Factors affecting risk of recurrence with periprosthetic infection in shoulder arthroplasty.

BACKGROUND: The goal of treating periprosthetic infection, besides its eradication, is to avoid recurrence. The purpose of this study was to evaluate the impact of increasing Infection Severity (IS) score (based on the 2018 International Consensus Meeting on Orthopedic Infections statement), single-stage revision, and pathogenicity of the infective organism on the risk of infection recurrence. METHODS: A database of 790 revisions performed by a single surgeon from 2004-2020 was reviewed for patients with minimum 2-year follow-up and ≥1 positive culture finding and/or pathology result from the revision surgical procedure. In total, 157 cases performed in 144 patients met the inclusion criteria. These cases were then categorized by infection probability (IS score) according to the 2018 consensus statement. Of 157 cases, 46 (29%) were classified as definitely or probably infected; 25 (16%), possibly infected; and 86 (55%), unlikely to be infected. Additionally, patients were grouped by single-stage surgery and pathogenicity of the infective organism. RESULTS: A recurrence in this study was classified as the growth of the same organism in any patient requiring revision surgery. The 86 cases in the group with unlikely infection showed a recurrence rate of 2.3%. The 25 cases in the group with possible infection showed a recurrence rate of 12%. The 46 cases in the group with definite or probable infection showed a recurrence rate of 17.4%. Patients in the definite/probable infection group had a higher rate of recurrence than those in the groups with possible infection and unlikely infection (P = .009). The IS score was higher in the recurrence group than the non-recurrence group (7.5 ± 4.3 vs. 3.9 ± 3.4, P < .001). Overall, patients who underwent 1-stage revision had a 5.0% recurrence rate, but among the 34 patients with an infection classification of definite or probable who underwent 1-stage revision, the recurrence rate was 5.9%. Cases of highly virulent methicillin-resistant Staphylococcus aureus also showed a recurrence rate of 30.8% compared with 4.0% and 5.9% for Cutibacterium acnes and coagulase-negative staphylococci, respectively (P = .005). CONCLUSION: Recurrent infection after treatment of a periprosthetic infection is associated with increasing severity scores, as defined in the 2018 consensus statement, and more aggressive microorganisms. However, a single-stage surgical procedure, even in patients with higher IS scores, did not impart a significantly increased risk of recurrence.

Do preoperative scapular fractures affect long-term outcomes after reverse shoulder arthroplasty?

BACKGROUND: Postoperative scapular stress fractures (SSFs) are a formidable problem after reverse shoulder arthroplasty (RSA). Less is known about patients who have these fractures preoperatively. The primary aim of this study was to examine postoperative satisfaction in patients undergoing primary RSA who have preoperative SSF and compared to a matched cohort without preoperative fracture. The secondary aim was to examine the differences in patient-reported outcomes between and within study cohorts. METHODS: A retrospective chart review of primary RSAs performed by a single surgeon from 2000 to 2020 was conducted. Patients diagnosed with cuff tear arthropathy (CTA), massive cuff tear (MCT), or rheumatoid arthritis (RA) were included. Five hundred twenty-five shoulders met inclusion criteria. Fractures identified on preoperative computed tomography scans were divided into 3 groups: (1) os acromiale, (2) multifragments (MFs), and (3) Levy types. Seventy-two shoulders had an occurrence of SSF. The remaining 453 shoulders were separated into a nonfractured cohort. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and visual analog scale (VAS) scores were compared pre- and postoperatively in the total fracture group and the nonfractured group cohort. The multifragment subgroup was also compared to the pooled Os/Levy subgroup. RESULTS: The total incidence of SSF in all shoulders was 13.7%. There was a difference in satisfaction scores at all time points between the nonfracture (7.9 ± 2.8) and total fracture group (5.4 ± 3.6, P < .001, at last visit). There was also a greater ASES total score in the nonfractured group vs the total fracture group at the final visit (69.4 ± 23.4 and 62.1 ± 24.2; P = .02). The MF group had worse ASES functional or VAS functional scores than the Os/Levy group at all time points: at 1 year, ASES function: MF 24.2 ± 14.5 and Os/Levy 30.7 ± 14.2 (P = .045); at 2 years, ASES function: MF 21.4 ± 14.4 and Os/Levy 35.5 ± 10.6 (P < .001); and at last follow-up, VAS function: MF 4.8 ± 2.8 and Os/Levy 6.4 ± 3.2 (P = .023). DISCUSSION: Scapular fractures were proportionally most common in patients diagnosed with CTA (16.3%) compared with a 9.2% and 8.6% incidence in patients diagnosed with MCT and RA, respectively. Patients with preoperative SSF still see an improvement in ASES scores after RSA but do have lower satisfaction scores compared with the nonfractured cohort. The multifragment fracture group has lower functional and satisfaction scores at all postoperative time points compared with both the nonfracture and the Os/Levy fracture group.

Glenoid-based reference system to differentiate shoulder pathologies on plain radiographs.

BACKGROUND: Shoulder radiographs are used for evaluation and the planning of treatment of various pathologies. Making a diagnosis of these pathologies on plain radiographs occurs by recognizing the relationship of the humeral head on the registry of the glenoid. Quantification of these changes in registry does not currently exist. We hypothesize that a geometric relationship of the humeral head and the glenoid exists that is defined on an anteroposterior Grashey view radiograph by the relationship of the best-fit circle of the humeral head relative to the best-fit circle of the glenoid such that relative measurements will define the normal shoulder and the pathologic shoulder. METHODS: One hundred fifty-six shoulders were included: 53 normal shoulders, 51 with primary glenohumeral osteoarthritis (GHOA), and 52 with cuff tear arthropathy (CTA). Humeral head best-fit circle was used to define the circle of the humeral head (cHH). A glenoid best-fit circle (cG) was defined by the following rules: (1) best fit of the glenoid articular surface and (2) was limited by the acromion such that either (a) it reaches maximal interaction with the inferior surface of the acromion or (b) the perimeter of the circle is at the lateralmost point of the acromion. The relationship between cHH and cG is defined by measurement of cHH in horizontal and vertical planes relative to the glenoid circle reference. The horizontal displacement angle (HDA) measures the horizontal position of cHH relative to cG, representing the degree of medialization toward the glenoid. The vertical displacement angle (VDA) measures the vertical position of cHH relative to cG, representing the degree of superiorization toward the acromion. Angles were compared by diagnosis and sex. RESULTS: The mean HDA was 61.0° (95% confidence interval [CI] 60.3°-61.7°) in normal shoulders, 79.9° (95% CI 76.9°-82.9°) in GHOA, and 63.4° (95% CI 61.7°-65.1°) in CTA (P < .001). The mean VDA was 43.1° (95% CI 42.2°-44.0°) in normal shoulders, 40.9° (95% CI 39.9°-42.0°) in GHOA, and 59.7° (95% CI 57.6°-61.7°) in CTA (P < .001). Interobserver reliability was 0.991 (95% CI 0.94-1.0) and intraobserver reliability was 0.998 (95% CI 0.99-1.0). The geometric relationship of cHH to the glenoid circle reference was plotted for each group. CONCLUSION: A geometric relationship exists of the humeral head in reference to the glenoid circle. Together, the HDA and the VDA distinguish between a normal shoulder and those with GHOA or CTA. This suggests that this novel methodology may provide a preoperative planning tool that is easily accessible.

Colon Involvement in Necrotizing Pancreatitis: Incidence, Risk Factors, and Outcomes.

OBJECTIVE: To investigate the incidence, risk factors, and outcomes of colon involvement in patients with necrotizing pancreatitis. SUMMARY/BACKGROUND DATA: Necrotizing pancreatitis is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply leading to ischemic complications; however, few data exist regarding this problem. We hypothesized that the development of colon involvement in necrotizing pancreatitis (NP) negatively affects morbidity and mortality. METHODS: Six hundred forty-seven NP patients treated between 2005 and 2017 were retrospectively reviewed to identify patients with colon complications, including ischemia, perforation, fistula, stricture/obstruction, and fulminant Clostridium difficile colitis. Clinical characteristics were analyzed to identify risk factors and effect of colon involvement on morbidity and mortality. RESULTS: Colon involvement was seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n = 29) followed by perforation (n = 18), fistula (n = 12), inflammatory stricture (n = 7), and fulminant C difficile colitis (n = 3). Statistically significant risk factors for developing colon pathology include tobacco use (odds ratio (OR), 2.0; 95% confidence interval (CI), 1.2-3.4, P = 0.009), coronary artery disease (OR, 1.9; 95% CI, 1.1-3.7; P = 0.04), and respiratory failure (OR, 4.7; 95% CI, 1.1-26.3; P = 0.049). When compared with patients without colon involvement, NP patients with colon involvement had significantly increased overall morbidity (86% vs 96%, P = 0.03) and mortality (8% vs 19%, P = 0.002). CONCLUSION: Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt its evaluation. Risk factors include tobacco use, coronary artery disease, and respiratory failure. Colon involvement in necrotizing pancreatitis is associated with substantial morbidity and mortality.

Novel Preoperative Patient-centered Surgical Wellness Program Impacts Length of Stay Following Pancreatectomy.

BACKGROUND/AIM: We created a novel, preoperative wellness program (WP) that promotes recovery. This study assessed its impact on patient outcomes after pancreatectomy. PATIENTS AND METHODS: Pancreatoduodenectomies (PD) and distal pancreatectomies (DP) performed from 2015 to 2018 were reviewed using our institutional NSQIP database. Patients in the WP had their medical conditions optimized and were provided with the following: chlorhexidine, topical mupirocin, incentive spirometer, and immune-nutrition supplements. RESULTS: Out of a total of 669 pancreatectomy patients (411 PD, 258 DP), 308 were enrolled in the WP (188 PD, 120 DP). In the PD subgroup, on multivariable analysis (MVA), the WP patients had shorter lengths of hospital stay (LOS) (12 vs. 10 days, p<0.001). On MVA, WP patients had less post-op transfusion (20 vs. 10%, p=0.027). For the combined groups on MVA, LOS continued to be significant (OR=0.89, 95%CI=0.82-0.97, p<0.007). CONCLUSION: A preoperative patient centered WP may reduce the length of stay.

Is resident assistance equivalent to fellows during hepatectomy?

OBJECTIVE: Hepatectomy is a complex operative procedure frequently performed at academic institutions with trainee participation. The aim of this study was to determine the effect of assistant's training level on outcomes following hepatectomy. METHODS: A retrospective review of a prospective, single-institution ACS-NSQIP database was performed for patients that underwent hepatectomy (2013-2016). Patients were divided by trainee assistant level: hepatopancreatobiliary (HPB) fellow versus general surgery resident (PGY 4-5). Demographic, perioperative, and 30-day outcome variables were compared using Chi-Square/Fisher's exact, Mann-Whitney U test, and multivariable regression. Cases involving a senior-level general surgery resident or HPB fellow as first assistant were included (n = 352). Those with a second attending, junior-level resident, or no documented assistant were excluded (n = 39). RESULTS: Patients undergoing hepatectomy with an HPB fellow as primary assistant had more frequent preoperative biliary stenting, longer operative time, and more concomitant procedures including biliary reconstruction, resulting in a higher rate of post-hepatectomy liver failure (PHLF) (15% vs. 8%, P = 0.044). However, trainee level did not impact PHLF on multivariable analysis (OR 0.60, 95% CI [0.29-1.25], P = 0.173). Fellows assisted with proportionally more major hepatectomies (45% vs. 31%; P = 0.010) and resections for hepatobiliary cancers (31% vs. 19%, P = 0.014). On stratified analysis of major and minor hepatectomies, outcomes were similar between trainee groups. CONCLUSION: Fellows performed higher complexity cases with longer operative time. Despite these differences, outcomes were similar regardless of assistant training level. Resident and HPB fellow participation in operations requiring liver resection provide comparable quality of care.

Outcomes of pancreatoduodenectomy in the cirrhotic patient: risk stratification and meta-analysis.

BACKGROUND: Cirrhosis increases the risk of perioperative mortality in gastrointestinal surgery. Though cirrhosis is sometimes considered a contraindication to pancreatoduodenectomy (PD), few data are available in this patient population. The aim of the present study is to identify predictors of outcome in cirrhotic patients undergoing PD. METHODS: Patients undergoing PD with biopsy-proved cirrhosis were evaluated. Primary endpoints were morbidity and mortality. Child score, MELD score, and radiographic evidence of portal hypertension (pHTN) were assessed for accuracy in preoperative risk stratification. A systematic review of the literature with meta-analysis was also performed to query morbidity and mortality of patients with cirrhosis reported to undergo PD. RESULTS: Between 2005 and 2015, 36 cirrhotic patients underwent PD; three year follow-up was complete. Median Child score was 6 (range 5-10); median MELD score was 9 (range 7-18). Perioperative (90-day) mortality was 6/36. Median survival was 37 months (range 0.2-116). MELD ≥ 10 was associated with increased mortality (4/13 vs. 2/13, p = 0.004). Irrespective of Child or MELD score, those with pHTN had poor outcomes including significantly greater intraoperative blood loss, increased incidence of major complication, and length of stay. Postoperative mortality was significantly higher with pHTN (3/16 vs. 1/13, p = 0.012). CONCLUSION: Pancreatoduodenectomy may be considered in carefully selected cirrhotic patients. MELD ≥ 10 predicts increased risk of postoperative mortality. Specific attention should be afforded to patients with preoperative radiographic evidence of portal hypertension as this group experiences poor outcomes irrespective of MELD or Child score.

Does cyst growth predict malignancy in branch duct intraductal papillary mucinous neoplasms? Results of a large multicenter experience.

BACKGROUND: Cyst growth of BD-IPMNs on follow-up imaging remains a concerning sign. AIMS: To describe cyst size changes over time in BD-IPMNs, and determine whether cyst growth rate is associated with increased risk of malignancy. METHODS: This is a retrospective study performed at two high volume tertiary centers. Mean cyst size at baseline (MCSB) and mean growth rate percentage (MGRP) were calculated. Rapid cyst growth was defined as MGRP ≥30%/year. Patient and cyst related characteristics were studied. RESULTS: 160 patients were followed for a median of 27.4 (12-114.5) months. MCSB was 15.1 ±â€¯8.0 mm. During follow-up, 73 (45.6%) showed any cyst size increase, of which 15 cysts (9.4%) exhibited MGRP ≥30%/year. Rapid cyst growth was not associated with patient or cyst characteristics. Cyst fluid molecular analysis from 101 cysts showed KRAS mutation in 26. Compared to KRAS-negative cysts, neither MCSB (16.0 mm vs. 17.7 mm; p = 0.3) nor MGRP (3.9%/year vs. 5.8%/year; p = 0.7) was significantly different. Eighteen patients underwent surgery; 15 (83%) had LGD, and 3 had advanced neoplasia. Two cysts with LGD and one cyst with advanced neoplasia had MGRP ≥30%/year. CONCLUSION: Increase in BD-IPMNs size was not associated with the known high risk patient or cyst-related characteristics. Rapid growth of BD-IPMNs was not associated with advanced neoplasia on surgical pathology.

Impact of Fellow Versus Resident Assistance on Outcomes Following Pancreatoduodenectomy.

BACKGROUND: Participation by surgical trainees in complex procedures is key to their development as future practicing surgeons. The impact of surgical fellows versus general surgery resident assistance on outcomes in pancreatoduodenectomy (PD) has not been well studied. The purpose of this study was to determine differences in patient outcomes based on level of surgical trainee. METHODS: Consecutive cases of PD (n = 254) were reviewed at a single high-volume institution over a 2-year period (July 2013-June 2015). Thirty-day outcomes were monitored through the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) and Quality In-Training Initiative. Patient outcomes were compared between PD assisted by general surgery residents versus hepatopancreatobiliary fellows. RESULTS: The hepatopancreatobiliary surgery fellows and general surgery residents participated in 109 and 145 PDs, respectively. The incidence of each individual postoperative complication (renal, infectious, pancreatectomy-specific, and cardiopulmonary), total morbidity, mortality, and failure to rescue were the same between groups. CONCLUSIONS: Patient operative outcomes were the same between fellow- and resident-assisted PD. These results suggest that hepatopancreatobiliary surgery fellows and general surgery residents should be offered the same opportunities to participate in complex general surgery procedures.

Management of Undifferentiated Solitary Mucinous Cystic Lesion of the Pancreas: A Clinical Dilemma.

BACKGROUND: Management of solitary mucinous cystic lesions of the pancreas (MCLs) relies on correct differentiation between branch duct intraductal papillary mucinous neoplasm (BD-IPMN) and mucinous cystic neoplasm (MCN). Current international consensus guidelines recommend resection for MCN, and unifocal BD-IPMN can be followed in the absence of worrisome features/high-risk stigmata. We hypothesized that preoperative differentiation of solitary MCLs is suboptimal, and that all solitary MCLs should be treated similarly. STUDY DESIGN: A retrospective review of an institutional database (2003 to 2016) identified 711 patients who underwent resection for pancreatic cyst. Only lesions that met cytologic or biochemical criteria for diagnosis of MCLs were included. Mucinous cystic neoplasms were defined by presence of ovarian stroma on pathology. Patients with formal preoperative diagnosis of BD-IPMN (multifocality, GNAS mutation) were excluded. RESULTS: One hundred and eighty solitary MCLs were identified on preoperative imaging (mean age 54 years, 24% men). On surgical pathology, 108 were MCNs and 72 BD-IPMNs. There was no difference in invasive rate (7 of 108 [6.5%] MCNs vs 4 of 72 [5.6%] BD-IPMN; p ≈ 1). Pancreatic ductal connectivity was reported on imaging/endoscopy in 10 of 108 (9%) MCNs and 22 of 72 (31%) BD-IPMNs, representing 67% accuracy in differentiating MCNs from BD-IPMNs. On multivariate analysis, typical risk factors failed to predict invasiveness in either MCNs or BD-IPMNs. When all undifferentiated solitary MCLs were analyzed together, older age (p = 0.03) and cyst size (p = 0.04) were associated with increased invasive rate in multivariate analysis. CONCLUSIONS: Unreliable differentiation and limited ability to predict invasiveness make solitary MCLs clinically challenging. With similar invasive rates, MCN and unifocal BD-IPMNs should be merged into one new entity for management, the undifferentiated solitary MCL.

Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients.

BACKGROUND: Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. STUDY DESIGN: From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter ≥5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. RESULTS: Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). CONCLUSIONS: Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.

Alterations in cyst fluid genetics following endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and paclitaxel.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS)-guided ethanol lavage with paclitaxel injection has been shown to be effective for the treatment of pancreatic cystic neoplasms; however, the evidence for effectiveness is based primarily on cyst resolution on imaging. The aim of this study was to evaluate changes in pancreatic cyst fluid DNA following EUS-guided pancreatic cyst ablation (PCA) with ethanol and paclitaxel. PATIENTS AND METHODS: In a single-center, prospective study, patients with suspected benign pancreatic cysts (15 - 50 mm in diameter; ≤ 5 compartments) underwent EUS-PCA with ethanol and paclitaxel followed 3 months later by repeat EUS-FNA, cyst aspiration for repeat DNA analysis, and possible repeat EUS-PCA. Abdominal imaging was repeated 3 - 4 months and 12 months after the second EUS. Changes in baseline pancreatic cyst fluid DNA, procedural complications, and radiographic changes in cyst volume were evaluated. RESULTS: A total of 22 patients (median age 67 years; 15 women) with cysts in the head or uncinate (n = 10), body or neck (n = 8), and tail (n = 4), measuring a median diameter of 25 mm (range 15 - 43 mm), underwent one (n = 22) or two (n = 9) EUS-PCA procedures. Baseline cyst DNA included mutations in 11 patients (50 %). Postablation cyst fluid (n = 19) showed elimination of all baseline mutations in eight patients, new mutations in three, and no changes in eight without a baseline mutation. The largest per-protocol postablation image-defined volume change (n = 20) from either of the follow-up abdominal imaging studies (n = 20) demonstrated complete response ( < 5 % original volume) in 10 patients (50 %), partial response (5 % - 25 % original volume) in 5 (25 %), and a persistent cyst (> 25 % original volume) in 5 (25 %). During a median follow-up of 27 months (range 17 - 42 months), adverse events from all EUS-PCAs (n = 31) included abdominal pain alone in four patients (13 %), pancreatitis in three (10 %), peritonitis in one (3 %), and gastric wall cyst in one (3 %). The adverse events were classified as moderately severe in four patients (three with pancreatitis, one with peritonitis). CONCLUSION: EUS-PCA with ethanol and paclitaxel may possibly eliminate mutant DNA in neoplastic pancreatic cysts. This technique leads to complete or partial image-defined resolution in 75 % of cysts but may lead to rare adverse events. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01643460).

Obesity increases malignant risk in patients with branch-duct intraductal papillary mucinous neoplasm.

BACKGROUND: Obesity is an established risk factor for pancreatic adenocarcinoma. No study has examined specifically the influence of obesity on malignant risk in patients with intraductal papillary mucinous neoplasm (IPMN), a group at substantial risk of pancreatic adenocarcinoma. We hypothesize that obesity is associated with a greater frequency of malignancy in IPMN. METHODS: Data on patients undergoing resection for IPMN between 1992 and 2012 at a high-volume university institution were collected prospectively. Clinicopathologic and demographic parameters were reviewed. Patients were classified according to World Health Organization categories of body mass index (BMI). Malignancy was defined as high-grade dysplastic or invasive IPMN. RESULTS: We collected data on 357 patients who underwent resection for IPMN. Of these, 274 had complete data for calculation of preoperative BMI and 31% had malignant IPMN. Of 254 patients with a BMI of <35 kg/m(2), 30% had malignant IPMN versus 50% in patients with BMI of ≥35 (P = .08). In branch-duct IPMN, patients with a BMI of <35 had 12% of malignant IPMN compared with 46% in severely obese patients (P = .01). Alternatively, in main-duct IPMN, no difference was found in the malignancy rate (48% vs 56%; P = .74). CONCLUSION: These findings suggest that obesity is associated with an increased frequency of malignancy in branch-duct IPMN. Obesity is a potentially modifiable risk factor that may influence oncologic risk stratification, patient counseling, and surveillance strategy.

Radiation dose from computed tomography in patients with necrotizing pancreatitis: how much is too much?

OBJECTIVES: Low-dose ionizing radiation from medical imaging has been indirectly linked with subsequent cancer. Computed tomography (CT) is the gold standard for defining pancreatic necrosis. The primary goal was to identify the frequency and effective radiation dose of CT imaging for patients with necrotizing pancreatitis. METHODS: All patients with necrotizing pancreatitis (2003-2007) were retrospectively analyzed for CT-related radiation exposure. RESULTS: Necrosis was identified in 18% (238/1290) of patients with acute pancreatitis (mean age = 53 years; hospital/ICU length of stay = 23/7 days; mortality = 9%). A median of five CTs/patient [interquartile range (IQR) = 4] were performed during a median 2.6-month interval. The average effective dose was 40 mSv per patient (equivalent to 2,000 chest X-rays; 13.2 years of background radiation; one out of 250 increased risk of fatal cancer). The actual effective dose was 63 mSv considering various scanner technologies. CTs were infrequently (20%) followed by direct intervention (199 interventional radiology, 118 operative, 12 endoscopic) (median = 1; IQR = 2). Magnetic resonance imaging did not have a CT-sparing effect. Mean direct hospital costs increased linearly with CT number (R = 0.7). CONCLUSIONS: The effective radiation dose received by patients with necrotizing pancreatitis is significant. Management changes infrequently follow CT imaging. The ubiquitous use of CT in necrotizing pancreatitis raises substantial public health concerns and mandates a careful reassessment of its utility.

EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study.

BACKGROUND: Surgery for pancreatic cysts is associated with significant morbidity. A pilot study previously demonstrated the safety of EUS-guided ethanol lavage of pancreatic cysts. OBJECTIVE: To determine whether EUS-guided ethanol lavage would decrease pancreatic cyst size more than saline solution lavage. DESIGN: Prospective, multicenter, randomized trial. SETTING: Two tertiary referral hospitals in the United States. PATIENTS: Patients referred for EUS with a 1- to 5-cm unilocular pancreatic cyst were randomized to blinded ethanol or saline solution lavage. Three months later, the cyst diameter was remeasured by EUS, and a second unblinded ethanol lavage was performed. INTERVENTIONS: EUS-guided pancreatic cyst lavage. MAIN OUTCOME MEASUREMENTS: Cyst ablation based on size changes from follow-up EUS, CT, and histology of resected specimens. RESULTS: Of 58 patients randomized, 16 were excluded and 42 underwent initial ethanol (n = 25) or saline solution (n = 17) lavage. Ethanol lavage resulted in a greater mean percentage of decrease in cyst surface area (-42.9; 95% CI, -58.4 to -27.4) compared with saline solution alone (-11.4; 95% CI, -25.0 to 2.2; P = .009). Nineteen (76.0%) of 25 and 14 (82.3%) of 17 patients randomized to ethanol and saline solution, respectively, underwent a second ethanol lavage. A follow-up CT scan demonstrated resolution in 12 (33.3%) of 36 cysts. Histology of 4 resected cysts demonstrated epithelial ablation ranging from 0% (saline solution alone) to 50% to 100% (1 or 2 ethanol lavages). Complication rates were similar in all groups. LIMITATION: Short-term follow-up. CONCLUSIONS: EUS-guided ethanol lavage results in a greater decrease in pancreatic cyst size compared with saline solution lavage with a similar safety profile. Overall CT-defined complete pancreatic cyst ablation was 33.3%.

Proteomic analysis of neuroblastoma subtypes in response to mitogen-activated protein kinase inhibition: profiling multiple targets of cancer kinase signaling.

INTRODUCTION: Survival for high-risk neuroblastoma (NB) remains poor despite aggressive therapy. Novel therapies are vital for improving prognosis. We previously showed differential NB subtype sensitivity to p42/44 mitogen-activated protein kinase (ERK/MAPK) pathway inhibition. In this study, we investigated proteomic changes associated with resistance or sensitivity to MAPK kinase (MEK) inhibition in NB subtypes. MATERIALS AND METHODS: SH-SY5Y (N-type), BE(2)-C (I-type), and SK-N-AS (S-type) were treated with MEK inhibitor U0126 (10 microM) for 1 and 24 h. Proteins were extracted from untreated and treated cells and analyzed for differential expression by two-dimensional polyacrylamide gel electrophoresis (2D-PAGE). Selected polypeptides were extracted from the gel and identified by liquid chromatography-linked tandem mass spectrometry (LC-MS/MS). RESULTS: We identified 15 proteins that were decreased by 2.5-fold between untreated and 1 h treated cells and subsequently up-regulated 5-fold after 24 h drug treatment. N-type NB (MEK-resistant) showed the least altered proteomic profile whereas the I-type (MEK-sensitive) and S-type NB (MEK-intermediate) generated significant protein changes. The majority of proteins identified were induced by stress. CONCLUSIONS: Protein differences exist between MEK inhibitor-treated NB subtypes. Identified polypeptides all have roles in mediating cellular stress. These data suggest that inhibition of the ERK/MAPK in NB subtypes leads to an intracellular stress response. The most resistant NB cell line to MEK inhibitor treatment generated the least protective protein profile, whereas the intermediate and most sensitive NB cells produced the most stress response. These findings suggest stress related protein expression may be targeted in assessing a response to ERK/MAPK therapeutics.

Pancreatic duct strictures are a common cause of recurrent pancreatitis after successful management of pancreatic necrosis.

BACKGROUND: Successful surgical management of pancreatic necrosis can result in structural changes that cause recurrent pancreatitis. The purpose of this study is to review our clinical experience managing recurrent pancreatitis in patients after successful pancreatic debridement. METHODS: We retrospectively reviewed 98 patients with pancreatic necrosis treated by debridement who made a complete recovery at our institution over an 8-year period (January 1995 to January 2003). RESULTS: Fourteen patients (14%) developed recurrent pancreatitis 5 to 39 months (median, 15 months) after recovery. Five patients (36%) had pancreatic pseudocysts and 9 (64%) had radiologic evidence of obstructive pancreatitis. All patients had either a high-grade pancreatic duct stricture (N=7) or complete duct cutoff (N=7), localized to the pancreatic neck (N=10) or proximal pancreatic body (N=4) identified by either endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. Two patients failed endoscopic stent therapy. All patients required re-operative treatment: 6 distal pancreatectomy, 6 pancreatico-jejunostomy Roux-en-Y, and 2 cystojejunostomy Roux-en-Y with no recurrence of pancreatitis after a median follow-up of 22 months. CONCLUSIONS: Recurrent pancreatitis occurs in 14% of patients after successful pancreatic debridement. Pancreatic duct obstruction in the neck or proximal body is the primary etiologic factor. Re-operation directed at alleviating this ductal obstruction by resection or drainage is effective.