Does specialized surgical training increase lymph node yield in colon cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

A rare cause of primary hepatic neoplasm: malignant peripheral nerve sheath tumor in the age of modern liver surgery.

Primary malignant peripheral nerve sheath tumor (MPNST) of the liver is rare. Histologic identification of spindle cells from a biopsy specimen and the potential clinical diagnoses are discussed. Potential metastatic and primary spindle cell lesions, as well as their impact on treatment decisions are considered. This was successfully treated with ablation assisted surgical resection and minimal blood loss.

Hepatic cytoreductive surgery for neuroendocrine cancer.

Patients with gut-based metastatic neuroendocrine tumors (NET) often present late in the course of their slowly progressive disease, when cancer has extended beyond the point of reasonable expectation for surgical cure. At this stage of disease, the tumor's overwhelming hormonal production often significantly impairs the patient's quality of life. Unlike patients with other malignancies that might involve a heavy burden of hepatic metastatic disease, many patients with metastatic NET continue to live for a long time despite escalating hormone-related symptoms. This establishes the justification and rationale for cytoreduction, a noncurative surgical intervention that reduces tumor burden and hormonal burden and thereby can significantly increase symptom-free survival in the setting of an often slow but inevitable disease progression.

Current management of common bile duct stones: is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure?

BACKGROUND: Although laparoscopic cholecystectomy (LC) and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of secondary common bile duct (CBD) stones, the use of these modalities as a single-stage procedure remains controversial. The aim of this study is to determine whether LC and intraoperative ERCP as a single procedure has any advantages to LC and either preoperative or postoperative therapeutic ERCP performed in 2 stages. METHODS: A retrospective 5-year review involved all patients undergoing both LC and ERCP for management of CBD stones from January 1997 to December 2001. Patients were categorized into 3 groups: (1) preoperative ERCP, followed by LC (ERCP then LC); (2) LC, followed by postoperative ERCP (LC then ERCP); and (3) LC with intraoperative ERCP as a single procedure (LC/ERCP). RESULTS: Sixty-seven patients were treated for secondary CBD stones. Forty-three patients underwent ERCP then LC, 10 underwent LC then ERCP, and 14 patients underwent LC/ERCP. There were no differences among the groups in terms of patient demographics or overall complication rates. CBD access and stone clearance was achieved in all 67 (100%) patients, with 1 mild ERCP-related complication in the ERCP-then-LC group. Overall complication rates, hospital length of stay, and total hospital charges were not statistically different among the 3 groups. CONCLUSION: Single-stage LC/ERCP provides efficacious therapy for CBD stones and may be beneficial in select patients who may not tolerate a second anesthetic procedure.

Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair?

BACKGROUND: Laparoscopic mesh repair has been advocated as treatment of choice for ventral hernias. The term "ventral hernia" refers to a variety of abdominal wall defects and laparoscopic papers have not reported defect specific analysis. The purpose of this study was to determine any advantages to laparoscopic mesh repair of umbilical hernias. METHODS: A retrospective review (January 1998 to April 2001) was made of patients undergoing umbilical hernia repair. Patients were categorized into three groups: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. Comparative analysis was performed. RESULTS: One-hundred and sixteen umbilical hernia repairs were performed in 112 patients: 30 laparoscopic mesh repairs, 20 open mesh repairs, and 66 open nonmesh repairs. The laparoscopic technique was used for larger defects and took more time with a trend toward fewer postoperative complications and recurrences. CONCLUSIONS: Laparoscopic umbilical hernia repair with mesh presents a reasonable alternative to conventional methods of repair.

Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair?

Recent studies have noted advantages of laparoscopic over open repair of ventral hernias. Because few reports have involved comparison with traditional repair we report a comparison between laparoscopic and open approaches. We retrospectively reviewed the records of patients undergoing ventral hernia repair over a 28-month period. Patients were grouped into three categories: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. There were 295 ventral hernia repairs and there was no difference in age, gender, operative complications, or hospital stay between the groups. Mesh and defect size was greater in the laparoscopic group. The overall postoperative complication rate was greater in the open group with mesh. Yet when specific wound complications were analyzed there was no difference between the groups. Furthermore a death occurred in the laparoscopic group from an unrecognized bowel injury. The recurrence rate was greatest in the open repair without mesh group. Finally hospital cost was greatest in the laparoscopic group and third-party reimbursement was better for the open techniques. We were unable to demonstrate a significant advantage to laparoscopic ventral hernia repair. Although many patients with large fascial defects were well served with this approach it may not be a better option for these patients.

Predictors of occult nodal metastasis in patients with thin melanoma.

HYPOTHESIS: Thin primary lesions are largely responsible for the rapid increase in melanoma incidence, making identification of appropriate candidates for nodal staging in this group critically important. We hypothesized that common clinical variables may accurately estimate the risk of nodal metastasis after wide excision and determine the need for sentinel node biopsy. DESIGN: Review of prospectively acquired data in a large melanoma database. SETTING: A tertiary referral center. PATIENTS: A total of 2211 patients with thin melanoma treated by wide local excision alone were identified in the database between January 1, 1971, and December 31, 2005. Of those, 1732 met entry criteria. MAIN OUTCOME MEASURES: We examined the rate of regional nodal recurrence and the impact of clinical and demographic variables by univariate and multivariate analyses. RESULTS: The overall nodal recurrence rate was 2.9%; median time to recurrence was 38.3 months. Univariate analysis of 1732 patients identified male sex (P < .001), increased Breslow thickness (P < .001), and increased Clark level (P < .001) as significant for nodal recurrence. Multivariate analysis identified male sex (hazard ratio, 3.5; 95% confidence interval, 1.8-7.0; P < .001), younger age (0.45; 0.24-0.86; P = .001), and increased Breslow thickness (2.5; 1.6-3.7; categorical P < .001) as significant for nodal recurrence. The Clark level was no longer significant (P = .63). Breslow thickness, age, and sex were used to develop a scoring system and nomogram for the risk of nodal involvement. Predictions ranged from 0.1% in the lowest-risk group to 17.4% in the highest-risk group. CONCLUSIONS: Many patients with thin melanoma will have nodal recurrence after wide excision alone. Three simple clinical variables may be used to estimate recurrence risk and select patients for sentinel node biopsy.

Importance of sentinel lymph node biopsy in patients with thin melanoma.

HYPOTHESIS: The status of the sentinel node (SN) confers important prognostic information for patients with thin melanoma. DESIGN, SETTING, AND PATIENTS: We queried our melanoma database to identify patients undergoing sentinel lymph node biopsy for thin (< or =1.00-mm) cutaneous melanoma at a tertiary care cancer institute. Slides of tumor-positive SNs were reviewed by a melanoma pathologist to confirm nodal status and intranodal tumor burden, defined as isolated tumor cells, micrometastasis, or macrometastasis (< or =0.20, 0.21-2.00, or >2.00 mm, respectively). Nodal status was correlated with patient age and primary tumor depth (< or = 0.25, 0.26-0.50, 0.51-0.75, or 0.76-1.00 mm). Survival was determined by log-rank test. MAIN OUTCOME MEASURES: Disease-free and melanoma-specific survival. RESULTS: Of 1592 patients who underwent sentinel lymph node biopsy from 1991 to 2004, 631 (40%) had thin melanomas; 31 of the 631 patients (5%) had a tumor-positive SN. At a median follow-up of 57 months for the 631 patients, the mean (SD) 10-year rate of disease-free survival was 96% (1%) vs 54% (10%) for patients with tumor-negative vs tumor-positive SNs, respectively (P < .001); the mean (SD) 10-year rate of melanoma-specific survival was 98% (1%) vs 83% (8%), respectively (P < .001). Tumor-positive SNs were more common in patients aged 50 years and younger (P = .04). The SN status maintained importance on multivariate analysis for both disease-free survival (P < .001) and melanoma-specific survival (P < .001). CONCLUSIONS: The status of the SN is significantly linked to survival in patients with thin melanoma. Therefore, sentinel lymph node biopsy should be considered to obtain complete prognostic information.

Management of T2 gallbladder cancer: are practice patterns consistent with national recommendations?

BACKGROUND: The national recommendation for the management of localized T2 gallbladder cancer (GBCA) is radical cholecystectomy. Although reported survival for localized T2 disease has been poor, groups have documented improvement with radical resection. We hypothesized that a discrepancy exists between national recommendations and current practice patterns. METHODS: Patients diagnosed with localized T2 GBCA between 1988 and 2002 were identified from the Surveillance, Epidemiology, and End Results registry. Age, sex, race, ethnicity, extent of surgery, and overall survival were assessed. Surgical procedure was categorized as cholecystectomy alone (CS), cholecystectomy plus lymph node dissection (CS+LN), radical cholecystectomy (RCS), or other. Survival calculations were made using the Kaplan-Meier method and compared with the log-rank test. RESULTS: Of 382 patients with pathologically confirmed T2 GBCA, 280 were women. The median patient age was 75 years. A total of 238 patients underwent CS, 76 underwent CS+LN, and 14 underwent RCS. The remaining 54 patients underwent a lesser or no procedure and were excluded from comparative analysis. The median survival was 14 months for all patients and 14, 14, and 8 months for subgroups treated with CS, CS+LN, and RCS, respectively. Rates of 5-year survival were 23%, 24%, and 36% for CS, CS+LN, and RCS subgroups, respectively. There was no significant difference in survival rates between RCS and CS+LN, or between RCS and CS. CONCLUSIONS: The majority of patients with T2 GBCA in the United States are not managed according to current national recommendations.

ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.

BACKGROUND: ERCP by means of long-limb Roux-en-Y surgical anastomoses has been reported primarily in patients with biliary or pancreatic anastamoses, but rarely in patients with an intact papilla. METHODS: All ERCP procedures attempted over a 6-year interval in patients with Roux-en-Y gastrojejunostomies and an intact papilla were reviewed. Patients with a prior Billroth II operation or alteration of the major papilla were excluded. Cannulation and therapy were primarily performed with a duodenoscope after exploration and placement of a guidewire in the afferent limb with a forward-viewing colonoscope. In some cases the duodenoscope was pulled into the afferent limb with a wire-guided balloon passed retrograde into the afferent limb. A follow-up of 30 days was obtained for all patients as part of a prospective ERCP outcome study. RESULTS: Of 15 patients in whom ERCP was attempted, the papilla was reached in 10 patients (67%), the bile duct being accessed in all 10. Needle-knife precut papillotomy after placement of a pancreatic duct stent was performed in 3 patients. Biliary sphincterotomy with a variety of techniques was successful in all 9 patients in whom it was attempted. Other maneuvers included stone extraction, sphincter of Oddi manometry, and biliary stent placement. Final diagnoses were sphincter of Oddi dysfunction (6), malignant biliary stricture (2), choledocholithiasis plus tumor (1), and choledocholithiasis (1). Complications occurred after 3 (12%) of 25 ERCP procedures including pancreatitis (1 mild, 1 moderate) and bleeding (1 mild), all in patients with sphincter of Oddi dysfunction. CONCLUSIONS: Diagnostic and therapeutic ERCP was ultimately successful in two thirds of patients with long-limb gastrojejunostomies and an intact papilla. The success of the ERCP is determined primarily by ability to advance a duodenoscope through the afferent limb. Once the major papilla was accessed with a duodenoscope, advanced biliary and pancreatic therapeutic techniques were feasible.