Genetics of phenological development and implications for seed yield in lentil.

Understanding phenology, its genetics and agronomic consequences, is critical for crop adaptation. Here we aim to (i) characterize lentil response to photoperiod with a focus on five loci: the lentil ELF3 orthologue Sn, two loci linked to clusters of lentil FT orthologues, and two loci without candidates in chromosomes 2 and 5 (Experiment 1: 36 lines, short and long days in a phytotron), and (ii) establish the phenology-yield relationship (Experiment 2: 25 lines, 11 field environments). A vintage perspective, where we quantify time trends in phenotype over three decades of breeding, links both experiments. Yield increased linearly from older to newer varieties at 29 kg ha-1 year-1 or 1.5% year-1, correlated negatively with flowering time in both winter- and summer-rainfall regimes, and decoupled from biomass in favourable environments. Time to flowering shortened from older to newer varieties at -0.56% year-1 in the field, and -0.42% year-1 (short days) and -0.99% year-1 (long days) in the phytotron. Early-flowering lines of diverse origin carried multiple early alleles for the five loci, indicating that at least some of these loci affect phenology additively. Current germplasm primarily features the early-flowering haplotype for an FTb cluster region, hence the potential to increase phenological diversity with yield implications.

Outcomes of mandible fracture treatment at an academic tertiary hospital: a 5-year analysis.

PURPOSE: To analyze the outcomes of mandible fractures treated using open reduction and internal fixation. PATIENTS AND METHODS: We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded. RESULTS: Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495). CONCLUSIONS: A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.

Does ketorolac have a preemptive analgesic effect? A randomized, double-blind, control study.

PURPOSE: To examine the effect of ketorolac used as preemptive analgesia on the intensity of pain and analgesic requirements in the postoperative period. PATIENTS AND METHODS: The present study was a randomized, double-blind, control study involving human subjects who underwent extraction of the mandibular third molars under intravenous anesthesia. The study group received 30 mg of intravenous ketorolac preoperatively, and the control group received a placebo. The pain intensity was measured using a visual analog scale. The decrease in postoperative pain was measured as the primary outcome variable. The interval to the first dose of analgesic, total analgesic requirements, and the global assessment were measured as secondary outcomes. The data were analyzed using the Student t test, Wilcoxon rank sum test, and χ(2) test. RESULTS: A total of 85 adult subjects, American Society of Anesthesiologists class I and II, participated in the present study. Randomization was effective, as shown by the absence of differences in the study variables between the 2 groups. Of the 85 patients, 29 were men and 56 were women. The average patient age was 22.6 years in the study group and 24 years in the control group. Those in the ketorolac group recorded lower visual analog scale pain scores at all intervals. However, the difference was statistically significant at the 4-hour interval (P = .01). The median interval to the use of rescue medication in the ketorolac group was 9.5 hours compared with 7 hours in the control group. However, no statistically significant difference was found in the interval to the rescue analgesic between the 2 groups (P = .39). No statistically significant difference was noted in the total amount of postoperative analgesics required in the first 72 hours between the 2 groups (P = .54). Also, no difference was seen in the global assessment between the 2 groups (P = .22). CONCLUSIONS: Those who received 30 mg of intravenous ketorolac preoperatively had less pain in the early (8-hour) postoperative period. The median interval to rescue medication was 2 hours longer in the ketorolac group. However, the difference in the total narcotic consumption was clinically and statistically insignificant between the ketorolac and control groups.

Pediatric perioperative measures of sleep, pain, anxiety and anesthesia emergence: A healing touch proof of concept randomized clinical trial.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the impact of healing touch (HT) on sleep, anxiety, anesthesia emergence and pain. METHODS: HT, sham HT, control with an aide (CP) and control groups without the presence of an aide (CNP), underwent polysomnography (PSG) preoperatively. The Yale Preoperative Anxiety Scale (YPAS) score was obtained preoperatively before medications were given and in the preoperative surgery area. Sedation score, anesthesia emergence score and vital signs were recorded. Pain scores were determined by the Observation Pain Assessment Scale (OPAS) postoperatively and at time of discharge. Preoperative laboratory blood was drawn for C-reactive protein (CRP), glucose, cortisol and vitamin D25 levels as indicators of stress and anxiety, and a HT satisfaction survey was given. RESULTS: Thirty-nine patients consented to participate and were randomly assigned to HT (9), HT sham (12), CP (7) and CNP (11) groups. Mean patient age was 13.0 years, and no significant group differences were found for age, sex, race or patient procedure, categorized as laser, burn reconstruction and plastic surgery reconstruction. Additionally, no significant group differences were detected for any of the PSG parameters, YPAS scores, OPAS scores, medications, anesthesia emergence score, bloodwork or satisfaction survey score. CRP, glucose and cortisol levels were higher in the CNP group, suggesting that pediatric patients undergoing elective surgeries may benefit from more pre-operative support, possibly by HT. CONCLUSIONS: Although no tracked parameters showed statistically significant findings, anecdotal HT benefits included enhanced relaxation and sounder sleep.

VEGF expression predicts survival in patients with peritoneal surface metastases from mucinous adenocarcinoma of the appendix and colon.

BACKGROUND: High levels of vascular endothelial growth factor (VEGF) in ovarian cancer metastases are associated with a worse prognosis in patients treated with chemotherapy. VEGF-directed therapy improves survival for those with metastatic colorectal cancer. Patients with mucinous adenocarcinomas metastatic to the peritoneal surfaces can be treated with cytoreductive surgery, and both tumor grade and cytoreduction status are prognostic. We hypothesized that angiogenic indices may be prognostic in patients undergoing cytoreductive surgery for mucinous adenocarcinoma of the appendix and colon. METHODS: Cytoreductive cases from a 5-year period from the University of Cincinnati peritoneal malignancy database were reviewed. CD 34 counts (blood vessels) and VEGF expression was evaluated by means of immunohistochemistry on specimens from patients undergoing cytoreductive surgery and intraperitoneal hyperthermic perfusion (IPHP) for mucinous adenocarcinoma. RESULTS: A total of 26 males and 9 females, with a mean age of 50 years, underwent cytoreductive surgery and IPHP for mucinous adenocarcinoma of appendiceal (n = 32) or colonic (n = 3) origin. With a mean follow-up of 18 months (range 1-63 months), 23 had disease recurrence and 12 were alive without recurrence. The mean survival was 19 months (range 1-63 months). CD34 counts did not correlate with recurrence or survival; however, average VEGF counts correlated with survival (P = 0.017), and, for patients with recurrence, this correlation was stronger (P = 0.002). CONCLUSIONS: These results suggest that markers of tumor angiogenesis may predict survival in patients with peritoneal surface metastases from mucinous adenocarcinoma. These findings provoke the hypothesis that antiangiogenic therapies may be effective in patients with this devastating disease.

Automated phenotyping for early vigour of field pea seedlings in controlled environment by colour imaging technology.

Early vigour of seedlings is a beneficial trait of field pea (Pisum sativum L.) that contributes to weed control, water use efficiency and is likely to contribute to yield under certain environments. Although breeding is considered the most effective approach to improve early vigour of field pea, the absence of a robust and high-throughput phenotyping tool to dissect this complex trait is currently a major obstacle of genetic improvement programs to address this issue. To develop this tool, separate trials on 44 genetically diverse field pea genotypes were conducted in the automated plant phenotyping platform of Plant Phenomics Victoria, Horsham and in the field, respectively. High correlation between estimated plant parameters derived from the automated phenotyping platform and important early vigour traits such as shoot biomass, leaf area and plant height indicated that the derived plant parameters can be used to predict vigour traits in field pea seedlings. Plant growth analysis demonstrated that the "broken-stick" model fitted well with the growth pattern of all field pea genotypes and can be used to determine the linear growth phase. Further analysis suggested that the estimated plant parameters collected at the linear growth phase can effectively differentiate early vigour across field pea genotypes. High correlation between normalised difference vegetation indices captured from the field trial and estimated shoot biomass and top-view area confirmed the consistent performance of early vigour field pea genotypes under controlled and field environments. Overall, our results demonstrated that this robust screening tool is highly applicable and will enable breeding programs to rapidly identify early vigour traits and utilise germplasm to contribute to the genetic improvement of field peas.

Spontaneous Pneumothoraces in Patients with Birt-Hogg-Dubé Syndrome.

RATIONALE: Spontaneous pneumothorax is a common complication of Birt-Hogg-Dubé syndrome (BHD). OBJECTIVES: The optimal approach to treatment and prevention of BHD-associated spontaneous pneumothorax, and to advising patients with BHD regarding risk of pneumothorax associated with air travel, is not well established. METHODS: Patients with BHD were recruited from the Rare Lung Diseases Clinic Network and the BHD Foundation and surveyed about disease manifestations and air travel experiences. RESULTS: A total of 104 patients completed the survey. The average age at diagnosis was 47 years, with an average delay from first symptoms of 13 years. Pulmonary cysts were the most frequent phenotypic manifestation of BHD, present in 85% of patients. Spontaneous pneumothorax was the presenting manifestation that led to the diagnosis of BHD in 65% of patients, typically after the second episode (mean, 2.4 episodes). Seventy-nine (76%) of 104 patients had at least one spontaneous pneumothorax during their lifetime, and 82% had multiple pneumothoraces. Among patients with multiple pneumothoraces, 73% had an ipsilateral recurrence, and 48% had a subsequent contralateral spontaneous pneumothorax following a sentinel event. The mean ages at first and second pneumothoraces were 36.5 years (range, 14-63 yr) and 37 years (range, 20-55 yr), respectively. The average number of spontaneous pneumothoraces experienced by patients with a sentinel pneumothorax was 3.6. Pleurodesis was generally performed after the second (mean, 2.4) ipsilateral pneumothorax and reduced the ipsilateral recurrence rate by half. A total of 11 episodes of spontaneous pneumothorax occurred among eight patients either during or within the 24-hour period following air travel, consistent with an air travel-related pneumothorax rate of 8% per patient and 0.12% per flight. Prior pleurodesis reduced the occurrence of a subsequent flight-related pneumothorax. CONCLUSIONS: Spontaneous pneumothorax is an important, recurrent manifestation of pulmonary involvement in patients with BHD, and pleurodesis should be considered following the initial pneumothorax to reduce the risk of recurrent episodes. In general, in patients with BHD, pneumothorax occurs in about 1-2 per 1,000 flights, and the risk is lower among patients with a history of prior pleurodesis.

Aeromedical Pediatric Burn Transportation: A Six-Year Review.

Aeromedical transportation has been shown to be a safe and efficient mode of transportation for critical care patients, including adult burn patients. Common flight concerns specific to the care of the burn patient are maintenance of intravenous lines and airway access, precision of ongoing fluid resuscitation, and effective treatment of hemodynamic instability. These concerns are particularly crucial when patients are transported by flight teams with limited burn experience. The purpose of this study was to review the safety and outcomes associated with 6 years of aeromedical pediatric burn transportation and to ascertain if differences exist when using a dedicated burn pediatric flight team versus a non-dedicated burn pediatric flight teams. Through a retrospective, IRB approved, chart review from January 2007 to January 2013, all aeromedical admissions were evaluated for demographic data, flight data, complications, and medical interventions. A total of 333 patients were transported by air, of which 282 transfers occurred during the first week of burn injury. In-flight complications occurred in <10% of patients and primarily involved airway and hemodynamic issues. There were no in-flight deaths. Patients transported by alternate teams were noted to be more hypothermic and hypotensive on admission (p < .001). Alternate teams were also noted to transfer older patients, spend less time with initial patient evaluation, and travelled shorter distances (p < .05). Aeromedical transportation of the pediatric burn patient is safe and associated with minimal complications. Communications with the transferring hospitals can facilitate transfer of the pediatric burn patient. When using alternate flight teams, particular attention should focus on resuscitation and maintenance of euthermia with large burn patients.

Factors associated with insulin and narcotic independence after islet autotransplantation in patients with severe chronic pancreatitis.

BACKGROUND: For patients who suffer from severe chronic pancreatitis, total pancreatectomy can alleviate pain, and islet autotransplantation (IAT) might preserve endocrine function and circumvent the complications of diabetes. Factors that determine success after this operation have not been clearly defined. STUDY DESIGN: From 2000 to 2004, 45 total or subtotal pancreatectomies with IAT were performed. Patient characteristics, narcotic usage and insulin requirements were recorded at routine followup. Narcotic usage was standardized by conversion to morphine equivalents (MEs). Univariate and multivariate statistical analyses were performed to determine factors associated with insulin and narcotic independence. RESULTS: Forty-five patients (30 women, 15 men), with a mean age of 39 years (range 16 to 62 years) underwent total or completion (n=41) or subtotal (n=4) pancreatectomies with IAT. Forty percent of patients were insulin free after a mean followup of 18months (range 1 to 46months). Factors associated in univariate analyses with insulin independence included female gender (p=0.004), lower body weight (kg) (p=0.04), more islet equivalents per kg body weight (IEQ/kg) transfused (<0.05), lower mean insulin requirement for the first 24hours postoperation (p=0.002), and lower mean insulin requirement at discharge (p=0.0005). A multiple logistic regression using gender, body mass index, and IEQ/kg identified female gender as the only notable variable associated with insulin independence. There was a notable reduction (p < 0.0001) of postoperative MEs (mean 90 mg) compared with preoperative MEs (mean 206 mg) for the entire cohort; 58% of patients are narcotic independent. In the subset of patients with>5months followup (n=32), 23 (72%) are narcotic free, with a substantial decrease in ME usage (p=0.01). CONCLUSIONS: The likelihood of glycemic control after IAT is related to both patient characteristics and islet cell mass. Based on these data, more islet cells may be required for insulin independence than previously thought.

Clinical safety and efficacy of probiotic administration following burn injury.

Provision of probiotics has been limited postburn by questionable potential for bacterial translocation and risk of infection in an immune-compromised population. The purpose of this study was to evaluate the safety of probiotic administration in acutely burned, pediatric patients. Subjects were randomized to receive probiotic (n = 10) vs placebo (n = 10) twice daily. The investigational product was initiated within 10 days of burn, and daily supplementation continued until wound closure. Nursing staff was provided education regarding optimal procedures to minimize potential for study product cross contamination. Clinical outcomes (infection, antibiotic, antifungal, and operative days, tolerance, and mortality) were recorded. Length of stay was modified for burn size. Student's t-test, χ test, and nonparametric Wilcoxon's rank-sum test were used for comparative analysis. No differences were noted (probiotic; placebo) for age (7.1 ± 2.2; 6.9 ± 1.7), burn size (38.0 ± 5.9; 45.5 ± 4.45), full thickness (24.6 ± 5.6; 32.1 ± 5.4), postburn day admit (0.8 ± 0.4; 1.1 ± 0.4), or inhalation injury (10%; 20%). Infection days, antibiotic use, constipation, and emesis were similar between groups. Trends toward increased antifungal and laxative use as well as diarrhea incidence were evident in the controls (P < .30). Flatulence was statistically higher with probiotics. The control group trended toward higher requirement for excision/graft procedure. Medical length of stay was not significantly different between groups; however, time required to complete wound healing was shortened with probiotics. This study documents safety and provides preliminary efficacy data relative to probiotic supplementation postburn.

Increased biliary fistulas after liver resection with the harmonic scalpel.

The Harmonic Scalpel (HS) is frequently used for hepatic resection. Yet, no current study addresses its utility compared to conventional methods. We reviewed our experience with this device to determine if it decreased perioperative complications when compared to the traditional clamp crushing technique. One hundred forty-nine anatomic hepatic resections were performed at our institution from September 1992 to February 2002. Patients were divided into two groups based on the technique of resection: HS [53% (n = 79)] versus clamp crushing [47% (n = 70)]. Use of the HS was associated with a shorter mean operative time (357 +/- 15.0 vs. 404 +/- 19.1 min; p = 0.05) and a trend toward decreased blood loss (1211 +/- 125.5 vs. 1411 +/- 180.7 mL; P = NS) and transfusion requirements (2.6 +/- 0.5 vs. 1.7 +/- 0.3 units; P = 0.10). However, use of the HS was associated with a significant increase in biliary fistulas [24% (n = 19) vs. 7% (n = 5); P = 0.01]. Use of the Harmonic Scalpel was associated with decreased operative time and a trend toward decreased blood loss and transfusion requirements. Its use was also associated with a significant increase in the incidence of postoperative bile leaks, and, therefore, surgeons must be vigilant during liver parenchymal transection when using this device.

Thrombocytopenia in the pediatric burn patient.

Thrombocytopenia is initially seen in patients with burn injury as a transient occurrence during the first week after injury. Subsequent decreases occur later in the course of treatment and are commonly due to sepsis, dilutional effects, and medication exposure. Although studies have demonstrated that thrombocytopenia in the critically ill patients is associated with a worse prognosis, there is limited literature as to the significance of thrombocytopenia in the pediatric burn patients. In this study, the authors evaluate the prognostic implications of thrombocytopenia in the pediatric burn patients. They performed a 5-year retrospective chart of patients aged 18 years or younger with burns >20% TBSA admitted to their institution. Data collected included patient demographics, burn etiology and %TBSA involvement, length of stay, pertinent laboratory values, and in-hospital morbidity and mortality. Of the 187 patients studied, thrombocytopenia occurred in 112 patients. Eighty-two percent demonstrated thrombocytopenia within the first week of injury and 18% demonstrated additional episodes of thrombocytopenia after this time. A reactive thrombocytosis occurred in 130 (70%) patients. The incidence of thrombocytopenia could not be attributed to age, gender, or burn etiology. However, patients with thrombocytopenia were more likely to have inhalation injury and extensive TBSA involvement than those without (P < .05). Sepsis was the cause of significant thrombocytopenia after the first week of hospitalization. Of the 187 patients, 14 died (7%). The incidence of thrombocytopenia in survivors and nonsurvivors was statistically significant in that nonsurvivors demonstrated a more profound drop in platelet count during the first week after injury and had a more depressed platelet recovery curve than survivors. The authors conclude that the early development of thrombocytopenia with depressed thrombocytosis in the pediatric burn patient is associated with increased mortality risk and is influenced by the extent of burn, inhalation injury, and the development of sepsis.

Psychosocial impact of childhood face burns: a multicenter, prospective, longitudinal study of 390 children and adolescents.

INTRODUCTION: This two-year longitudinal study of the health-related quality of life (HRQoL) of children with face burns was conducted in three regional pediatric burn care centers. Subjects were 390 children less than 18 years old at injury, admitted for burn treatment from September 2001 to December 2004. METHODS: HRQoL was assessed using the age-specific Burn Outcomes Questionnaire (BOQ) administered at scheduled time points following discharge up to 24 months thereafter. A psychosocial score was determined from domains of the BOQ, and these scores from children with both face burns and grafts were compared to those of children with non-face burns or with face burns but no face grafts. RESULTS: The parents of both the 0-4 year olds and the 5-18 year olds, who had facial burns and grafts, reported decreased BOQ psychosocial scores. When the teenagers (11-18 year olds) with facial burns and grafts filled out the BOQ themselves, they also reported low psychosocial scores compared to those with no facial burns with grafts. CONCLUSIONS: Severe face burn influences HRQoL in children. Additional psychosocial support is suggested to enhance recovery for patients with severe face burns and their families during the years following injury.

The impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with hemorrhagic brain injury.

BACKGROUND: More elderly trauma patients are identified with preinjury use of clopidogrel, aspirin, or warfarin (CAW). The purpose of this study was to determine whether preinjury CAW use was an important predictor of mortality in patients aged >or=50 years with blunt, hemorrhagic brain injury (HBI). METHODS: A retrospective review of patients with blunt, HBI aged >or=50 years with subgroup analysis for older (>70 years) and younger (50-70 years) patients was performed. CAW use was analyzed for differences in age, gender, hospital length of stay (LOS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), mechanism of injury (MOI), platelet transfusion therapy (PLT), disposition at discharge, and in-hospital mortality. RESULTS: From January 2003 to October 2005, 416 patients were identified. The mean age was 69+/-1 years. No differences were found for ISS (24 +/- 0.5), GCS (12 +/- 0.2), or LOS (8 +/- 0.4 days). CAW use was present in 40% of patients and significantly higher in older patients. Mortality was not different between older and younger CAW(+) patients, but it significantly increased for older CAW(-) patients. Significant predictors of death included age, ISS, and GCS (P<.02). CONCLUSIONS: Preinjury CAW use in older blunt, HBI patients is not associated with increased mortality. Age was a significant predictor of mortality independent of CAW use.

The relationship of lymph node dissection and colon cancer survival in the Veterans Affairs Central Cancer Registry.

BACKGROUND: The extent of lymphadenectomy in colon cancer may impact potential to cure and accuracy of staging. METHODS: The Veterans Affairs Central Cancer Registry database was queried for TNM stage I-III colon adenocarcinoma patients and yielded 5,823 individuals. The number of lymph nodes examined, number positive, and the positive:examined lymph node ratio were studied with respect to overall survival by using log-rank and Kaplan-Meier analysis. RESULTS: The overall survival (OS) in stage II patients was greater with the higher number of lymph node (LN) examined. For stage II patients, the 5-year OS was 34%, 43%, 47%, and 55% for the lowest to highest quartiles (P = .007). For stage III patients, the 5-year OS was 31%, 27%, 38%, and 53% for the lowest to highest quartiles (not significant overall). OS is greater with an increased number of positive lymph nodes (P < .001). The lymph node ratio was more powerful prognostically with a 5-year OS of 27% for the highest quartile versus 44% for the lowest. CONCLUSIONS: More extensive lymphadenectomy is associated with improved OS in stage II colon cancer patients. The positive:examined LN ratio is more powerful prognostically than the number of nodes examined or LN positivity.

Learning styles vary among general surgery residents: analysis of 12 years of data.

PURPOSE: Understanding the learning styles of individuals may assist in the tailoring of an educational program to optimize learning. General surgery faculty and residents have been characterized previously as having a tendency toward particular learning styles. We seek to understand better the learning styles of general surgery residents and differences that may exist within the population. METHODS: The Kolb Learning Style Inventory was administered yearly to general surgery residents at the University of Cincinnati from 1994 to 2006. This tool allows characterization of learning styles into 4 groups: converging, accommodating, assimilating, and diverging. The converging learning style involves education by actively solving problems. The accommodating learning style uses emotion and interpersonal relationships. The assimilating learning style learns by abstract logic. The diverging learning style learns best by observation. Chi-square analysis and analysis of variance were performed to determine significance. RESULTS: Surveys from 1994 to 2006 (91 residents, 325 responses) were analyzed. The prevalent learning style was converging (185, 57%), followed by assimilating (58, 18%), accommodating (44, 14%), and diverging (38, 12%). At the PGY 1 and 2 levels, male and female residents differed in learning style, with the accommodating learning style being relatively more frequent in women and assimilating learning style more frequent in men (Table 1, p < or = 0.001, chi-square test). Interestingly, learning style did not seem to change with advancing PGY level within the program, which suggests that individual learning styles may be constant throughout residency training. If a resident's learning style changed, it tended to be to converging. In addition, no relation exists between learning style and participation in dedicated basic science training or performance on the ABSIT/SBSE. CONCLUSIONS: Our data suggests that learning style differs between male and female general surgery residents but not with PGY level or ABSIT/SBSE performance. A greater understanding of individual learning styles may allow more refinement and tailoring of surgical programs.

Intraoperative margin re-resection for colorectal liver metastases.

OBJECTIVE: Evaluate recurrence and survival in patients who underwent intraoperative margin re-resection for colorectal cancer liver (CRC) metastases. DESIGN: Retrospective analysis. SETTING: University Hospital, Cincinnati, Ohio. Academic medical center. PARTICIPANTS: Cohort of 118 patients who underwent resection of CRC liver metastases between 1992 and 2004. All patients were divided into 3 groups: resection margin (MOR) less than 1 cm (n = 64), MOR greater than 1 cm (n = 33), and re-resection margin (re-MOR) greater than 1 cm (n = 21). RESULTS: Patients with a margin greater than 1 cm, when compared with re-MOR greater than 1 had decreased incidence of liver and distant recurrence (p < 0.05) as well as improved disease-free survival (39.2 vs 22.9 months, p = 0.023). Differences in overall survival (58.6 vs 44.2 months, p = 0.14) were not significant. CONCLUSION: Intraoperative re-resection is associated with an increased risk of local and distant recurrence, which may be a reflection of both inadequate surgery and underlying tumor biology.

Reduced morbidity following cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion.

BACKGROUND: Cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion (IPHC) are an aggressive treatment for patients with peritoneal based malignancies or those with peritoneal dissemination of select histology. Although promising, this therapeutic regimen has been associated with significant morbidity, long hospital stays, and, in some reports, moderate risk for perioperative mortality. Recent experience suggests that these outcomes may be improved. METHODS: Thirty-three patients underwent cytoreductive surgery and intraperitoneal hyperthermic perfusion during the period of December 1999 to July 2002. All patients underwent resection by a three-surgeon team, followed by IPHC with an open technique. Peritonectomy was performed with the goal of total gross excision of disease. RESULTS: Thirty-five procedures were performed in 33 patients (20 female) with a mean age of 49 years (range, 26-72). Complete cytoreduction was achieved in 22 cases (63%), and in 6 cases (17%) residual disease was <4 mm. There were nine major perioperative complications (27%) and no perioperative deaths. The median hospital stay was 11 days. CONCLUSIONS: These results demonstrate that cytoreductive surgery and IPHC can be performed with morbidity and mortality rates in line with those of other major oncologic operations. Employment of a three-surgeon approach, limited peritonectomy, and an open technique may help to reduce the morbidity from this aggressive treatment. Continued investigation of this promising treatment regimen is warranted.