Early experience with focused telemedicine implementation in an academic colorectal surgery practice.

BACKGROUND: The need to continue providing care to patients during the corona virus disease 2019 pandemic facilitated telemedicine's rapid adoption, including in surgical clinic settings. Our purpose was to evaluate integration of telemedicine into an academic colorectal surgery practice and assess physician experiences providing telemedicine care. METHODS: Patients seen in colorectal surgery clinic by telemedicine and in person from March 31, 2020 to August 31, 2020 were evaluated. Demographic and clinical outcomes were assessed for patients. Physician responses to a survey were collected. RESULTS: Two hundred and thirty-one telemedicine visits were performed by 4 physicians, comprising 20% of visits during the study period. Patients were 47.6% male and 90.9% Caucasian. In addition, 85.7% were established patients and 21.2% were postoperative visits. Diagnoses evaluated by telemedicine included benign and malignant anorectal and colorectal disease as well as inflammatory bowel disease. All providers reported being able to provide adequate care via telemedicine and were planning to continue providing telemedicine. Patients seen via telemedicine were more likely to be Caucasian and less likely to be African American (P < .001) and more likely to be established patients than those seen in person (P < .001). CONCLUSION: During the COVID-19 pandemic, telemedicine was most successfully used to facilitate care for established patients, particularly the long-term care of colorectal cancer and inflammatory bowel disease. We identified significant differences in ethnicity between patients seen via telemedicine and those seen in person. Telemedicine represents an exciting advancement in patient care, although ongoing study is required regarding providing access to this technology to all colorectal surgery patients, particularly minority populations.

Questioning Aid for Rich, Real-Time Discussion (QARRD): A Tool to Improve Critical Thinking in Clinical Settings.

Introduction: Critical thinking skills are crucial for health professionals, especially in clinical settings. However, most health professions educators engage learners with only lower-level concepts such as definitions, fact recall, or basic explanations. Employing strategic questioning methods that require learners to use higher-order thinking can help develop clinical reasoning skills. Methods: The Questioning Aid for Rich, Real-time Discussion (QARRD) was created for health professions educators to purposefully implement concepts from Bloom's taxonomy and hierarchical questioning in clinical settings. The tool was introduced to faculty in a 1-hour, interprofessional workshop that described learning science and evidence-based questioning methods. Participants practiced QARRD questioning strategies and completed a pre/post case-based evaluation in which they developed discussion prompts for learners. Results: Thirty-seven educators participated in two separate workshops. The majority (71%) of preworkshop prompts were lower-order thinking skills (remembering/understanding). After the workshop, the complexity of participants' discussion prompts increased significantly. Most postworkshop prompts (69%) reflected higher-level thinking skills (apply/analyze/evaluate/create). Many participants reported that, despite previously knowing about Bloom's taxonomy, they had not known how to implement this learning framework in clinical instruction until completing the QARRD training. Discussion: The QARRD is a versatile, practical tool for health professions educators to practice promoting higher-level thinking in clinical settings. QARRD strategies allow educators to make small, purposeful adjustments to instructional methods that meaningfully engage learners to help facilitate clinical reasoning. This workshop can be delivered at other institutions and adapted as a virtual grand rounds to broadly enhance strategic questioning in clinical education.

Gastric Electrical Stimulators Causing Erosion Through the Colonic Wall.

Gastroparesis is a chronic motor disorder of the stomach characterized by the demonstration of delayed gastric emptying without obstruction and a grouping of symptoms including nausea, vomiting, early satiety, postprandial fullness, bloating and abdominal pain. When conservative medical management is not effective, gastric electrical stimulation is an effective alternative. Gastric electrical stimulation, in general, has had a low complication rate as of yet, with the most common being infection of the implanted device. We present a complication in which the gastric electrical stimulator electrodes eroded through the colonic wall.

Preoperative Opioid Prescription Is Associated With Major Complications in Patients With Crohn's Disease Undergoing Elective Ileocolic Resection.

BACKGROUND: Opioid use has grown exponentially over the last decade. The effect of preoperative opioid prescription in patients with Crohn's disease undergoing surgery is unknown. OBJECTIVE: The purpose of this study was to identify whether preoperative opioid prescription is associated with adverse postoperative outcomes in Crohn's disease. DESIGN: This is a single-institution retrospective observational study. SETTINGS: This study was performed at an academic tertiary care center. Details of preoperative opioid prescription were collected from the Kentucky All-Schedule Prescription Electronic Reporting database and the electronic databases of bordering states. PATIENTS: Consecutive patients undergoing ileocolic resection for Crohn's disease from 2014 to 2018 were included. MAIN OUTCOME MEASURES: The outcomes examined were major complications (Clavien-Dindo ≥3a), length of stay, and 30-day hospital readmission. RESULTS: Fifty one of 118 patients were prescribed opioids within 6 months preoperatively (range, 0-33,760 morphine milligram equivalents). Patients with preoperative opioid prescription compared with no preoperative opioid prescription required more daily opioids during hospital admission (p = 0.024). Nineteen patients had a major postoperative complication (preoperative opioid prescription: 26% (13/51) vs no preoperative opioid prescription: 9% (6/67)). On multivariable analysis, preoperative opioid prescription (OR = 2.994 (95% CI, 1.024-8.751); p = 0.045) was a significant risk factor for a major complication. Preoperative opioid prescription was associated with increased length of stay (p < 0.001) and was a risk factor for readmission (OR = 2.978 (95% CI, 1.075-8.246); p = 0.036). Twenty-four patients were readmitted. Using a cutoff for higher opioid prescription of 300 morphine milligram equivalents within 6 months preoperation (eg, 60 tablets of hydrocodone/acetaminophen 5/325), preoperative opioid prescription remained a risk factor for major postoperative complications (OR = 3.148 (95% CI, 1.110-8.928); p = 0.031). LIMITATIONS: This was a retrospective study and could not assess nonprescribed opioid use. CONCLUSIONS: Preoperative opioid prescription was a significant risk factor for adverse outcomes in patients with Crohn's disease undergoing elective ileocolic resection. See Video Abstract at http://links.lww.com/DCR/B113. LA PRESCRIPCIÓN PREOPERATORIA DE OPIOIDES SE ASOCIA CON COMPLICACIONES MAYORES EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIÓN ILEOCÓLICA ELECTIVA: El uso de opioides ha crecido exponencialmente en la última década. Se desconoce el efecto de la prescripción preoperatoria de opioides en pacientes con enfermedad de Crohn sometidos a cirugía.Identificar si la prescripción preoperatoria de opioides está asociada con resultados postoperatorios adversos en la enfermedad de Crohn.Este es un estudio observacional retrospectivo de una sola institución.Este estudio se realizó en un centro académico de atención terciaria. Los detalles de la prescripción preoperatoria de opiáceos se recopilaron de la base de datos de "Kentucky All-Schedule Prescription Electronic Reporting" y de las bases de datos electrónicas de los estados fronterizos.Pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre 2014-2018.Los resultados examinados fueron complicaciones mayores (Clavien-Dindo ≥3a), duración de la estancia y el reingreso hospitalario de 30 días.A cincuenta y uno de 118 pacientes se le recetaron opioides dentro de los 6 meses preoperatorios (rango, 0 a 33,760 equivalentes de miligramos de morfina). Los pacientes con prescripción preoperatoria de opioides en comparación con ninguna prescripción preoperatoria de opioides requirieron más opioides diarios durante el ingreso hospitalario (p = 0,024). Diecinueve pacientes tuvieron una complicación postoperatoria importante (prescripción preoperatoria de opioides: 26% [13/51] frente a ninguna prescripción preoperatoria de opioides: 9% [6/67]). En el análisis multivariable, la prescripción de opioides preoperatorios (OR = 2.994, IC 95%: 1.024-8.751, p = 0.045) fueron factores de riesgo significativos para una complicación mayor. La prescripción preoperatoria de opioides se asoció con un aumento de la duración de la estadía (p <0.001) y fue un factor de riesgo para el reingreso (OR = 2.978, IC 95%: 1.075-8.246, p = 0.036). Veinticuatro pacientes fueron readmitidos. Utilizando un límite para una mayor prescripción de opioides de 300 miligramos equivalentes de morfina dentro de los 6 meses previos a la operación (p. Ej., 60 tabletas de hidrocodona / acetaminofén 5/325), la prescripción preoperatoria de opioides siguió siendo un factor de riesgo para complicaciones postoperatorias mayores (OR = 3.148 IC 95%: 1.110-8.928, p = 0.031).Este fue un estudio retrospectivo y no pudo evaluar el uso de opioides no prescritos.La prescripción preoperatoria de opioides fue un factor de riesgo significativo para los resultados adversos en pacientes con enfermedad de Crohn sometidos a resección ileocólica electiva. Consulte Video Resumen en http://links.lww.com/DCR/B113.

Drug-induced expression of EpCAM contributes to therapy resistance in esophageal adenocarcinoma.

BACKGROUND: With a less than 5% overall survival rate, esophageal adenocarcinoma (EAC) is one of the leading causes of death in the United States. Epithelial cell adhesion molecule (EpCAM) is a cancer stem cell (CSC) marker that is expressed in various epithelial carcinomas, including EAC. Accumulating evidence indicates that CSC subpopulations can initiate cancer development and, in addition, drive metastasis, recurrence and drug resistance. It has also been reported that EpCAM up-regulation in EAC may lead to an aggressive behavior and, thus, an adverse clinical outcome. Here, we aimed to determine whether treatment with standard chemotherapeutic agents may induce EpCAM expression and, concomitantly, increases in malignant potential and drug resistance in EAC. METHODS: EpCAM expression was assessed in 20 primary human EAC/adjacent normal tissues, as well as in a human EAC-derived cell line (OE-19), in a pre-malignant Barrett's Esophagus cell line (Bar-T) and in a benign esophageal cell line (HET 1-A), using immunohistochemistry, Western blotting and qRT-PCR, respectively. Drug-induced resistance was investigated in OE-19-derived spheres treated with (a combination of) adriamycin, cisplatin and 5-fluorouracil (ACF) using survival, adhesion and flow cytometric assays, respectively, and compared to drug resistance induced by standard chemotherapeutic agents (CTA). Finally, ACF treatment-surviving cells were evaluated for their tumor forming capacities both in vitro and in vivo using spheroid formation and xenograft assays, respectively. RESULTS: High EpCAM expression was observed in esophageal cancer tissues and esophageal cancer-derived cell lines, but not in adjacent benign esophageal epithelia and benign esophageal cell lines (HET 1-A and Bar-T). The OE-19 cell spheres were drug resistant and EpCAM expression was significantly induced in the OE-19 cell spheres compared to the non-sphere OE-19 cells. When OE-19 cell spheres were challenged with ACF, the EpCAM mRNA and protein levels were further up-regulated up to 48 h, whereas a decreased EpCAM expression was observed at 72 h. EpCAM down-regulation by RNA interference increased the ACF efficacy to kill OE-19 cells. Increased EpCAM expression coincided with the CSC marker CD90 and was associated with an aggressive growth pattern of OE-19 cell spheres in vivo. CONCLUSIONS: From our data we conclude that an ACF-induced increase in EpCAM expression reflects the selection of a CSC subpopulation that underlies tumor development and drug resistance in EAC.

Exposure to bile acids alters the intracellular location and function of MnSOD in Barrett's esophagus.

BACKGROUND: Oxidative stress secondary to bile-acid exposure has been associated with metaplastic degeneration of normal esophageal mucosa into Barrett's esophagus (BE) cells and eventually esophageal adenocarcinoma. We previously reported that the macromolecular response of BE cells to this stress was largely regulated by the expression of manganese-dependent mitochondrial superoxide dismutase (MnSOD). As the mitochondrion plays a vital role in MnSOD activation, this study sought to determine the location and activity of MnSOD within BE cells after exposure to oxidative stress. METHODS: A human BE cell line, BAR-T cell, was exposed 0.4 mM concentrations of taurocholic acid (Tau) or a 0.4 mM 1:1 mixture of bile salts for 4 h. Cell viability was performed with 3-(4, 5-dimthyl-thiazol-2-yl)-2, 5-diphenyltetrazolium bromide assays. Proteins were extracted and separated into mitochondrial, nuclear, and cytoplasmic fractions followed by analysis by a western blot and enzymatic activities. RESULTS: BAR-T cell showed resistance to the bile-salt insults. Expression of MnSOD was significantly increased in the cells exposed to a mixture of bile acids and Tau versus control. Mitochondria MnSOD is abundant and highly active. Nuclear fraction displayed presence of both MnSOD and Cu/zinc superoxide dismutase secondary to bile-acid exposure; however, the MnSOD was inactive in nuclear fraction. CONCLUSIONS: This is the first study to specifically evaluate cellular fraction MnSOD expression, increased in BE cells in response to the oxidative stress of bile exposure. Mitochondrial MnSOD contributes to resistance of BAR-T cells to the bile-salt insults. Further investigation is required to determine the potential correlation between bile exposure and BE to adenocarcinoma progression via MnSOD-mediated cell signaling.

Multiquadrant robotic colorectal surgery: the da Vinci Xi vs Si comparison.

The newly introduced da Vinci Xi Surgical System hopes to address the shortcomings of its predecessor, specifically robotic arm restrictions and difficulty working in multiple quadrants. We compare the two robot platforms in multiquadrant surgery at a major colorectal referral center. Forty-four patients in the da Vinci Si group and 26 patients in the Xi group underwent sigmoidectomy or low anterior resection between 2014 and 2016. Patient demographics, operative variables, and postoperative outcomes were compared using descriptive statistics. Both groups were similar in age, sex, BMI, pelvic surgeries, and ASA class. Splenic flexure was mobilized in more (p = 0.045) da Vinci Xi cases compared to da Vinci Si both for sigmoidectomy (50 vs 15.4%) and low anterior resection (60 vs 29%). There was no significant difference in operative time (219.9 vs 224.7 min; p = 0.640), blood loss (170.0 vs 188.1 mL; p = 0.289), length of stay (5.7 vs 6 days; p = 0.851), or overall complications (26.9 vs 22.7%; p = 0.692) between the da Vinci Xi and Si groups, respectively. Single-dock multiquadrant robotic surgery, measured by splenic flexure mobilization with concomitant pelvic dissection, was more frequently performed using the da Vinci Xi platform with no increase in operative time, bleeding, or postoperative complications. The new platform provides surgeons an easier alternative to the da Vinci Si dual docking or combined robotic/laparoscopic multiquadrant surgery.

Squamous Cell Carcinoma Originating from a Crohn's Enterocutaneous Fistula.

Purpose. Squamous cell carcinoma (SCC) developing within fistulae and chronic wounds in patients with Crohn's disease is a rare phenomenon with few reported studies in the literature. Clinical suspicion for SCC in Crohn's disease patients with chronic painful fistulae is low, leading to delayed diagnosis and treatment. We present a patient with long-standing Crohn's disease complicated by malignant degeneration of an enterocutaneous fistula tract. Methods. Workup with MRI, CT, and fistulogram revealed a 7 × 3 cm fistulous connection between a loop of small intestine and the patient's perineum. Biopsies of the fistula tract confirmed the diagnosis of SCC. Results. The patient underwent an abdominoperineal resection with positive margins and is currently awaiting radiation therapy. Conclusions. This is the second case reported within the English literature of SCC arising from an enterocutaneous fistula in the setting of Crohn's disease. Based on the findings in this case report and others presented in the literature, a high degree of suspicion of malignancy should be present in patients with chronic painful, poor-healing fistulae, especially in the absence of infection.

A Highly Predictive Model for Diagnosis of Colorectal Neoplasms Using Plasma MicroRNA: Improving Specificity and Sensitivity.

OBJECTIVE: To develop a plasma-based microRNA (miRNA) diagnostic assay specific for colorectal neoplasms, building upon our prior work. BACKGROUND: Colorectal neoplasms [colorectal cancer (CRC) and colorectal advanced adenoma (CAA)] frequently develop in individuals at ages when other common cancers also occur. Current screening methods lack sensitivity, specificity, and have poor patient compliance. METHODS: Plasma was screened for 380 miRNAs using microfluidic array technology from a "Training" cohort of 60 patients, (10 each) control, CRC, CAA, breast cancer, pancreatic cancer, and lung cancer. We identified uniquely dysregulated miRNAs specific for colorectal neoplasia (P < 0.05, false discovery rate: 5%, adjusted α = 0.0038). These miRNAs were evaluated using single assays in a "Test" cohort of 120 patients. A mathematical model was developed to predict blinded sample identity in a 150 patient "Validation" cohort using repeat-sub-sampling validation of the testing dataset with 1000 iterations each to assess model detection accuracy. RESULTS: Seven miRNAs (miR-21, miR-29c, miR-122, miR-192, miR-346, miR-372, and miR-374a) were selected based upon P value, area under the curve (AUC), fold change, and biological plausibility. Area under the curve (±95% confidence interval) for "Test" cohort comparisons were 0.91 (0.85-0.96) between all neoplasia and controls, 0.79 (0.70-0.88) between colorectal neoplasia and other cancers, and 0.98 (0.96-1.0) between CRC and colorectal adenomas. In our "Validation" cohort, our mathematical model predicted blinded sample identity with 69% to 77% accuracy, 67% to 76% accuracy, and 86% to 90% accuracy for each comparison, respectively. CONCLUSIONS: Our plasma miRNA assay and prediction model differentiate colorectal neoplasia from patients with other neoplasms and from controls with higher sensitivity and specificity compared with current clinical standards.

Epithelial cell adhesion molecule in human hepatocellular carcinoma cell lines: a target of chemoresistence.

BACKGROUND: The low survival rate of hepatocellular carcinoma (HCC) is partly attributable to its resistance to existing chemotherapeutic agents. Until now, there have been limited chemotherapeutic agents for liver cancer. Epithelial cell adhesion molecule (EpCAM) has been found to be over-expressed during stages of carcinogenesis and has been associated with poor overall survival in many cancers. The aim of this study was to evaluate EpCAM expression in HCC and evaluate the effects of EpCAM to established chemotherapy. METHODS: Three human hepatocellular carcinoma cell lines--HepG2, Hep3B and HuH-7--were pre- and post-treated with doxorubicin, 5-fluorouracil (5-FU) and cisplatin. Cell viability and EpCAM protein expression were measured by MTT assay and Western Blotting respectively. EpCAM positive cells were analyzed by flow cytometry. To evaluate the effects of doxorubicin efficacy on EpCAM positive cells, a small interfering RNA (siRNA) specific to EpCAM was transfected into the cells and treated with doxorubicin. RESULTS: EpCAM was significantly down-regulated by doxorubicin treatment in all three HCC cell lines (P <0.05 or 0.01). EpCAM expression was down-regulated by the 5-FU and cisplatin in HepG2 cells, however the EpCAM expression was up-regulated by 5-FU and cisplatin in Hep3B cell line. EpCAM expression was down-regulated by 5-FU, and up-regulated by cisplatin in Huh-7 cell line. Flow cytometry assay showed doxorubicin exposure decreased EpCAM positive cell quantities in three HCC cell lines. EpCAM siRNA knock-down attenuated cell mortality after doxorubicin exposure. CONCLUSION: All of these findings demonstrate that EpCAM is one of targets of chemoresistence.

Prognostic factors in melanoma patients with tumor-negative sentinel lymph nodes.

BACKGROUND: Sentinel lymph node (SLN) biopsy for melanoma results in accurate nodal staging, which guides treatment decisions. Patients with a negative SLN biopsy in general have a favorable prognosis, but certain subsets are at increased risk for recurrence and death. This study aimed to identify risk factors predictive of prognosis in patients with a tumor-negative SLN biopsy for cutaneous melanoma. METHODS: In this post-hoc analysis of data from a multicenter prospective randomized trial, clinicopathologic data of patients with cutaneous melanoma ≥1.0 mm Breslow thickness and tumor-negative SLN were analyzed. Disease-free survival, overall survival (OS), and local and in-transit recurrence-free survival were compared by Kaplan-Meier analysis. Risk factors for worse survival were identified with Cox proportional hazard models. RESULTS: This analysis included 1,998 patients with tumor-negative SLN with a median follow-up of 70 months. Ulceration, Breslow thickness, nonextremity tumor location, and age ≥45 years were independent risk factors for worse disease-free survival and OS. Breslow thickness and ulceration were the only factors on multivariate analysis that predicted local and in-transit recurrence-free survival. Estimated 5-year OS rates ranged from 55.5 to 95.4% on the basis of the defined risk factors. CONCLUSION: There is a wide range of prognosis among patients with tumor-negative SLN. Breslow thickness, ulceration, age, and anatomic location of the primary melanoma are important independent factors predicting survival and recurrence among such patients. These factors can be used to stratify prognosis among patients with tumor-negative SLN to formulate rational long-term follow-up strategies as well as identify high-risk, SLN-negative patients for clinical trials of adjuvant therapy.

Esophageal anastomotic leak does not affect ability to receive adjuvant treatment.

BACKGROUND: Esophageal anastomotic leak is associated with high morbidity and mortality and potentially lethal if not recognized promptly and treated aggressively. While many studies have attempted to delineate the surgical techniques associated with lower rates of anastomotic leak, few have attempted to determine its long term effects on adjuvant therapy and patient quality of life. METHODS: We reviewed our prospective 350 patient esophageal-gastric database and found 194 esophageal anastomoses performed from 1994 to 2013. Leaks were classified based on timing, severity, and location. We then compared their postoperative courses of adjuvant treatment, morbidity/mortality, and quality of life measured by Karnofsky performance status and EORTC score. Statistical correlations were calculated with χ(2) , T-test, Kaplain-Meier, ANOVA, and Cox Regression analyses as appropriate. RESULTS: Of 194 patients receiving esophageal anastomoses for cancer, 35 (18%) developed clinically diagnosed anastomotic leak 27 from esophagogastric and 8 from esophagojejunal. These groups were similar in preoperative history, preoperative staging, and type of tumor. Type of operation and variations in operative technique did not significantly affect leak rate. Patients with a leak were more likely to require intraoperative transfusion (47.1% vs. 24.1%, P = 0.013). As expected, they had a greater prevalence of perioperative complications to include pneumonia (38.6% vs. 16.3%, P = 0.001), pulmonary embolus (11.3% vs. 4.3%, P = 0.043), ileus (11.4% vs. 1.6%, P = 0.006%), empyema (11.4% vs. 0%, P > 0.001), and catheter related blood stream infections (8.6% vs. 0%, P = 0.001). Despite this increase in perioperative morbidity, there was no statistically significant difference in 90 day peri-operative mortality (2.8% vs. 2.3%) with similar ability to receive adjuvant therapy (38.6% vs. 48.0%, P = 0.303), quality of life scores (93.2 vs. 93.1, P = 0.9), and survival at 12 months (93% vs. 94%, P = 0.3). CONCLUSION: Anastomotic leak after oncologic resection does not preclude adjuvant therapy and, when managed appropriately, does not affect long term performance status or survival.

Caudate lobe resections: a single-center experience and evaluation of factors predictive of outcomes.

BACKGROUND: Despite the increasing frequency of liver resection for multiple types of disease, caudate lobe resection remains a rare surgical event. The goal of this study is to review our experience and evaluate possible predictors of adverse outcomes in patients undergoing caudate lobectomy. METHODS: We reviewed a 1,900-patient prospective hepato-pancreatico-biliary database from January 2000 to December 2011, identifying 36 hepatectomy patients undergoing caudate lobe resection. Clinicopathologic characteristic and outcome data were compared using chi-square, T-test, ANOVA, Kaplan-Meier, and Cox regression analysis. Primary endpoints were the incidence and severity of complications, and secondary endpoints were blood loss, hospital stay, and transfusion requirements. Patients were also divided in two groups with group A being patients operated on before December 2007 and group B after 2007. We compared the demographics, risk factors, complication rates, and operative details between the two groups. RESULTS: Thirty-six patients underwent caudate lobe resection for cholangiocarcinoma (47.2%), metastatic colorectal cancer (36.1%), hepatocellular carcinoma (8.3%), or benign disease (8.3%). Nine patients (29%) had additional liver resection. Median overall survival (OS) was 21 months. Complications occurred in 52.7% (19/36) of patients with a median grade of 2. Tobacco abuse was associated with an increased risk of operative complications (73.3% vs. 38.9%, p = 0.03). Prior history of cardiac disease was associated with a higher complication rate (87% vs. 42%, p = 0.03). Neoadjuvant chemotherapy, biliary procedures, hepatitis, and prior major abdominal surgery were not predictive of complications. Major complication was also predicted by the volume of RBC transfusion (2.7 vs. 4.1 units, p = 0.003). In our subgroup analysis of the patients undergoing surgery before and after 2007, the two groups were well matched based on age, comorbidities, and risk factors. The complication rates and rates of high-grade complications were similar, but blood loss (600 ml vs. 400 ml, p = 0.03), inflow occlusion time (Pringle time 12.6 vs. 6, p = 0.00), and hospital stay (9.5 vs. 7 days, p = 0.01) were significantly lower in group B. CONCLUSIONS: With appropriate patient selection, caudate lobe resection is an effective component of surgery for hepatic disease. Tobacco use and prior cardiac history increase the risk of complications.

The impact of colorectal cancer screening in a veteran hospital population.

Colon and rectal cancer is the second most common cause of cancer death in the United States. Screening effectively decreases colorectal cancer mortality. This study aims to evaluate the impact of colorectal cancer screening within a Veterans Affairs Medical Center and treatment outcomes. Institutional Review Board approval was obtained for a retrospective analysis of all colorectal cancer cases that were identified through the Tumor Registry of the Robley Rex VA Medical Center from 2000 to 2009. Data collected included age at diagnosis, race, risk factors, diagnosis by screening versus symptomatic evaluation, screening test, tumor location and stage, operation performed, operative mortality, and survival. A value of P < 0.05 on Fisher's exact, χ(2), analysis of variance, or Cox regression analyses was considered significant. Three hundred fifty-four patients with colorectal cancer (255 colon, 99 rectal) were identified. One hundred twenty-one patients (34%) were diagnosed by screening. In comparison with those diagnosed by symptom evaluation (n = 233), these patients had earlier stage cancers, were more likely to have a curative intent procedure, and had improved 5-year survival rates. Older patients (older than 75 years old) were more likely to present with symptoms. High-risk patients were more likely to have colonoscopic screening than fecal occult blood testing. More blacks had Stage IV disease than nonblacks. Curative intent 30-day operative mortality was 2.1 per cent for colectomy and 0 per cent for rectal resection. Screening for colorectal cancer in the veteran population allows for better survival, detection at an earlier stage, and higher likelihood of resection.

Lymph node ratio is a significant predictor of disease-specific mortality in patients undergoing esophagectomy for cancer.

The seventh edition of the American Joint Committee on Cancer esophageal cancer staging system classifies nodal status by the number of malignant nodes (LNMs) found. This may be confounded by variations in lymphadenectomy and specimen review. The ratio of lymph nodes containing metastases to the total nodes excised (LNR) has been suggested as an alternative. We seek to validate the use of LNR for staging and determine the effect of the total lymph node yield (LNY) on its accuracy. A review of our prospective esophageal database identified 94 patients who underwent esophagectomy for cancer at out institution from 1992 until 2010. Univariate and multivariate analyses were performed. The mean age of our patients was 59.4 years. Transthoracic esophagectomy was performed in all but three instances. The majority of tumors were adenocarcinoma, 76 per cent. Overall survival at 2 and 5 years was 52 and 29 per cent, respectively. LNY correlated with LNM (r = 0.302, P = 0.001) but not LNR (r = 0.012, P = 0.912). Using Kaplan-Meier analysis, LNR had no effect on disease-specific (DS) survival (P = 0.803). However, a Cox proportional hazards regression model showed LNR to be a significant predictor of DS mortality (hazard ratio, 9.47; P = 0.049). The lack of correlation between LNR and LNY suggests that LNR may be a more robust staging method when LNY is low. Furthermore, LNR was found to be a significant predictor of DS mortality when controlling for other factors influencing survival. However, neither a staging system based on LNR nor its efficacy compared with the current system could be determined from these data.

Necrotizing peripheral vasculitis/vasculopathy following the use of cocaine laced with levamisole.

The objective of this study was to describe a novel presentation of peripheral vasculitis associated with levamisole-adulterated cocaine. Cocaine abuse is widespread in the United States with 5.3 million people using cocaine in 2008. Over the past decade, drug enforcement officials have noticed the presence of levamisole in confiscated cocaine samples as an adulterant. Known side effects of cocaine-related levamisole ingestion have included agranulocytosis and a cutaneous acral purpura that is histopathologically characterized by a mixture of inflammation (vasculitis) and occlusion (vasculopathy). A 54-year-old man who nasally ingested cocaine laced with levamisole developed widespread necrotic/purpuric skin lesions on approximately 20% of his body with an acral accentuation. These lesions were complicated by multiple areas of sloughing and necrosis. He was initially treated with topical silver sulfadiazine dressing changes but progressed to require debridement and split-thickness skin grafting. Peripheral vasculitis/vasculopathy with severe necrosis resembling Coumadin necrosis is a relatively recently recognized sequelae from levamisole-adulterated cocaine use.

Epidermal growth factor expression in esophageal adenocarcinoma: a clinically relevant target?

INTRODUCTION: There has been recent widespread enthusiasm in epidermal growth factor (EGFR) as a molecularly active target in esophageal adenocarcinoma (EAC). However, there is limited data on the extent of EGFR expression in EAC. Thus, the aim of this study was to evaluated EGFR, pErk1/2, and total Erk1/2 expression in malignant and benign specimens. METHODS: Baseline expression of EGFR in the human normal squamous, Barrett's, and EAC cell lines were determined as well as after bile acid treatment and curcumin pretreatment. In addition, EGFR expression was also evaluated in 60 matched normal and malignant EAC resected specimens. RESULTS: The in vitro studies in the Het-1a, BarT, and OE19 cell lines failed to show any measurable expression of EGFR via Western blot technique. The marker serving as the positive control for the study, MnSOD, showed expression in each cell line for all three treatment regimens at approximately 24 kDa EGFR, showing moderate staining in the malignant tumor specimens and low staining in the benign tissue specimens. pErk1/2 showed low staining in the malignant tumor specimens and no staining in the benign tissue specimens. Total Erk1/2 showed high staining in both the malignant tumor specimens and benign tissue specimens. The differences in the mean staining scores for the malignant versus benign tissue specimens for pErk1/2 and total Erk1/2 are not statistically significant (p = 0.0726 and p = 0.7054, respectively). CONCLUSION: Thus, in conclusion, EGFR expression has been confirmed to be limited to non-existent in EAC and thus its use as a clinically active target is limited at best. Prior to the use of these expensive anti-EGFR therapies, confirmation of overexpression should be verified.

Impact of histology on survival in retroperitoneal sarcomas.

BACKGROUND: The current American Joint Committee on Cancer AJCC staging system applies to all soft-tissue sarcomas and does not allow for consideration of many features unique to retroperitoneal sarcomas (RPSs). The aim of this study was to analyze factors predictive of recurrence and survival for patients with resected RPSs. METHODS: This was a retrospective analysis of consecutive patients with primary RPS who underwent resection. A 3-tiered histological classification was examined: atypical lipomatous tumors (ALTs), non-ALT liposarcomas (LPSs), and other. Univariate and multivariate analyses were used to identify factors associated with differences in disease-free survival (DFS) and overall survival (OS) among groups. RESULTS: Sixty RPS patients were analyzed: 16 patients (27%) had ALTs, 7 patients (12%) had LPSs, and 37 patients (62%) had other histologies. A comparison of the 3 groups showed a significant difference in OS among groups (P < .017). High-grade tumors favored shorter DFS (P = .06) but were not associated with decreased OS when compared with low-grade tumors (P = .86). CONCLUSIONS: These findings support an alternative staging system for RPS, inclusive of histology, which may prove useful in operative planning and prognostication.