Obesity Increases Risk for Wound Complications After Pediatric Foot Surgery: A Retrospective Cohort Review Using the NSQIP-Pediatric Database.

BACKGROUND: As the incidence of childhood obesity continues to rise, so too does the number of obese children who undergo foot surgery. As the childhood obesity epidemic rolls on, pediatric orthopaedic surgeons will encounter obese patients with even greater frequency. Therefore, a comprehensive understanding of the risks associated with obesity is valuable to maximize patient safety. The purpose of this study is to retrospectively evaluate the relationship between obesity and postoperative outcomes in patients undergoing pediatric foot surgery across multiple institutions using a large national database. METHODS: Pediatric patients who had undergone foot surgery were retrospectively identified using the American College of Surgeons 2012-2017 Pediatric National Surgical Quality Improvement (ACS-NSQIP-Pediatric) database by cross-referencing reconstructive foot-specific CPT codes with ICD-9/ICD-10 diagnosis codes. Center for Disease Control BMI-to-age growth charts were used to stratify patients into normal-weight and obese cohorts. Univariate and multivariate analyses were performed to describe and assess outcomes in obese compared with normal-weight patients. RESULTS: Of the 3924 patients identified, 1063 (27.1%) were obese. Compared with normal-weight patients, obese patients were more often male (64.7% vs. 58.7%; P =0.001) and taller (56.3 vs. 51.3 inches; P <0.001). Obese patients had significantly higher rates of overall postoperative complications (3.01% vs. 1.32%; P =0.001) and wound dehiscence (1.41% vs. 0.59%; P =0.039). Multivariate analysis found that obesity was an independent predictor of both wound dehiscence [adjusted odds ratio (OR)=2.16; 95% CI=1.05-4.50; P =0.037] and surgical site infection (adjusted OR=3.03; 95% CI=1.39-6.61; P =0.005). Subgroup analysis of patients undergoing clubfoot capsular release procedures identified that obese patients had a higher rate of wound dehiscence (3.39% vs. 0.51%; P =0.039) compared with normal-weight patients. In multivariate analysis, obesity was an independent predictor of dehiscence (adjusted OR=5.71; 95% CI=1.46-22.31; P =0.012) in this procedure group. There were no differences in complication rates between obese and normal-weight patients in a subgroup analysis of tarsal coalition procedures or clubfoot tibialis anterior tendon transfer procedures. CONCLUSION: Obese children undergoing foot surgery had higher overall complication rates, wound complications, and surgical site infections compared with children of normal weight. As the incidence of childhood obesity continues to rise, this information may be useful in assessing and discussing surgical risks with patients and their families. LEVEL OF EVIDENCE: III.

Predictors of long-term success after laparoscopic Roux-en-Y gastric bypass in African-American women.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides sustained weight loss. However, short-term studies have suggested that African Americans (AAs) are not as successful as Caucasians (CAs) after LRYGB. OBJECTIVE: The present study was designed to test the hypothesis that at longer term follow-up AAs are just as successful as CAs after LRYGB. SETTING: University hospital, United States. METHODS: A nested case-control study designed to examine the effect of race as covariate in the long-term success of women undergoing LRYGB. The study matched 3 controls per case subject, and the final numbers for analyses were 78 case patients (AA) and 204 control patients (CA). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression analysis. RESULTS: The 2 cohorts (N = 282) were well matched for age (AA 40.3±9.1 years versus CA 41.1±8.9 years), preoperative body mass index (AA 50.6±7.5 kg/m(2) versus CA 50.2±7.1 kg/m(2)), prevalence of type 2 diabetes (T2D) (AA 20.5% versus CA 21.1%), hypertension (AA 69.1% versus CA 52%), and sleep apnea (AA 35.9% versus CA 34.8%). In the AA group, the long-term curve for percentage of excess weight loss (EWL) was significantly (P<.001) lower than the CA group at any time-point. In the present model, diagnosis of T2D in the AA group (OR = 6.1 E8) significantly (P = .002) predicted adequate EWL at 3 years, after controlling for relevant confounders. CONCLUSION: Race significantly affected the long-term EWL at 3 years for patients undergoing LRYGB at the authors' institution. Future research should be directed at determining potential genetic reasons for these differences, including genes associated with T2D.

Sequencing the full-length of the phosphatase and tensin homolog (PTEN) gene in hepatocellular carcinoma (HCC) using the 454 GS20 and Illumina GA DNA sequencing platforms.

BACKGROUND: Phosphatase and tensin homolog (PTEN) is a tumor-suppressor gene that is mutated in cancer of the liver, pancreas, endometrium, and prostate. PTEN-dependent pathways are involved in mediating cell growth and invasion. To sequence the whole gene (including introns and exons), we have taken advantage of new technologies that allow for rapid, inexpensive sequencing to great depth. METHODS: DNA from 15 HCC specimens were pooled, and long-range PCR was performed by using the GeneAmp XL PCR kit. Primer parameters included: length of 20-30 base pairs (bp), melting temperature of -68 degrees C, and G/C content of 50-60%. PCR products were then column-purified and pooled, and DNA libraries were prepared for "shotgun sequencing" on both the 454 GS and Illumina GA sequencing platforms. RESULTS: We successfully amplified approximately 98.9% of the PTEN gene by using one long-range PCR protocol applied to 24 primer sets, resulting in 20 amplicons approximately 6.5 kilobases (kb) in length, 2 amplicons approximately 10 kb in length, and 2 amplicons approximately 2.5 kb in length. Sequencing of fragmented PCR products on both sequencing platforms identified six high-frequency SNPs that were catalogued in dbSNP as known variants. CONCLUSIONS: Shotgun sequencing based on a single long-range PCR protocol in pooled samples is an efficient and relatively inexpensive way to sequence an entire gene.

Analysis of recent pediatric orthotopic liver transplantation outcomes indicates that allograft type is no longer a predictor of survivals.

Two strategies to increase the donor allograft pool for pediatric orthotopic liver transplantation (OLT) are deceased donor segmental liver transplantation (DDSLT) and living donor liver transplantation (LDLT). The purpose of this study is to evaluate outcomes after use of these alternative allograft types. Data on all OLT recipients between February 2002 and December 2004 less than 12 years of age were obtained from the United Network for Organ Sharing database. The impact of allograft type on posttransplant survivals was assessed. The number of recipients was 1260. Of these, 52% underwent whole liver transplantation (WLT), 33% underwent DDSLT, and 15% underwent LDLT. There was no difference in retransplantation rates. Immediate posttransplant survivals differed, with WLT patients having improved 30-day patient survivals compared to DDSLT and LDLT patients (P = 0.004). Although unadjusted 1-year patient survivals were better for WLT versus DDSLT (P = 0.01), after risk adjustment, 1-year patient survivals for WLT (94%), DDSLT (91%), and LDLT (93%) were similar (P values > 0.05). Unadjusted allograft survivals were better for WLT and LDLT in comparison with DDSLT (P = 0.009 and 0.018, respectively); however, after adjustment, these differences became nonsignificant (all P values > 0.05). For patients < or = 2 years of age (n = 833), the adjusted 1-year patient and allograft survivals were also similar (all P values > 0.05). In conclusion, in the current era of pediatric liver transplantation, WLT recipients have better immediate postoperative survivals. By 1 year, adjusted patient and allograft survivals are similar, regardless of the allograft type.

Long-term outcomes following liver transplantation for hepatic hemangioendothelioma: the UNOS experience from 1987 to 2005.

INTRODUCTION: Hepatic hemangioendothelioma (HEH) is a vascular neoplasm with intermediate malignant potential. Outcomes after liver transplantation have only been reported as small, single-institution experiences. The purpose of this study was to evaluate patient and allograft survivals after liver transplantation in a large, multi-institutional cohort of patients with HEH. METHODS: Using the United Network for Organ Sharing (UNOS) database, we identified 110 patients with a diagnosis of HEH who underwent 126 transplants between 1987 and 2005. Patient and allograft survivals were calculated using Kaplan-Meier survival curves. Log rank tests were used to determine the influence of study variables on outcomes. RESULTS: Of the 110 transplanted patients, 75 patients (68%) were female, 80 patients (73%) were Caucasian, and the median age was 36 years old (23%<4 y.o., 71%>18 y.o.). The 30-day posttransplant mortality rate was 2.4%. At a median patient follow-up interval of 24 months, 1- and 5-year patient and allograft survivals were 80% and 64%, and 70% and 55%, respectively. Pretransplant medical status, but not age, was found to statistically correlate with patient survival. CONCLUSION: These data indicate that survivals after transplantation for HEH are favorable. Given the propensity for recurrence after resection, these data support consideration of liver transplantation for all patients with significant intrahepatic tumor burden.

Outcomes analysis for 280 patients with cholangiocarcinoma treated with liver transplantation over an 18-year period.

Cholangiocarcinoma is an aggressive malignancy with 5-year survival rates<15%. Selected patients present with localized but unresectable disease and are candidates for orthotopic liver transplantation (OLT). The purpose of this study was to evaluate a multi-institutional experience with liver transplantation for this malignancy. Two hundred eighty patients with cholangiocarcinoma treated with OLT from 1987 to 2005 were identified in The United Network for Organ Sharing database. Patient and allograft survivals were calculated and the potential prognostic value of multiple clinicopathologic variables was assessed. At a median follow-up interval of 452 days (range: 0-6,166 days), 1- and 5-year patient survivals were 74 and 38%, respectively, with 49 actual 5-year survivors and 21 actual 10-year survivors. Posttransplant 1- and 5-year allograft survivals were 69 and 36%, respectively. Study variables associated with improved survivals included diagnosis of cholangiocarcinoma pre-OLT [5-year overall survival (OS): 68 vs. 20% for patients with incidental diagnoses at the time of OLT, p<0.001] and OLT after 1993 (5-year OS: 45 vs. 30% pre-1994, p<0.01). In contrast, the diagnosis of concomitant primary sclerosing cholangitis did not impact survivals (5-year OS: 41 vs. 50% without primary sclerosing cholangitis, p=0.402). Selected cholangiocarcinoma patients treated with OLT experience a survival benefit. Diagnosis of cancer prior to OLT allows for better staging and pre-OLT therapy that may translate into improved outcomes. These data support the continued development of multimodality cholangiocarcinoma treatment protocols that include OLT.

Gene overexpression in pancreatic adenocarcinoma: diagnostic and therapeutic implications.

Pancreatic cancer is the deadliest of cancers, and effective diagnostic and therapeutic strategies are lacking. Global gene expression profiling holds promise for improved diagnosis and treatment. Knowledge of the location and timing of gene overexpression and the function of these genes, including their effects on signaling pathways, is important. These data may be used to develop histologic and serum biomarkers as well as to develop immunotherapeutic, molecular targeting, and gene therapy strategies. We have compiled a list of overexpressed genes in pancreatic cancer for which overexpression was confirmed by reverse transcriptase polymerase chain reaction, immunohistochemistry, and/or in situ hybridization following initial identification by global gene expression profiling. The techniques used in the determination of overexpression, problems encountered in global gene expression profiling, and the diagnostic and therapeutic implications of overexpression are discussed. The S100 gene family, mesothelin, prostate stem cell antigen, and 14-3-3 sigma, may have important clinical implications in pancreatic cancer diagnosis and treatment.