture, allowing reinsufflation of the abdomen and completion of the laparoscopic repair. This method enables us to safely remove any retained omentum from the hernia sac and utilize the same incision for mesh insertion. We utilize only 5 mm trocars without the need for a larger port through which to place the mesh into the abdomen. This reduces the risk of postoperative trocar site hernias as the opening for mesh insertion is covered by the mesh after it is fixed in place. This technique may also decrease the need for conversion to open hernia repair by allowing an alternative approach to reduce incarcerated omentum.

Laparoscopic cholecystectomy became the procedure of choice for symptomatic stone disease of the gallbladder. Complications associated with this new method are discussed and compared with those of open cholecystectomy. Laparoscopy alone shows a morbidity of 0.2-3.7 percent and mortality of 0.1 percent. The complications of laparoscopic cholecystectomy are divided in early--lesion of the bile ducts, hemorrhage or coagulation injuries--and late complications, as formation of abscess, pulmonary embolism, herniation at the site of trocar insertion or stricture of the common bile duct. Compared with open cholecystectomy, the laparoscopic procedure is safe too in the treatment of symptomatic stone disease of the gallbladder.

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

A consensus on the optimal surgical approach for repair of a paraesophageal hernia has not been reached. The aim of this study was to examine the outcomes of open and laparoscopic paraesophageal hernia repairs (PHR), both with and without mesh. A review of the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2011 was conducted. Patients who underwent an open or laparoscopic PHR were included. The primary outcome was 30-day mortality. Secondary outcomes included infections, respiratory and cardiac complications, intraoperative or perioperative transfusions, sepsis, and septic shock. Statistical analyses using odds ratios were performed comparing the open and laparoscopic approaches. A total of 4470 patients were identified using NSQIP; 2834 patients had a laparoscopic repair and the remaining 1636 patients underwent an open PHR. Compared with the laparoscopic approach, the open repair group had significantly higher 30-day mortality (odds ratio, 4.75; 95% co...

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

"Background: Cancer invading multiple adjacent structures occurs in up to 25% of patients. In these circumstances extensive resection is required to eliminate the primary tumor. The purpose of this review is to provide more information about the use of en bloc right hemicolectomy with pancreaticoduodenectomy and its outcomes. Methods: A retrospective chart review of patients that had en bloc right hemicolectomy/pancreaticoduodenectomy for locally advanced cancer at between 2005 and 2011. Results: Eight cases were identified. There were five males and three females with a mean age of 63 years (34 - 78 years). Colon cancer was the most common indication of the procedure, the remaining cases had the following diagnosis: gastrointestinal stromal tumor (GIST), gallbladder carcinoma, liposarcoma, and two pancreatic cancer. The average operative time was six hours (range 243 - 747 minutes). Mean estimated blood loss was 1700 ml; requiring transfusion of 3.5 units of red blood cells on average (range 3 – 4). All patients were admitted in the intensive care unit for an average for 2.5 days (range 2 – 4). The most common complications during hospitalization were fever, diarrhea secondary to Clostridium difficile and ileus. All patients had negative margins. The average length of stay (LOS) was 17 days (12- 24 days). Two out of eight patients died after the surgery, 3 and 26 months respectively; mean follow up time was two years (range 3 months – 6 years). Conclusions: En bloc right hemicolectomy and pancreaticoduodenectomy can be used to treat locally advanced cancer. This procedure is associated with increased operative time, high rate of ICU requirement, and longer length of stay; however, it offers a favorable long-term survival."

Myoepitheliomas are rare tumors that occur in the salivary glands. These lesions are extremely rare, and there are no specific guidelines for its treatment. Here, we report a case in which a myoepithelial carcinoma was found after a right groin lipoma excision. We discuss the surgical technique and the pathology. Myoepitheliomas are tumors of epithelial origin. While most of these are benign, myoepithelial carcinomas do exist and comprise 10 per cent of myoepitheliomas.1, 2 Myoepithelial carcinomas may occur with preexisting benign lesions such as pleomorphic adenomas.3 Most of these tumors occur in the salivary glands. Histologically, cells assume a myoepithelioid appearance with increased mitotic activity4 (Fig. 1). Most of these tumors are insidious in onset. The patient may only notice a painless mass, delaying the diagnosis by months to years. When these tumors occur in the oropharynx or nasopharynx symptoms such as nasal obstruction, ear fullness, and otitis media can occur.3, 4 Therefore, when these masses occur in areas such as the thigh, diagnostic imaging such as CT and MRI allow for anatomy and extension of the tumor to be better delineated. A 54-year-old female with a history of papillary thyroid cancer status after thyroidectomy and radioactive iodine was incidentally diagnosed with myoepithelial carcinoma of the right groin. At initial presentation, she reported noticing a new mass medial to a previous lipoma excision that occurred 7 years earlier. She underwent an excision of the mass, measuring 7.5 cm in diameter. Histopathologic review demonstrated myoepithelial carcinoma with positive microscopic margins. Review of outside-hospital slides showed malignant spindle and epithelioid cells consistent with myoepithelial carcinoma. Mitoses were less than 5 per high-powered field. Positron emission tomography-computed tomography scan performed at that time showed uptake in the surgical bed and did not show uptake at other sites. Given the positive microscopic margins along with increased uptake seen on positron emission tomography-computed tomography, wide local excision of the previous surgical site was pursued to obtain negative margins. A 6-cm elliptical incision was made starting over the pubic bone, extending toward the anterior superior iliac spine. The area of excision was carried down to fascia. The external oblique aponeurosis was removed, and the inguinal ligament was kept intact. Lymph nodes below the inguinal ligament down to the femoral vessels were removed as well. A Jackson–Pratt drain was placed in the cavity to prevent potential seroma formation. She recovered well postoperatively and was discharged home from hospital on day 2. The final pathology showed four lymph nodes negative for tumor or malignancy. The specimen did show a minute focus of residual malignant neoplasm (1 mm in size) with negative margins. The patient’s final stage was T2bN0. Patient proceeded to receive four weeks of radiation therapy to that area. Presently, the patient is doing well without any complications. She will obtain repeat CT imaging and MRI imaging to assess disease regression and to monitor for recurrence. Myoepithelial carcinomas (malignant myoepitheliomas) are soft tissue tumors that usually occur in the salivary gland. While most of them are benign, some are carcinomas. They are usually multinodular in appearance, with diverse cytologic and morphologic patterns including nests, cords, and sheets of epithelioid, clear, spindle, or plasmacytoid cells in hyalinized or chondromyxoid stroma. Tumors with benign morphology or mild low-grade atypia are classified as myoepitheliomas. Those that have severe atypia are classified as carcinomas or malignant mixed tumors.4 Hornick et al.4 studied 101 cases of myoepithelial tumors and showed that in 33 cases with low-grade cytology, 18 per cent recurred locally and none metastasized. Among Address correspondence and reprint requests to Jennifer D. Son, M.D., Department of Surgery, Rush University Medical Center, Chicago, IL 60612. E-mail: jennifer.d.son@gmail.com.

Mesenteric cysts are benign congenital cysts typically discovered incidentally during abdominal explorations for other reasons. When feasible, they should be excised to prevent recurrence, bowel obstruction or volvulus, and resulting complications. We present a unique case of an infant, diagnosed prenatally by ultrasound with possible bowel obstruction, found to have micro and macro chylous mesenteric cysts. Although initially asymptomatic with normal abdominal x-ray and discharged on day of life 2, the parents were taught how to recognize symptoms of bowel obstruction. He presented at 1 month with obstructive symptoms, was confirmed to have large mesenteric cystic structures on ultrasound, and was immediately taken to the operating room. Due to the extensive number of cysts and intimate involvement of the largest cyst with the superior mesenteric artery, he was treated with partial excision and observation since resection may have resulted in short gut syndrome. Given a prenatal ul...

BACKGROUND Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are devastating complications of surgery. Patients who undergo complex ventral hernia repair (CVHR) may be at risk for IAH and ACS. METHODS We performed a retrospective review of 175 patients who underwent CVHR by a single surgeon. Body mass index (BMI), prior hernia repair, operative time, bladder pressure, serum creatinine, sedation, paralytic therapy, and ventilator support were reviewed. RESULTS IAH was identified in 33 patients; 11 patients developed ACS. Paralytic therapy was employed in 29 patients for an average of 1.4 days. Elevated BMI was independently associated with an increased risk of IAH (p = 0.006) and ACS (p = 0.02). CONCLUSION Patients who undergo CVHR are at risk of developing IAH and ACS in the postoperative period. Elevated BMI and longer operative time are independent risk factors for the development of IAH. IAH and ACS can be successfully managed with surgical critical care.

Esophageal dilators (EDs) are commonly used during antireflux surgery but are a known cause of esophageal perforation. We hypothesized that the usage of ED during laparoscopic fundoplications (LFs) would not improve dysphagia rates or outcome. A retrospective review of 268 consecutive patients and a postoperative patient survey were performed to compare outcomes in patients undergoing LF. Eighty-nine patients had an ED placed and 179 did not. Significant postoperative dysphagia occurred in seven (8%) and six (3%), respectively (P = 0.123) and postoperative heartburn in five (6%) and three (2%), respectively (P = 0.865), in a mean 26.8-month follow-up. Patient survey results demonstrated good to excellent satisfaction in 89 per cent of patients in both groups. We conclude that the results of LF are equivalent with respect to control of heartburn and risk of dysphagia regardless of ED usage. Selective rather than routine use of EDs is recommended.

As the effort to reduce postoperative morbidity and mortality continues, the search for modifiable patient risk factors to reduce complications is ongoing. Tobacco use is associated with impaired wound healing, but its effect on inguinal hernia repair has not been studied in a large population. An ACS-NSQIP dataset was used to evaluate the effect of tobacco use on outcomes of inguinal hernia repairs. The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic inguinal hernia repairs, by primary procedure CPT codes, between years 2009-2012. Tobacco use was registered, as defined by the ACS-NSQIP, in two ways: current smoking (within the past 12 months), or history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate outcome variables for 30-day morbidity by type of smoking status, while adjusting for preoperative risk factors. During the study period, 90,162 patients underwent inguinal hernia repair. 76 % of the cases we...

A retrospective review of esophagectomy for esophageal carcinoma between 1982 and 1999 was performed. Two hundred twenty-two patients (mean age 61.7 years) underwent esophagectomy: 128 transhiatal, 74 Ivor Lewis, and 20 abdominal. Most tumors were adenocarcinoma (65%); the majority were in the lower third or cardia (78%). Excluding operative mortality the one-, 3-, and 5-year survival rates were 67, 39, and 31 per cent (median survival, 16.3 months) respectively. The hospital mortality rate was 6.8 per cent. Through univariate analysis race other than white, history of weight loss, poor or moderate differentiation (P = 0.05), full-thickness invasion (P = 0.02), positive lymph nodes (P < 0.01), Ivor Lewis esophagectomy (P = 0.02), intraoperative blood transfusion (P = 0.01), and tumor location in the upper or middle third in node-positive patients (P = 0.02) were associated with a poorer survival. Adjuvant therapy improved survival for patients with positive lymph nodes (P < 0.01). In multivariate analysis positive lymph nodes, tumor location, intraoperative blood transfusion, and adjuvant therapy were independent predictors of survival. To optimize survival esophagectomy for esophageal carcinoma should be performed without blood transfusion, and node-positive patients should receive multimodal therapy.

... ontents Foreword by Steven G. Economou vii Preface ix Contributors xxi ection 1: ead and ec CHAPTER 1 Cancer of the Lip 2 Tina J. Hieken CHAPTER 2 Cancer of the Floor of the Mouth 10 John A. Greager CHAPTER 3 Cancer of the Hard Palate 14 Nader Sadeghi and ...

The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0-151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors. A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preop...

Intraoperative cholangiography (IOC) remains a subject of much debate among laparoscopic surgeons. When IOC is indicated, the surgeon&amp;amp;amp;#39;s preference for routine cholangiography (RC) or selective cholangiography (SC) may have an impact on the outcome of IOC and cholecystectomy. Hereafter, we present our experience with cholangiography in patients with clear indications for IOC when operated on by surgeons favoring SC versus RC. Between January 1, 1999, and December 1, 2000, 389 patients underwent laparoscopic cholecystectomy at Loyola University Medical Center. One hundred fifty-one patients had indication for IOC (jaundice, pancreatitis, increased liver function tests (LFTs), abnormal anatomy, ductal dilatation, or ductal stones identified on preoperative ultrasound), and they constitute the sample for this study. The results of IOC and subsequent outcome of cholecystectomy were reviewed using the electronic medical database. Thirty-nine patients were operated on by 2 surgeons favoring RC and 112 by 12 favoring SC. Patient demographics were similar in both groups. Only 30 (27%) of the SC group had attempted IOC with 28 successful IOCs (25% of all patients). In contrast, 38 (97%) of the RC group had successful IOC, which was significantly higher than the SC group (P &amp;amp;amp;lt; 0.0001 by chi2 test). Adverse events included conversions to open, postoperative endoscopic retrograde cholangiopancreatography, bile leak, repeat operative intervention, pancreatitis, elevated LFTs, intra-abdominal and wound infection, prolonged emesis, and persistent abdominal pain. Two (5%) adverse events occurred in the RC group, which was significantly less than the 33 (30%) adverse events in the SC group (P = 0.002 by chi2 test). Conversions to open were significantly less in the RC group, with no conversions in the RC group and 20 (18%) in the SC group (P = 0.005). There were no mortalities in this series. In a univariate analysis, age and gender did not correlate with increased risk of complications. In conclusion, surgeons who perform SC are less likely to attempt IOC even when IOC is indicated. More conversions to open and more adverse events occurred following cholecystectomy by those favoring SC. Our study further supports routine cholangiography during laparoscopic cholecystectomy.

Phase I of this study compared students&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; experiences regarding patient demographics, surgical content, and clinical skill practice in three different hospital settings: university, community, and public. Phase II examines the aspects of clerkship performance that contribute to students&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; final grades. An instrument to track the experiences of students on their surgical clerkship was developed and piloted. Data were analyzed to compare the frequency of common surgical tasks performed and exposure to various surgical topics and patient demographics as well as to identify factors that explain variance on student grades. Students performed an average of 33 clinical tasks per week and were exposed to a broad range of surgical topics. Analysis of variance results demonstrated no significant differences between public, private, or university settings with respect to students&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; clinical practice opportunities or content exposure. Clinical evaluations and National Board of Medical Examiners scores account for 75.5 per cent of the variance in students&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; final grades. There was no significant correlation between patient load and clinical task load with final clerkship grades. The common clinical and didactic components of a surgical clerkship can balance a student&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience with surgical topics and tasks performed. It is important to utilize this information in program review of multisite clerkships to ascertain and enhance the validity of student performance measures.

Determine the utility of mock oral examinations in preparation for the American Board of Surgery certifying examination (ABS CE). Between 2002 and 2012, blinded data were collected on 63 general surgery residents: 4th and 5th-year mock oral examination scores, first-time pass rates on ABS CE, and an online survey. Fifty-seven residents took the 4th-year mock oral examination: 30 (52.6%) passed and 27 (47.4%) failed, with first-time ABS CE pass rates 93.3% and 81.5% (P = .238). Fifty-nine residents took the 5th-year mock oral examination: 28 (47.5%) passed and 31 (52.5%) failed, with first-time ABS CE pass rates 82.1% and 93.5% (P = .240). Thirty-eight responded to the online survey, 77.1% ranked mock oral examinations as very or extremely helpful with ABS CE preparation. Although mock oral examinations and ABS CE passing rates do not directly correlate, residents perceive the mock oral examinations to be helpful.

Right upper quadrant pain is a very common Symptom and is usu-ally attributed to cholelithiasis when, in fact, the differential diagnosis is quite extensive. Biliary colic is actually a misnomer since the pain from cholelithiasis is usually constant, not intermittent, and may radiate to the patient’s back. It may be associated with fatty food intolerance and there may be a history of jaundice or pancreatitis. The differential diagnosis of right upper quadrant pain includes peptic ulcer disease, hepatobiliary Cancer, pneumonia, myocardial infarction, hepatitis, Pyelonephritis, Fitz-Hugh-Curtis Syndrome, nephrolithiasis, appendici-tis, and pancreatitis.

Right lower quadrant pain can be one of the most difficult and frustrating complaints seen in the office or the Emergency Room as there are a multitude of disease processes included in the differential diagnosis. The most likely causes vary according to sex.

In order to prevent the perioperative morbidity and mortality associated with malnutrition, evaluation of nutritional status early in the clinical course and throughout treatment is essential. The most cornmon nutritional deficiency is protein-calorie malnutrition, the least common is vitamin or mineral deficiency; multiple factors can contribute to either. The clinical examination may reveal obvious problems which lead to or result from nutritional deficits, i.e. poor dentition inhibiting oral intake; alopecia as a result of zinc deficiency. A review of current medical data and past medical history will identify conditions that influence nutritional status such as chronic or acute disease states, surgery, chemotherapy, radiation therapy, andlor medications with possible drug-nutrient interactions. Diet history allows for review of current oral intake with emphasis on eating habits and preferences, physical activity, and recent alterations in intake. Stressed or catabolic patients may develop total or partial starvation quickly, assessment of anthropometrics and somatic protein stores can determine severity of malnutrition. Severe weight loss over time can be categorized as follows: &gt;2% in one week; &gt;5% in one month; &gt;7.5% in three months; and &gt;10% in six months. Significant weight loss is considered to be loss of 10–20% of usual body weight.

Cirrhosis or thrombosis of the portal vein can cause portal hypertension and gastric or esophageal varices. When a patient presents with hematemesis and has known liver disease the ABC’s of resuscitation and stabilization are undertaken and esophagogastroduodenoscopy (EGD) is performed. EGD can be both diagnostic (identifying varices) and therapeutic; sclerotherapy with an agent such as sodium moruate can stop the bleeding. Unfortunately, for active or diffuse esophageal hemorrhage from varices, the endoscopist is unlikely to be able to stop the bleeding at the first attempt.