Prospective evaluation of finger two-point discrimination and carpal tunnel syndrome among women with breast cancer receiving adjuvant aromatase inhibitor therapy.

PURPOSE: Aromatase inhibitors (AIs) are associated with musculoskeletal symptoms and risk of developing carpal tunnel syndrome (CTS), which can impair quality of life and prompt treatment discontinuation. The incidence of CTS and clinical utility of diagnostic tests such as 2-point discrimination (2-PD) have not been prospectively examined among women receiving AIs. METHODS: Postmenopausal women with stage 0-III hormone receptor-positive breast cancer who were enrolled in a randomized clinical trial investigating adjuvant AIs (Exemestane and Letrozole Pharmacogenetics, ELPh) underwent prospective evaluation of 2-PD with the Disc-criminator™ (sliding aesthesiometer) and completed a CTS questionnaire at baseline, 3, 6, and 12 months, following initiation of AI. Changes in mean 2-PD were analyzed with multivariable mixed effects modelling. A p value < 0.05 was considered statistically significant. RESULTS: Of 100 women who underwent baseline 2-PD testing, CTS was identified by questionnaire in 11% at baseline prior to AI initiation. Prevalence of CTS at any time in the first year was 26%. A significant increase in worst 2-PD score was observed from baseline to 3 months (3.7 mm to 3.9 mm, respectively, p = 0.03) when adjusted for age, prior chemotherapy, randomized treatment assignment, and diabetes. There were no significant differences in treatment discontinuation due to CTS between the arms. CONCLUSION: For women receiving adjuvant AI, 2-PD scores were significantly worse at 3 months compared to baseline. Studies are required to assess whether change in 2-PD is an adequate objective assessment for CTS with AI therapy. Early diagnosis of CTS may expedite management, improve AI adherence, and enhance breast cancer outcomes.

Preoperative thrombocytopenia and outcomes of hepatectomy for hepatocellular carcinoma.

BACKGROUND: Platelet count is known to be an indirect indicator of portal hypertension but is not a part of the model for end-stage liver disease (MELD) score or the Child-Pugh score for risk stratification in hepatobiliary surgery. METHODS: Data from 2097 hepatic resections for hepatocellular carcinoma (HCC) were evaluated from 2005-2012 using the National Surgical Quality Improvement Program database. Patient demographics, morbidity, and mortality were evaluated. RESULTS: Median age and body mass index were 64 y and 26.5 kg/m(2), respectively. Majority of the patients had American Society of Anesthesiologists ≥3 (78.1%) and median MELD score was 7. On multivariate analysis, thrombocytopenia (platelet count <150/nL) and severe thrombocytopenia (platelet count <100/nL) were independently associated with an increased risk of mortality (odds ratio [OR], 1.79; P = 0.024 and OR, 4.19; P < 0.001), cardiopulmonary complications (OR, 1.61; P = 0.009 and OR, 1.96; P = 0.018), need for blood transfusion (OR, 1.35; P = 0.05 and OR, 1.60; P = 0.05), septic complications (OR, 1.53; P = 0.025 and OR, 1.96; P = 0.016), reintubation (OR, 1.91; P = 0.004 and OR, 2.64; P = 0.003), and renal insufficiency and/or failure (OR, 2.48; P = 0.001 and OR, 4.96; P < 0.001), respectively. CONCLUSIONS: Thrombocytopenia, which is an indirect indicator for portal hypertension, is significantly associated with adverse outcomes after hepatectomy, independent of the MELD score. Platelet count should be integrated into the selection criteria for hepatic resections for HCC.

Risk factors and outcomes of blood transfusions in adrenalectomy.

BACKGROUND: Blood transfusion has been shown to be associated with adverse long-term and short-term outcomes. We sought to evaluate the preoperative risk factors associated with blood transfusion and its effects on postoperative outcomes after adrenalectomy. METHODS: We performed a retrospective analysis of 4735 adrenalectomies (3664 laparoscopic and 1071 open) from 2005-2012 using the National Surgical Quality Improvement Program database. Data on preoperative risk factors and postoperative morbidity and mortality were evaluated. RESULTS: Median age and body mass index were 54 y and 29.3 kg/m(2), respectively. Most patients were female (60.0%). Of the total, 60.6% patients had American Society of Anesthesiologists score ≥3. On multivariate analysis, increasing age (odds ratio [OR] = 1.02, P < 0.001), open adrenalectomy (OR = 14.0, P < 0.001), preoperative hematocrit <38% (OR = 2.96, P < 0.001), and operative time >150 min (OR: 3.69, P < 0.001) were associated with an increased need for intraoperative blood transfusions. The need for intraoperative blood transfusions was an independent predictor of postoperative complications including mortality (OR = 12.7, P < 0.001), overall morbidity (OR = 3.2, P < 0.001), serious morbidity (OR = 3.8, P < 0.001), wound complication (OR = 2.1, P = 0.006), cardiopulmonary complication (OR = 3.6, P < 0.001), septic complication (OR = 2.5, P = 0.007), reoperation (OR = 3.6, P < 0.001), and prolonged length of stay (OR = 4.3, P < 0.001). There was an independent and incremental increase (10%-20%) in the risk of morbidity and mortality with each unit of blood transfused (P < 0.01). CONCLUSIONS: Age, open surgery, preoperative anemia, American Society of Anesthesiologists score, and prolonged operative time are associated with an increased need for blood transfusions in laparoscopic and open adrenalectomy. Intraoperative transfusion was independently and incrementally associated with significant morbidity and mortality after laparoscopic and open adrenalectomy.

Resident participation and postoperative outcomes in adrenal surgery.

BACKGROUND: The changing paradigm of surgical residency training has raised concerns about the effects on the quality of training. The purpose of this study is to identify if resident participation in laparoscopic adrenalectomy (LA) and open adrenalectomy (OA) cases is associated with deleterious outcomes. MATERIALS AND METHODS: This is a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. Data from patients undergoing LA and OA from 2005 to 2010 were queried. Preoperative variables as well as intra- and post-operative outcomes for each procedure were evaluated. Multivariate logistic regression was used to analyze if resident participation was associated with significant differences in outcomes, compared with no resident participation. Subset analysis was done to determine possible differences in outcomes based on the level of resident participating, divided into junior (Post Graduate Year [PGY]1-3), senior (PGY4-5), or fellow (≥PGY6) levels. RESULTS: A total of 3219 adrenalectomies were performed. Of these, 735 (22.8%) were OAs and 2484 (77.2%) were LAs. Residents were involved in 2582 (80.2%) surgeries, which comprised 1985 (76.9%) LAs and 597 (23.1%) OAs. Senior residents or fellows performed majority of the cases (85.2%). Mean operative time was significantly higher with resident participation in LA (P < 0.0001) and OA group (P < 0.0001). On multivariate analysis, resident participation was not associated with significant differences in the operative outcomes of 30-d mortality or postoperative complications after laparoscopic or OA. CONCLUSIONS: Although resident participation does increase operative time in LA and OA, this does not appear to be clinically significant and does not result in adverse patient outcomes.

Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery.

BACKGROUND: Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation. METHODS: Thirty-seven patients who had unilateral or bilateral breast reconstruction via a DIEP flap or implant-based reconstruction, with or without radiation therapy (minimum follow-up, 18 months; range, 18-61 months) were studied. Of the 74 breasts, 27 had DIEP flaps, 29 had implants, and 18 were nonreconstructed. Eleven breasts with implants and 10 with DIEP flaps had had prereconstruction radiation therapy. The primary outcome was mean patient-perceived static and moving cutaneous pressure threshold in nine areas. We used univariate and multivariate analyses to assess what independent factors affected the return of sensation (significance, P < 0.05). RESULTS: Implants provided better static (P = 0.071) and moving sensation (P = 0.041) than did DIEP flaps. However, among irradiated breasts, skin over DIEP flaps had significantly better sensation than did that over implants (static, P = 0.019; moving, P = 0.028). Implant reconstructions with irradiated skin had significantly worse static (P = 0.002) and moving sensation (P = 0.014) than did nonirradiated implant reconstructions. CONCLUSIONS: Without irradiation, skin overlying implants is associated with better sensation recovery than DIEP flap skin. However, with irradiation, DIEP flap skin had better sensation recovery than did skin over implants. Neurotization trended toward improvement in sensation in DIEP flaps.

Recent advances in the surgical treatment of differentiated thyroid cancer: a comprehensive review.

Differentiated thyroid cancers have become one of the fastest growing malignancies in the world. While surgery has remained the cornerstone of management of these tumors, the surgical approach has seen numerous innovations over the past few decades. The use of video-assistance and robotics has revolutionized thyroid surgery. This paper provides a comprehensive evaluation of the different approaches to thyroid surgery, the utility of prophylactic and therapeutic lymph node dissection, and evidence-based guidelines in the treatment of differentiated thyroid cancers. Minimally invasive video-ssisted thyroidectomy is both safe and effective in the hands of the trained surgeon and, in selected patient populations, has comparative perioperative morbidity and better cosmesis as compared to conventional open thyroidectomy. It is universally accepted that therapeutic central lymph node dissection should be performed when metastatic lymph nodes are identified on physical exam, ultrasound, or intraoperatively. In the absence of overt nodal metastasis, the role of elective prophylactic central lymph node dissection remains a matter of debate and prospective, randomized studies are warranted to evaluate the utility of this procedure.

Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis.

OBJECTIVE: To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques. BACKGROUND: LDP is increasingly performed as an alternative approach for distal pancreatectomy in selected patients. Multiple studies have tried to assess the safety and efficacy of LDP compared with ODP. METHODS: A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model. RESULTS: Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57-0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24-0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality. CONCLUSIONS: LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.

The role of preoperative neck ultrasounds to assess lymph nodes in patients with suspicious or indeterminate thyroid nodules.

BACKGROUND AND OBJECTIVES: Currently there are no recommendations for obtaining a preoperative neck ultrasound for patients with suspicious or indeterminate thyroid nodules. Because a preoperative surgical ultrasound can detect suspicious lymph nodes that could result in ultimately altering surgical management, we chose to study which variables were predictive of this change. METHODS: Medical records of 173 patients who presented between January 2006 and December 2010 with suspicious or indeterminate thyroid cytology were retrospectively reviewed. Clinicopathological variables were analyzed to determine factors predictive of malignancy and a change in operative approach. RESULTS: One hundred thirty-four of 173 patients were evaluable. Seventeen of 134 (12.6%) of the preoperative ultrasounds were suspicious. Seven of 134 (5.2%) patients underwent a formal lymph node dissection based on ultrasound findings. Size of tumor, Bethesda FNAB category, and male gender were associated with malignancy while thyroid nodule microcalcifications and category of FNAB were associated with performing lymph node dissections. CONCLUSION: Thyroid nodule microcalcifications on ultrasound and category of FNAB appear to be the best predictors of metastatic disease. Because the surgical approach was altered in only a few patients, further analysis is needed to delineate whether performing cervical ultrasound for suspicious/indeterminate nodules is cost effective.

Long-term outcome in patients with primary hyperparathyroidism who underwent minimally invasive parathyroidectomy.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) has become a well-accepted treatment for selected patients with primary hyperparathyroidism (PHPT). However, few studies have evaluated long-term outcomes for this operative approach. We therefore chose to examine both the long-term symptom resolution and biochemical cure following MIP for PHPT. METHODS: A total of 460 PHPT patients who underwent a MIP between 2004 and 2009 were successfully mailed a questionnaire that assessed preoperative and postoperative Parathyroidectomy Assessment of Symptoms (PAS) scores, most recent calcium and parathyroid hormone (PTH) levels, and information about any reoperation for PHPT. Long-term evaluation of symptomatic and biochemical cure was performed. RESULTS: A total of 200 patients (43.5%) responded to our correspondence. The mean age of the patients was 58.7 ± 11.9 years, 74.5% were female, and 78.5% were Caucasian. The mean follow-up was 37 ± 19 months. The mean PAS scores fell by 117 ± 14 at long-term follow-up after MIP (P < 0.0001). All 13 symptoms comprising the PAS score diminished, of which ten did so significantly (P < 0.01). There was a significant drop in the mean serum calcium (preop. 11.1 mg/dl, postop. 9.6 mg/dl; P < 0.0001) and PTH (preop. 130.9 pg/ml, postop. 45.7 pg/ml; P < 0.0001) at long-term follow-up. Five patients (2.5%) developed recurrent disease (calcium > 10.5 mg/dl), and one (0.5%) underwent a reoperation for persistent disease and was subsequently cured. CONCLUSIONS: This study demonstrates that MIP has long-term benefits in terms of excellent symptom resolution and a high biochemical cure rate (97%) in selected patients who have PHPT, preoperative localization with sestamibi scans, and assessment of intraoperative PTH level.

Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: Review of a single surgeon's early experience.

BACKGROUND: The purpose of this study is to describe the early experience of a single surgeon just out of training, including preoperative conditioning, surgical approach, and outcomes in bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction patients. METHODS: We retrospectively reviewed 54 consecutive patients who underwent 108 DIEP flap breast reconstructions performed by a single surgeon over an initial 2.5-year period. RESULTS: There was 100% overall flap survival. The unplanned reoperation rate was 7.6% (n = 4). Minor complications including nonoperative infection, minor wound dehiscence, and donor site seroma occurred in 26% of patients (n = 14). Significant late complications were abdominal wall bulge (n = 1) and fat necrosis < 10% of volume (n = 1). Tissue expander explantation due to infection occurred in 25% of attempted staged patients (two of eight); this did not seem to compromise their oncologic treatment or final reconstruction outcome. CONCLUSION: This study demonstrates the efficacy of the DIEP flap for bilateral autologous breast reconstruction in the immediate, staged, and delayed settings.

Bilateral simultaneous breast reconstruction with SGAP flaps.

BACKGROUND: Two work-horse approaches to postmastectomy breast reconstruction are the deep inferior epigastric perforator flap and the superior gluteal artery perforator (SGAP) flap [and its variation, the lateral septocutaneous superior gluteal artery perforator flap]. Our purpose was fourfold: 1) to analyze our experience with the SGAP flaps for simultaneous bilateral breast reconstruction; 2) to analyze our experience with lateral septocutaneous superior gluteal artery perforator flaps for that procedure; 3) to compare our results with those in the literature; and 4) to highlight the importance of preoperative three-dimensional computed tomographic angiography. METHODS: A retrospective chart review was completed for 23 patients who underwent breast reconstruction between December 2005 and January 2010 via an SGAP flap (46 flaps). We reviewed flap weight, ischemia time, length of stay, overall flap survival, fat necrosis development, and emergency re-exploration. RESULTS: Mean weights were 571.2 ± 222.0 g (range 186-1,117 g) and 568.0 ± 237.5 g (range 209-1,115 g) for the left and right buttock flap, respectively. Mean ischemia time was 129.1 ± 15.7 and 177.7 ± 24.7 minutes for the first and second flap, respectively. Mean hospital stay was 5.3 ± 2.5 days. All flaps survived. Fat necrosis developed in five flaps (10.8%), and emergency re-exploration was required in three patients (three flaps). CONCLUSIONS: When harvesting abdominal tissue is a poor option, the SGAP flap is an efficacious procedure for patients desiring autologous breast reconstruction, and bilateral procedures can be performed simultaneously.

Presence of pancreatic intraepithelial neoplasia in the pancreatic transection margin does not influence outcome in patients with R0 resected pancreatic cancer.

BACKGROUND: Margin status is one of the strongest prognosticators after resection of pancreatic ductal adenocarcinoma (PDAC). The clinical significance of pancreatic intraepithelial neoplasia (PanIN) at a surgical margin has not been established. METHODS: A total of 208 patients who underwent R0 resection for PDAC between 2004 and 2008 were selected. Intraoperative frozen section slides containing the final pancreatic parenchymal transection margin were evaluated for presence or absence, number, and grade of PanINs. Data were compared to clinicopathologic factors, including patient survival. RESULTS: PanIN lesions were present in margins in 107 of 208 patients (51.4%). Median number of PanINs per pancreatic resection margin was 1 (range, 1-11). A total of 72 patients had PanIN-1 (34.6%), 44 had PanIN-2 (21.1%), and 16 had PanIN-3 (7.2%) at their margin. Overall median survival was 17.9 (95% confidence interval, 14-21.9) months. Neither the presence nor absence of PanIN nor histological grade had any significant correlation with important clinicopathologic characteristics. There were no significant survival differences between patients with or without PanIN lesions at the resection margin or among patients with PanIN-3 (carcinoma in situ) versus lower PanIN grades. However, patients with R1 resection had a significantly worse outcome compared with patients without invasive cancer at a margin irrespective of the presence of PanIN (P=0.02). CONCLUSIONS: The presence of PanINs at a resection margin does not affect survival in patients who undergo R0 resection for PDAC. These results have significant clinical implications for surgeons, because no additional resection seems to be indicated when intraoperative frozen sections reveal even high-grade PanIN lesions.

Frailty Predicts Morbidity after Colectomy for Ulcerative Colitis.

The rate of ulcerative colitis (UC), an inflammatory bowel disease, has been on the rise in the United States for the last several decades. Colectomy can be performed when other treatment options cannot provide a reasonable quality of life to patients with UC. Frailty has been shown to be a strong tool for evaluating preoperative risk factors for poor postoperative outcomes. The National Surgical Quality and Improvement Program cross-institutional database was used for this study. Data from 943 patients who underwent colectomy for UC between 2005 and 2012 were evaluated. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used in the National Surgical Quality and Improvement Program to assess frailty. Outcome measures included serious morbidity; overall morbidity; cardiopulmonary, septic, and wound complications; and Clavien class IV (requiring ICU) and V (mortality) complications. Median age was 46 years and median body mass index was 25.5 Kg/m2. In all, 54.3 per cent of patients were male and 39.38 per cent of patients were American Society of Anesthesiologists Class lll or higher. The median mFI was 0 (0-0.54). As the mFI increased from 0 (nonfrail) to 0.18 and above, the overall morbidity increased from 25.40 to 52.1 per cent (P < 0.05), serious morbidity increased from 14.9 to 42.1 per cent (P < 0.05), septic complications increased from 9.87 to 21.49 per cent (P < 0.05), cardiopulmonary complications increased from 2.98 to 23.14 per cent (P < 0.05), Clavien class IV complications increased from 3.5 to 26.5 per cent (P < 0.05), and Clavien V complications increased from 0.16 to 6.61 per cent (P < 0.05). On multivariate analysis, mFI was an independent predictor of septic complications [Adjusted Odds Ratio (AOR): 31.26; P = 0.006], cardiopulmonary complications (AOR: 216.3; P ≤ 0.001), serious morbidity(AOR: 66.8; P ≤ 0.001), overall morbidity (AOR: 25.5; P ≤ 0.001), Clavien class IV (AOR: 204.9; P ≤ 0.001) complications, and return to the operating room (AOR: 14.29; P = 0.048). Frailty is associated with an increase in morbidity and mortality after colectomy in patients with UC. mFI is an easy-to-use tool and can play an important role in the risk stratification of these patients.

Frailty Predicts Morbidity and Mortality after Colectomy for Clostridium difficile Colitis.

Frailty has been noted as a powerful predictive preoperative tool for 30-day postoperative complications. We sought to evaluate the association between frailty and postoperative outcomes after colectomy for Clostridium difficile colitis. The National Surgical Quality and Improvement Program cross-institutional database was used for this study. Data from 470 patients with a diagnosis of C. difficile colitis were used in the study. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with the National Surgical Quality and Improvement Program to assess frailty. Outcome measures included serious morbidity, overall morbidity, and Clavien IV (requiring ICU) and Clavien V (mortality) complications. The median age was 70 years and body mass index was 26.9 kg/m2. 55.6 per cent of patients were females. 98.5 per cent of patients were assigned American Society of Anesthesiologists Class III or higher. The median mFI was 0.27 (0-0.63). Because mFI increased from 0 (non-frail) to 0.55 and above, the overall morbidity increased from 53.3 per cent to 84.4 per cent and serious morbidity increased from 43.3 per cent to 78.1 per cent. The Clavien IV complication rate increased from 30.0 per cent to 75.0 per cent. The mortality rate increased from 6.7 per cent to 56.2 per cent. On a multivariate analysis, mFI was an independent predictor of overall morbidity (AOR: 13.0; P < 0.05), mortality (AOR: 8.8; P = 0.018), cardiopulmonary complications (AOR: 6.8; P = 0.026), and prolonged length of hospital stay (AOR: 6.6; P = 0.045). Frailty is associated with increased risk of complications in C. difficile colitis patients undergoing colectomy. mFI is an easy-to-use tool and can play an important role in the risk stratification of these patients who generally have significant morbidity and mortality to begin with.

High prevalence of silent brain infarction in patients presenting with mechanical heart valve thrombosis.

BACKGROUND: Symptomatic thromboembolic events including stroke occur frequently in patients with mechanical heart valves, particularly among those who are poorly anticoagulated. OBJECTIVE: This study set out to determine the prevalence of silent brain infarction (SBI) in this population. METHODS: This was a post hoc analysis of data from a randomized controlled trial carried out in a tertiary-care academic medical center. The trial included participants from a randomized controlled trial of fibrinolytic therapy (FT) in patients with left-sided prosthetic valve thrombosis (PVT), who had undergone pre-treatment computed tomography (CT) scans of the brain. The prevalence of SBI in this population was investigated. MAIN OUTCOME MEASURE: Prevalence of silent brain infarction. RESULTS: Silent brain infarction was present in 27 of 72 patients (37.5%; 95% confidence interval [CI] 27.2, 49.1). Most patients with SBI (57; 82.6%) had sub-therapeutic anticoagulation at presentation. We identified baseline characteristics that were associated with the presence of SBI using a logistic regression model. Atrial fibrillation (AF) was strongly associated with the presence of SBI (odds ratio [OR] 5.60; 95% CI 1.32, 23.87; p = 0.02). CONCLUSION: The high prevalence of SBI among this cohort of young patients with mechanical heart valves is alarming and calls for urgent efforts to improve the quality of anticoagulation. CLINICAL TRIAL REGISTRATION: Registered in the US National Institutes of Health registry at http://clinicaltrials.gov as NCT00232622.

Predicting the risk of perioperative mortality in patients undergoing pancreaticoduodenectomy: a novel scoring system.

OBJECTIVE: To develop and validate a risk score to predict the 30- and 90-day mortality after a pancreaticoduodenectomy or total pancreatectomy on the basis of preoperative risk factors in a high-volume program. DESIGN: Data from a prospectively maintained institutional database were collected. In a random subset of 70% of patients (training cohort), multivariate logistic regression was used to develop a simple integer score, which was then validated in the remaining 30% of patients (validation cohort). Discrimination and calibration of the score were evaluated using area under the receiver operating characteristic curve and Hosmer-Lemeshow test, respectively. SETTING: Tertiary referral center. PATIENTS: The study comprised 1976 patients in a prospectively maintained institutional database who underwent pancreaticoduodenectomy or total pancreatectomy between 1998 and 2009. MAIN OUTCOME MEASURES: The 30- and 90-day mortality. RESULTS: In the training cohort, age, male sex, preoperative serum albumin level, tumor size, total pancreatectomy, and a high Charlson index predicted 90-day mortality (area under the curve, 0.78; 95% CI, 0.71-0.85), whereas all these factors except Charlson index also predicted 30-day mortality (0.79; 0.68-0.89). On validation, the predicted and observed risks were not significantly different for 30-day (1.4% vs 1.0%; P = .62) and 90-day (3.8% vs 3.4%; P = .87) mortality. Both scores maintained good discrimination (for 30-day mortality, area under the curve, 0.74; 95% CI, 0.54-0.95; and for 90-day mortality, 0.73; 0.62-0.84). CONCLUSIONS: The risk scores accurately predicted 30- and 90-day mortality after pancreatectomy. They may help identify and counsel high-risk patients, support and calculate net benefits of therapeutic decisions, and control for selection bias in observational studies as propensity scores.

Presence of pancreatic intraepithelial neoplasia in the pancreatic transection margin does not influence outcome in patients with R0 resected pancreatic cancer.

BACKGROUND: Margin status is one of the strongest prognosticators after resection of pancreatic ductal adenocarcinoma (PDAC). The clinical significance of pancreatic intraepithelial neoplasia (PanIN) at a surgical margin has not been established. METHODS: A total of 208 patients who underwent R0 resection for PDAC between 2004 and 2008 were selected. Intraoperative frozen section slides containing the final pancreatic parenchymal transection margin were evaluated for presence or absence, number, and grade of PanINs. Data were compared to clinicopathologic factors, including patient survival. RESULTS: PanIN lesions were present in margins in 107 of 208 patients (51.4%). Median number of PanINs per pancreatic resection margin was 1 (range, 1-11). A total of 72 patients had PanIN-1 (34.6%), 44 had PanIN-2 (21.1%), and 16 had PanIN-3 (7.2%) at their margin. Overall median survival was 17.9 (95% confidence interval, 14-21.9) months. Neither the presence nor absence of PanIN nor histological grade had any significant correlation with important clinicopathologic characteristics. There were no significant survival differences between patients with or without PanIN lesions at the resection margin or among patients with PanIN-3 (carcinoma in situ) versus lower PanIN grades. However, patients with R1 resection had a significantly worse outcome compared with patients without invasive cancer at a margin irrespective of the presence of PanIN (P = 0.02). CONCLUSIONS: The presence of PanINs at a resection margin does not affect survival in patients who undergo R0 resection for PDAC. These results have significant clinical implications for surgeons, because no additional resection seems to be indicated when intraoperative frozen sections reveal even high-grade PanIN lesions.

Severe aortic stenosis in a veteran population: treatment considerations and survival.

BACKGROUND: We examined factors affecting the choice of surgical versus medical treatment of severe aortic stenosis and evaluated associated patient survival. METHODS: We retrospectively reviewed data from all patients diagnosed with severe aortic stenosis at a Veterans Affairs medical facility between January 1997 and April 2008. RESULTS: Of 345 patients with severe aortic stenosis, 260 (75%) underwent surgical evaluation, and 205 (59%) underwent aortic valve replacement (AVR). The patient's decision to decline surgical referral or AVR (n = 47) and severe comorbidities (n = 34) were the top two reasons for medical treatment rather than AVR. The AVR group was younger (69.5 +/- 9.6 years versus 75.7 +/- 8.6 years; p < 0.001) and had a higher prevalence of symptoms (96% versus 71%; p < 0.001) than the medical group. The medical group had a lower cardiac ejection fraction (0.42 +/- 0.15 versus 0.50 +/- 0.12; p < 0.001) and was less likely to be independent in activities of daily living (64% versus 74%). The AVR group had higher survival rates than the medical patients at 1 year (92% versus 65%), 3 years (85% versus 29%), and 5 years (73% versus 16%; log-rank test p < 0.0001). Valve replacement was independently associated with decreased mortality (hazard ratio, 0.17; 95% confidence interval, 0.10 to 0.27; p < 0.0001). CONCLUSIONS: The management of severe aortic stenosis in veterans is sometimes limited to medical evaluation and treatment. Surgeons should be involved in the complex process of risk assessment, to select patients with severe aortic stenosis who would benefit from the survival advantage associated with AVR.