Recent Journal Articles: Surgery -- Neurotransmitter.net

Recent Articles in Annals of Surgery

Mukherjee S
Mental training in surgical education.
Ann Surg. 2007 Dec;246(6):1118. [Abstract]

Immenroth M, B�rger T, Brenner J, Nagelschmidt M, Troidl H, Ebersp�cher H
Mental Training in Surgical Education.
Ann Surg. 2007 Dec;246(6):1118-1119. [Abstract]

Oelschlager B, Pellegrini C, Nelson J, Mitsumori L, Hunter J, Sheppard B, Jobe B, Soper N, Brunt M, Pollisar N, Swanstrom L
Does a Biologic Prosthesis Really Reduce Recurrence After Laparoscopic Paraesophageal Hernia Repair?
Ann Surg. 2007 Dec;246(6):1117-1118. [Abstract]

Lange JF, Wijsmuller A, van Geldere D
Prophylactic Ilioinguinal Neurectomy in Open Inguinal Hernia Repair: A Double-blind Randomized Controlled Trial.
Ann Surg. 2007 Dec;246(6):1116. [Abstract]

Rice TW, Blackstone EH
Does a biologic prosthesis really reduce recurrence after laparoscopic paraesophageal hernia repair?
Ann Surg. 2007 Dec;246(6):1116-7. [Abstract]

Shah A, Pietrobon R, Cook C, Sheth NP, Nguyen L, Guo L, Jacobs DO, Kuo PC
Little Science, Big Science: Strategies for Research Portfolio Selection in Academic Surgery Departments.
Ann Surg. 2007 Dec;246(6):1110-1115.
OBJECTIVE:: To evaluate National Institutes of Health (NIH) funding for academic surgery departments and to determine whether optimal portfolio strategies exist to maximize this funding. SUMMARY BACKGROUND DATA:: The NIH budget is expected to be relatively stable in the foreseeable future, with a modest 0.7% increase from 2005 to 2006. Funding for basic and clinical science research in surgery is also not expected to increase. METHODS:: NIH funding award data for US surgery departments from 2002 to 2004 was collected using publicly available data abstracted from the NIH Information for Management, Planning, Analysis, and Coordination (IMPAC) II database. Additional information was collected from the Computer Retrieval of Information on Scientific Projects (CRISP) database regarding research area (basic vs. clinical, animal vs. human, classification of clinical and basic sciences). The primary outcome measures were total NIH award amount, number of awards, and type of grant. Statistical analysis was based on binomial proportional tests and multiple linear regression models. RESULTS:: The smallest total NIH funding award in 2004 to an individual surgery department was a single $26,970 grant, whereas the largest was more than $35 million comprising 68 grants. From 2002 to 2004, one department experienced a 336% increase (greatest increase) in funding, whereas another experienced a 73% decrease (greatest decrease). No statistically significant differences were found between departments with decreasing or increasing funding and the subspecialty of basic science or clinical research funded. Departments (n = 5) experiencing the most drastic decrease (total dollars) in funding had a significantly higher proportion of type K (P = 0.03) grants compared with departments (n = 5) with the largest increases in total funding; the latter group had a significantly increased proportion of type U grants (P = 0.01). A linear association between amount of decrease/increase was found with the average amount of funding per grant and per investigator (P < 0.01), suggesting that departments that increased their total funding relied on investigators with large amounts of funding per grant. CONCLUSIONS:: Although incentives to junior investigators and clinicians with secondary participation in research are important, our findings suggest that the best strategy for increasing NIH funding for surgery departments is to invest in individuals with focused research commitments and established track records of garnering large and multiple research grants. [Abstract]

Walter CJ, Dumville JC, Hewitt CE, Moore KC, Torgerson DJ, Drew PJ, Monson JR
The Quality of Trials in Operative Surgery.
Ann Surg. 2007 Dec;246(6):1104-1109.
OBJECTIVE:: This study aimed to assess the reported quality of trials in operative surgery. SUMMARY BACKGROUND DATA:: Randomized controlled trials (RCTs) in operative surgery have previously been criticized for using weak methodology despite no evidence to suggest their quality is any different from nonsurgical trials. STUDY DESIGN:: All surgical RCTs published in the British Medical Journal, the Journal of the American Medical Association, The Lancet, and the New England Journal of Medicine between 1998 and 2004 were identified. The adequacy of the reported methodology used to perform the randomization, power calculation, and recruitment was assessed for each trial using predefined criteria. The results from the surgical trials were compared with a randomly selected control group of nonsurgical RCTs, which were matched for journal and year of publication. RESULTS:: Sixty-six surgical RCTs were identified. Adequate reporting of randomization sequence generation was seen in 42% (n = 28) of surgical trials and 30% (n = 20) of nonsurgical trials, and adequate allocation concealment was recorded in 46% (n = 30) and 47% (n = 31), respectively. When combining these 2 interrelated steps of randomization, only 26% (n = 17) of surgical trials and 23% (n = 15) of nonsurgical trials reported both adequately. Adequate recruitment was recorded in 52% (n = 33 of 63) surgical and 55% (n = 33 of 60) nonsurgical trials, with approximately a quarter (n = 17 and n = 16, respectively) of the trials in both the surgical and nonsurgical categories reporting an adequate power calculation. CONCLUSIONS:: There was no evidence that the reported quality of surgical trials was different to nonsurgical trials. However, approximately half or less of all the trials reviewed reported adequate methodology. [Abstract]

Englesbe MJ, Dimick JB, Sonnenday CJ, Share DA, Campbell DA
The Michigan Surgical Quality Collaborative: Will a Statewide Quality Improvement Initiative Pay for Itself?
Ann Surg. 2007 Dec;246(6):1100-1103.
OBJECTIVE:: In this article, we detail a unique collaboration between hospitals in Michigan and a major third party payer, using a "pay for participation model." The payer has made a significant investment in this regional surgical quality improvement (QI) program and funds each center's participation. RESULTS:: Based on the documented costs and incidence of surgical complications at our center, we estimate that a 1.8% annual reduction in complication rates is required for the payer to recoup its investment in this regional QI program. If we achieve our goal of a 3% reduction in complications per year over the 3-year program, the payer will save $2.5 million in payments. Our findings suggest that only a very modest improvement in surgical results, of a magnitude that seems realistically achievable based on similar QI initiatives, is necessary to financially justify payer involvement in a statewide quality improvement initiative. CONCLUSION:: The framework of this program should be used by surgeons to attract private payers into QI collaboratives, facilitating improved patient outcomes and decreased health care expenditures. [Abstract]

Lopushinsky SR, Fowler RA, Kulkarni GS, Fecteau AH, Grant DR, Wales PW
The Optimal Timing of Intestinal Transplantation for Children With Intestinal Failure: A Markov Analysis.
Ann Surg. 2007 Dec;246(6):1092-1099.
OBJECTIVE:: Identify an optimal approach to the timing of intestinal transplantation for children dependent on total parenteral nutrition (PN). SUMMARY BACKGROUND DATA:: Children with short bowel syndrome are frequently dependent on PN for growth and development. Intestinal transplantation is often considered after PN-related complications occur, but optimal timing of transplantation is controversial. METHODS:: A Markov analytic model was used to determine life expectancy (LY) and quality-adjusted life years on a theoretical cohort of 4-year-old subjects for two treatment strategies: (1) standard care consisting of PN and referral to transplantation according to accepted guidelines and (2) early listing for isolated small intestine transplantation. RESULTS:: Early listing for intestinal transplantation was associated with 0.27 additional life years (13.16 vs. 12.89) and 0.76 additional quality-adjusted life years (10.51 vs. 9.75) as compared with current standard care. The unadjusted analysis was sensitive to the development of PN-associated liver disease, at a threshold of approximately 11% per year, and its related probability of dying at a threshold of 80% 2-year mortality. Early listing for transplantation was the dominant strategy until the probability of late bowel rejection reached 35% per year. CONCLUSIONS:: Children with short bowel syndrome dependent on PN should be considered for intestinal transplantation earlier than what is current practice. [Abstract]

Sosa JA, Mehta PJ, Wang TS, Yeo HL, Roman SA
Racial disparities in clinical and economic outcomes from thyroidectomy.
Ann Surg. 2007 Dec;246(6):1083-91.
CONTEXT:: Thyroid disease is common, and thyroidectomy is a mainstay of treatment for many benign and malignant thyroid conditions. Overall, thyroidectomy is associated with favorable outcomes, particularly if experienced surgeons perform it. OBJECTIVE:: To examine racial differences in clinical and economic outcomes of patients undergoing thyroidectomy in the United States. DESIGN, SETTING, PATIENTS:: The nationwide inpatient sample was used to identify thyroidectomy admissions from 1999 to 2004, using ICD-9 procedure codes. Race and other clinical and demographic characteristics of patients were collected along with surgeon volume and hospital characteristics to predict outcomes. MAIN OUTCOME MEASURES:: Inpatient mortality, complication rates, length of stay (LOS), discharge status, and mean total costs by racial group. RESULTS:: In 2003-2004, 16,878 patients underwent thyroid procedures; 71% were white, 14% black, 9% Hispanic, and 6% other. Mean LOS was longer for blacks (2.5 days) than for whites (1.8 days, P < 0.001); Hispanics had an intermediate LOS (2.2 days). Although rare, in-hospital mortality was higher for blacks (0.4%) compared with that for other races (0.1%, P < 0.001). Blacks trended toward higher overall complication rates (4.9%) compared with whites (3.8%) and Hispanics (3.6%, P = 0.056). Mean total costs were significantly lower for whites ($5447/patient) compared with those for blacks ($6587) and Hispanics ($6294). The majority of Hispanics (55%) and blacks (52%) had surgery by the lowest-volume surgeons (1-9 cases per year), compared with only 44% of whites. Highest-volume surgeons (>100 cases per year) performed 5% of thyroidectomies, but 90% of their patients were white (P < 0.001). Racial disparities in outcomes persist after adjustment for surgeon volume group. CONCLUSIONS:: These findings suggest that, although thyroidectomy is considered safe, significant racial disparities exist in clinical and economic outcomes. In part, inequalities result from racial differences in access to experienced surgeons; more data are needed with regard to racial differences in thyroid biology and surveillance to explain the balance of observed disparities. [Abstract]

Tonelli F, Marcucci T, Fratini G, Tommasi MS, Falchetti A, Brandi ML
Is Total Parathyroidectomy the Treatment of Choice for Hyperparathyroidism in Multiple Endocrine Neoplasia Type 1?
Ann Surg. 2007 Dec;246(6):1075-1082.
OBJECTIVE:: The aim of the present report is to describe the results obtained with total parathyroidectomy (TPTX) guided by rapid intraoperative parathyroid hormone (PTH) evaluation, followed by immediate parathyroid autograft with fresh tissue. SUMMARY BACKGROUND DATA:: Surgery for hyperparathyroidism (HPT) in multiple endocrine neoplasia type 1 (MEN1) is performed with various surgical approaches. METHODS:: We report our 16-year experience of surgical treatment of 51 MEN1-HPT patients using TPTX and thymectomy. Forty-five patients underwent TPTX as the first surgical procedure, whereas for 6 patients, a parathyroid operation was the second surgical procedure. PTH intraoperative values less than 10 pg/mL, at the end of the surgery, were indicative for reimplantation of a few fragments ( approximately 7) of fresh parathyroid tissue in the brachioradial muscle of the forearm. Parathyroid autograft was performed in all patients, except 3 in whom the fourth parathyroid gland was not found. RESULTS:: Persistent hypoparathyroidism occurred in 13 patients (25%), with higher incidence in patients undergoing a second surgical revision for cervical recurrence than in patients submitted to the first surgery. At follow-up, 5 recurrences ( approximately 10%) in the forearm were observed after a mean time of 7 +/- 5 (M +/- SD) years. No cervical recurrence was documented. The forearm recurrence was treated with removal of 1 or 2 enlarged fragments obtaining the resolution of HPT in all but 1 case. CONCLUSIONS:: Based on the occurrence of complications in our experience, TPTX followed by autograft and guided by intraoperative PTH monitoring represents a better surgical option in MEN1-HPT compared with other surgical approaches. [Abstract]

Halazun KJ, Al-Mukhtar A, Aldouri A, Malik HZ, Attia MS, Prasad KR, Toogood GJ, Lodge JP
Right Hepatic Trisectionectomy for Hepatobiliary Diseases: Results and an Appraisal of Its Current Role.
Ann Surg. 2007 Dec;246(6):1065-1074.
OBJECTIVE:: To assess the results of 275 patients undergoing right hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA:: Right hepatic trisectionectomy is considered one of the most extensive liver resections, and few reports have described the long-term results of the procedure. METHODS:: Short- and long-term outcomes of 275 consecutive patients who underwent right hepatic trisectionectomy from January 1993 to January 2006 were analyzed. RESULTS:: Of the 275 patients, 160 had colorectal metastases, 49 had biliary tract cancers, 20 had hepatocellular carcinomas, 20 had other metastatic tumors, and 12 had benign diseases. Fourteen of the 275 patients underwent right hepatic trisectionectomy as part of auxiliary liver transplantation for acute liver failure and were excluded. Concomitant procedures were carried out in 192 patients: caudate lobectomy in 45 patients, resection of tumors from the liver remnant in 57 patients, resection of the extrahepatic biliary tree in 45 patients, and lymphadenectomy in 45 patients. One-, 3-, 5-, and 10-year survivals were 74%, 54%, 43%, and 36%, respectively. Overall hospital morbidity and 30-day and in-hospital mortalities were 41%, 7%, and 8%, respectively. Survivals for individual tumor types were acceptable, with 5-year survivals for colorectal metastasis and cholangiocarcinoma being 38% and 32%, respectively. Multivariate analysis disclosed the amount of intraoperative blood transfusion to be the sole independent predictor for the development of hospital morbidity. Age over 70 years, preoperative bilirubin levels, and the development of postoperative renal failure were found to be independent predictors of long-term survival. CONCLUSION:: Right hepatic trisectionectomy remains a challenging procedure. The outcome is not influenced by additional concomitant resection of tumors from the planned liver remnant. Caution must be taken when considering patients older than 70 years for such resections. [Abstract]

Mathur A, Pitt HA, Marine M, Saxena R, Schmidt CM, Howard TJ, Nakeeb A, Zyromski NJ, Lillemoe KD
Fatty pancreas: a factor in postoperative pancreatic fistula.
Ann Surg. 2007 Dec;246(6):1058-64.
OBJECTIVE:: To determine whether patients who develop a pancreatic fistula after pancreatoduodenectomy are more likely to have pancreatic fat than matched controls. BACKGROUND:: Pancreatic fistula continues to be a major cause of postoperative morbidity and increased length of stay after pancreatoduodenectomy. Factors associated with postoperative pancreatic fistula include a soft pancreas, a small pancreatic duct, the underlying pancreatic pathology, the regional blood supply, and surgeon's experience. Fatty pancreas previously has not been considered as a contributing factor in the development of postoperative pancreatic fistula. METHODS:: Forty patients with and without a pancreatic fistula were identified from an Indiana University database of over 1000 patients undergoing pancreatoduodenectomy and matched for multiple parameters including age, gender, pancreatic pathology, surgeon, and type of operation. Surgical pathology specimens from the pancreatic neck were reviewed blindly for fat, fibrosis, vessel density, and inflammation. These parameters were scored (0-4+). RESULTS:: The pancreatic fistula patients were less likely (P < 0.05) to have diabetes but had significantly more intralobular (P < 0.001), interlobular (P < 0.05), and total pancreatic fat (P < 0.001). Fistula patients were more likely to have high pancreatic fat scores (50% vs. 13%, P < 0.001). Pancreatic fibrosis, vessel density, and duct size were lower (P < 0.001) in the fistula patients and negative correlations (P < 0.001) existed between fat and fibrosis (R = -0.40) and blood vessel density (R = -0.15). CONCLUSIONS:: These data suggest that patients with postoperative pancreatic fistula have (1) increased pancreatic fat and (2) decreased pancreatic fibrosis, blood vessel density, and duct size. Therefore, we conclude that fatty pancreas is a risk factor for postoperative pancreatic fistula. [Abstract]

Ikeyama T, Nagino M, Oda K, Ebata T, Nishio H, Nimura Y
Surgical Approach to Bismuth Type I and II Hilar Cholangiocarcinomas: Audit of 54 Consecutive Cases.
Ann Surg. 2007 Dec;246(6):1052-7.
OBJECTIVE:: To clarify the optimal surgical strategy for Bismuth type I and II hilar cholangiocarcinomas. SUMMARY BACKGROUND DATA:: Local or hilar resections is often performed for Bismuth type I and II tumors; however, reported outcomes have been unsatisfactory with a high recurrence and low survival rate. To improve survival, some authors have recommended right hepatectomy. However, the clinical value of this approach has not been validated. METHODS:: Records of 54 consecutive patients who underwent resection of a Bismuth type I or II hilar cholangiocarcinoma were analyzed retrospectively. Through 1996, bile duct resection or the smallest necessary hepatic segmentectomy was performed. Beginning in 1997, choice of resection was based on the cholangiographic tumor type. For nodular or infiltrating tumor, right hepatectomy was indicated; for papillary tumor, bile duct resection with or without limited hepatectomy was chosen. RESULTS:: Right hepatectomy was performed in 5 (20.8%) of 24 patients through 1996 and was done in 22 (73.3%) of 30 patients from 1997 (P = 0.0003). In patients without pM1 disease, R0 resection was achieved more frequently in the later period than in the earlier period (23 of 24 = 95.8% vs. 13 of 21 = 61.9%, P = 0.0073), which lead to better survival (5-year survival, 44.3% vs. 25.0%, P = 0.0495). In the 31 patients with nodular or infiltrating tumor, who tolerated surgery and did not have pM1 disease, survival was better in the 18 patients who underwent right hepatectomy than in those who did not (5-year survival, 62.9% vs. 23.1%, P = 0.0030). In cases of papillary tumor, bile duct resection with or without limited hepatectomy was sufficient to improve long-term survival. CONCLUSIONS:: The surgical approach to Bismuth type I and II hilar cholangiocarcinomas should be determined according to cholangiographic tumor type. For nodular and infiltrating tumors, right hepatectomy is essential; for papillary tumor, bile duct resection with or without limited hepatectomy is adequate. [Abstract]

Ishizuka M, Nagata H, Takagi K, Horie T, Kubota K
Inflammation-based prognostic score is a novel predictor of postoperative outcome in patients with colorectal cancer.
Ann Surg. 2007 Dec;246(6):1047-51.
OBJECTIVE:: To investigate the significance of preoperative Glasgow prognostic score (GPS) for postoperative prognostication of patients with colorectal cancer. BACKGROUND:: Recent studies have revealed that the GPS, an inflammation-based prognostic score that includes only C-reactive protein (CRP) and albumin, is a useful tool for predicting postoperative outcome in cancer patients. However, few studies have investigated the GPS in the field of colorectal surgery. METHODS:: The GPS was calculated on the basis of admission data as follows: patients with an elevated level of both CRP (>10 mg/L) and hypoalbuminemia (Alb <35 g/L) were allocated a score of 2, and patients showing 1 or none of these blood chemistry abnormalities were allocated a score of 1 or 0, respectively. Prognostic significance was analyzed by univariate and multivariate analyses. RESULTS:: A total of 315 patients were evaluated. Kaplan-Meier analysis and log-rank test revealed that a higher GPS predicted a higher risk of postoperative mortality (P < 0.01). Univariate analyses revealed that postoperative TNM was the most sensitive predictor of postoperative mortality (odds ratio, 0.148; 95% confidence interval, 0.072-0.304; P < 0.0001). Multivariate analyses using factors such as age, sex, tumor site, serum carcinoembryonic antigen, CA19-9, CA72-4, CRP, albumin, and GPS revealed that GPS (odds ratio, 0.165; 95% confidence interval, 0.037-0.732; P = 0.0177) was associated with postoperative mortality. CONCLUSIONS:: Preoperative GPS is considered to be a useful predictor of postoperative mortality in patients with colorectal cancer. [Abstract]

Uen YH, Lin SR, Wu DC, Su YC, Wu JY, Cheng TL, Chi CW, Wang JY
Prognostic Significance of Multiple Molecular Markers for Patients With Stage II Colorectal Cancer Undergoing Curative Resection.
Ann Surg. 2007 Dec;246(6):1040-1046.
OBJECTIVE:: The aim of this study was to determine whether our constructed high-sensitivity colorimetric membrane-array method could detect circulating tumor cells (CTCs) in the peripheral blood of stage II colorectal cancer (CRC) patients and so identify a subgroup of patients who are at high risk for relapse. SUMMARY BACKGROUND DATA:: Adjuvant chemotherapy is not routinely recommended in patients diagnosed with UICC stage II CRC. However, up to 30% of patients with stage II disease relapse within 5 years of surgery from recurrent or metastatic disease. The identification of reliable prognostic factors for high-risk stage II CRC patients is imperative. METHODS:: Membrane-arrays consisting of a panel of mRNA markers that included human telomerase reverse transcription (hTERT), cytokeratin-19 (CK-19), cytokeratin-20 (CK-20), and carcinoembryonic antigen (CEA) mRNA were used to detect CTCs in the peripheral blood of 194 stage II CRC patients who underwent potentially curative (R0) resection between January 2002 and December 2005. Digoxigenin (DIG)-labeled cDNA were amplified by RT-PCR from the peripheral blood samples, which were then hybridized to the membrane-array. All patients were followed up regularly, and their outcomes were investigated completely. RESULTS:: Overall, 53 of 194 (27.3%) stage II patients were detected with the expression of all 4 mRNA markers using the membrane-array method. After a median follow up of 40 months, 56 of 194 (28.9%) developed recurrence/metastases postoperatively. Univariately, postoperative relapse was significantly correlated with the depth of invasion (P < 0.001), the presence of vascular invasion (P < 0.001), the presence of perineural invasion (P = 0.048), the expression of all 4 mRNA markers (P < 0.001), and the number of examined lymph nodes (P = 0.031). Meanwhile, using a multivariate logistic regression analysis, T4 depth of tumor invasion (P = 0.013), the presence of vascular invasion (P = 0.032), and the expression of all 4 mRNA markers (P < 0.001) were demonstrated to be independent predictors for postoperative relapse. Combination of the depth of tumor invasion, vascular invasion, and all 4 mRNA markers as predictors of postoperative relapse showed that patients with any 1 positive predictor had a hazard ratio of about 27-fold to develop postoperative relapse (P < 0.001; 95% CI = 11.42-64.40). The interval between the detection of all 4 positive molecular markers and subsequently developed postoperative relapse ranged from 4 to 10 months (median: 7 months). Furthermore, the expression of all 4 mRNA markers in all stage II CRC patients, or either stage II colon or rectal cancer patients were strongly correlated with poorer relapse-free survival rates by survival analyses (all P < 0.001). CONCLUSIONS:: The pilot study suggests that the constructed membrane-array method for the detection of CTCs is a potential auxiliary tool to conventional clinicopathological variables for the prediction of postoperative relapse in stage II CRC patients who have undergone curative resection. [Abstract]

Chevallier JM, Paita M, Rodde-Dunet MH, Marty M, Nogues F, Slim K, Basdevant A
Predictive Factors of Outcome After Gastric Banding: A Nationwide Survey on the Role of Center Activity and Patients' Behavior.
Ann Surg. 2007 Dec;246(6):1034-1039.
BACKGROUND:: Systematic studies of postoperative outcome of bariatric surgery provide information on the predictors of success. Surgeon's and institution experience and patient's behavior after surgery are key determinant of success or failure. Data on clinical trials generally reflect the experience of skilled obesity surgery centers. Little is known about the current practice at a nationwide level. The present study was realized in the frame of a national survey on medical and surgical practices conducted by the public health insurance system. The objective was to analyze systematically and prospectively the outcome of all bariatric surgery procedures consecutively performed in a given period, as registered by the French National Medical Insurance Service. This study at a nationwide level focused on predictive factors of success and analyzed how the experience of the centers relates to the patients' outcomes at 1 and 2 years after surgery. METHODS:: This study examined prospectively the 2-year predictors of success of all consecutive 1236 bariatric operations performed at a nationwide level. Most (87.3%) were laparoscopic adjustable gastric banding (LAGB), so that the non-LAGB were eliminated from the study. Data were collected independently by consultants of the French National Medical Insurance Service: characteristics of the patients, evolution of body mass index (BMI), physical activity and comorbidities, changes in behavior, complications, reoperations. Information was available on the activity of the surgical teams. Excess weight loss (EWL) >50% was considered a "success," and EWL <50% "not a success." A backstep logistic regression (likelihood ratio test) was used to determine predictive factors. RESULTS:: Statistical analysis showed significant differences in EWL with the following data: age <40 years (P < 0.01), initial BMI <50 kg/m (P < 0.001), experience of the surgeon(s) >2 procedures per week (P < 0.01), recovery of physical activity (P < 0.001), and change in eating habits (P < 0.001). Compared with 15- to 39-year-old patients, 40- to 49-year-old patients have a 1.5 higher risk not to have a success after surgery and over 50-year-old patients a 1.8 higher risk. Morbidly obese patients (40 < BMI < 49) had a 2.6 times higher risk not to have a success than patients with severe obesity (35 < BMI < 39). Superobese patients (BMI >50) had a 5.4 times higher risk not to succeed than patients with severe obesity. Being operated by a team with a surgical activity over 15 bariatric procedures/2 months doubles the chance of a successful operation when compared with patients operated by surgical teams having only performed 1 or 2 bariatric procedures. Patients who had not recovered or increased their physical activity after operation had a 2.3 times higher risk not to have a success than those who did. Patients who had not changed their eating habits had a 2.2 times higher risk not to have a success than those who did. CONCLUSIONS:: This nationwide survey shows that the best profile for a success after gastric banding is a patient <40 years, with an initial BMI <50 kg/m, willing to change his eating habits and to recover or increase his physical activity after surgery and who has been operated by a team usually performing >2 bariatric procedures per week. This study emphasizes that obesity surgery requires a significant experience of the surgical team and a multidisciplinary approach to improve behavioral changes. [Abstract]

Peeters A, O?brien PE, Laurie C, Anderson M, Wolfe R, Flum D, Macinnis RJ, English DR, Dixon J
Substantial Intentional Weight Loss and Mortality in the Severely Obese.
Ann Surg. 2007 Dec;246(6):1028-1033.
OBJECTIVE:: To compare all-cause mortality in a surgical weight loss cohort with a similarly aged, obese population-based cohort. SUMMARY BACKGROUND DATA:: Significant weight loss following bariatric surgery improves the comorbidities associated with obesity. Improved survival as a result of surgical weight loss has yet to be clearly demonstrated using clinical data. METHODS:: The surgical weight loss cohort was a series of consecutive patients treated with a laparoscopic adjustable gastric band in Melbourne between June 1994 and April 2005. The Melbourne Collaborative Cohort Study (MCCS) provided a community control cohort, recruited between 1992 and 1994 and followed to June 2005 to determine vital status. Height and weight were recorded at baseline in both studies. Subjects between 37 and 70 years and with a body mass index (BMI) of >/=35 were included. Vital status was determined by follow-up and searching of death registries. Survival time was compared using Kaplan-Meier estimates, and hazard of death was determined using Cox regression, adjusting for sex, age at baseline, and BMI at baseline. RESULTS:: Of 966 weight loss patients (mean age 47 years, mean BMI 45 kg/m), the median follow-up time was 4 years. Mean weight loss after 2 years was 22.8% +/- 9% (58% of excess weight). The MCCS cohort included 2119 severely obese members (mean age, 55 years; mean BMI, 38 kg/m; median follow-up time, 12 years). There were 4 deaths in the weight loss cohort and 225 deaths in the MCCS cohort. Weight loss patients had 72% lower hazard of death than the community control cohort (hazard ratio, 0.28; 95% confidence interval, 0.10-0.85). CONCLUSIONS:: Substantial surgical weight loss in a morbidly obese population was associated with a significant survival advantage. [Abstract]

Nguyen NT, Hinojosa MW, Fayad C, Varela E, Konyalian V, Stamos MJ, Wilson SE
Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery.
Ann Surg. 2007 Dec;246(6):1021-7.
BACKGROUND:: Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. OBJECTIVE:: To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. PATIENTS AND INTERVENTIONS:: Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. RESULTS:: During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01). CONCLUSIONS:: Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures. [Abstract]

Bright T, Watson DI, Tam W, Game PA, Astill D, Ackroyd R, Wijnhoven BP, Devitt PG, Schoeman MN
Randomized Trial of Argon Plasma Coagulation Versus Endoscopic Surveillance for Barrett Esophagus After Antireflux Surgery: Late Results.
Ann Surg. 2007 Dec;246(6):1016-1020.
OBJECTIVE:: To determine the efficacy of endoscopic argon plasma coagulation (APC) for ablation of Barrett esophagus. SUMMARY BACKGROUND DATA:: APC has been used to ablate Barrett esophagus. However, the long-term outcome of this treatment is unknown. This study reports 5-year results from a randomized trial of APC versus surveillance for Barrett esophagus in patients who had undergone a fundoplication for the treatment of gastroesophageal reflux. METHODS:: Fifty-eight patients with Barrett esophagus were randomized to undergo either ablation using APC or ongoing surveillance. At a mean 68 months after treatment, 40 patients underwent endoscopy follow-up. The efficacy of treatment, durability of the neosquamous re-epithelialization, and safety of the procedure were determined. RESULTS:: Initially, at least 95% ablation of the metaplastic mucosa was achieved in all treated patients. At the 5-year follow-up, 14 of 20 APC patients continued to have at least 95% of their previous Barrett esophagus replaced by neosquamous mucosa, and 8 of these had complete microscopic regression of the Barrett esophagus. Five of the 20 surveillance patients had more than 95% regression of their Barrett esophagus, and 4 of these had complete microscopic regression (1 after subsequent APC treatment). The length of Barrett esophagus shortened significantly in both study groups, although the extent of regression was greater after APC treatment (mean 5.9-0.8 cm vs. 4.6-2.2 cm). Two patients who had undergone APC treatment developed a late esophageal stricture, which required endoscopic dilation, and 2 patients in the surveillance group developed high-grade dysplasia during follow-up. CONCLUSIONS:: Regression of Barrett esophagus after fundoplication is more likely, and greater in extent, in patients who undergo ablation with APC. In most patients treated with APC the neosquamous mucosa remains stable at up to 5-year follow-up. The development of high-grade dysplasia only occurred in patients who were not treated with APC. [Abstract]

Braga M, Frasson M, Vignali A, Zuliani W, Di Carlo V
Open right colectomy is still effective compared to laparoscopy: results of a randomized trial.
Ann Surg. 2007 Dec;246(6):1010-5.
OBJECTIVE:: The primary goal of this study was to clarify whether a laparoscopic (LPS) approach could be considered the dominant strategy in patients undergoing right colectomy. SUMMARY BACKGROUND DATA:: Because few nonrandomized or small sized studies have been carried out so far, definitive conclusions about the role of LPS right colectomy cannot be drawn. METHODS:: Two hundred twenty-six patients, candidates for right colectomy, were randomly assigned to LPS (n = 113) or open (n = 113) resection. The postoperative care protocol was the same for both groups. Trained members of the surgical staff who were not involved in the study registered postoperative morbidity. Follow-up was carried out for 30 days after hospital discharge. The following costs were calculated: surgical instruments, operative room occupation, routine care, postoperative morbidity, and hospitalization. RESULTS:: Conversion rate in the LPS group was 2.6% (3 of 113). Operative time (in minutes) was longer in the LPS group (131 vs. 112, P = 0.01). Postoperative morbidity rate was 18.6% in the open group and 13.3% in the LPS group (P = 0.31). Postoperative stay was one day longer in the open group (P = 0.002). No difference was found in postoperative quality of life. The additional operative charge in the LPS group was euro980 per patient randomized (euro821 for surgical instruments and euro159 for longer operative time). The savings in the LPS group was euro390 per patient randomized (euro144 for shorter length of hospital stay and euro246 for the lower cost of postoperative morbidity). The net balance resulted in a euro590 extra charge per patient randomly allocated to the LPS group. CONCLUSION:: LPS slightly improved postoperative recovery. This translated into a savings that covered only 40% of the extra operative charge. Therefore, open right colectomy could be still considered an effective procedure. [Abstract]

Morino M, Toppino M, Forestieri P, Angrisani L, Allaix ME, Scopinaro N
Mortality After Bariatric Surgery: Analysis of 13,871 Morbidly Obese Patients From a National Registry.
Ann Surg. 2007 Dec;246(6):1002-1009.
OBJECTIVE:: To define mortality rates and risk factors of different bariatric procedures and to identify strategies to reduce the surgical risk in patients undergoing bariatric surgery. SUMMARY BACKGROUND DATA:: Postoperative mortality is a rare event after bariatric surgery. Therefore, comprehensive data on mortality are lacking in the literature. METHODS:: A retrospective analysis of a large prospective database was carried out. The Italian Society of Obesity Surgery runs a National Registry on bariatric surgery where all procedures performed by members of the Society should be included prospectively. This Registry represents at present the largest database on bariatric surgery worldwide. RESULTS:: Between January 1996 and January 2006, 13,871 bariatric surgical procedures were included: 6122 adjustable silicone gastric bandings (ASGB), 4215 vertical banded gastroplasties (VBG), 1106 gastric bypasses, 1988 biliopancreatic diversions (BPD), 303 biliointestinal bypasses, and 137 various procedures. Sixty day mortality was 0.25%. The type of surgical procedure significantly influenced (P < 0.001) mortality risk: 0.1% ASGB, 0.15% VBG, 0.54% gastric bypasses, 0.8% BPD. Pulmonary embolism represented the most common cause of death (38.2%) and was significantly higher in the BPD group (0.4% vs. 0.07% VBG and 0.03% ASGB). Other causes of mortality were the following: cardiac failure 17.6%, intestinal leak 17.6%, respiratory failure 11.8%, and 1 case each of acute pancreatitis, cerebral ischemia, bleeding gastric ulcer, intestinal ischemia, and internal hernia. Therefore, 29.4% of patients died as a result of a direct technical complication of the procedure. Additional significant risk factors included open surgery (P < 0.001), prolonged operative time (P < 0.05), preoperative hypertension (P < 0.01) or diabetes (P < 0.05), and case load per Center (P < 0.01). CONCLUSIONS:: Mortality after bariatric surgery is a rare event. It is influenced by different risk factors including type of surgery, open surgery, prolonged operative time, comorbidities, and volume of activity. In defining the best bariatric procedure for each patient the different mortality risks should be taken into account. Choice of the procedure, prevention, early diagnosis, and therapy for cardiovascular complications may reduce postoperative mortality. [Abstract]

Omloo JM, Lagarde SM, Hulscher JB, Reitsma JB, Fockens P, van Dekken H, Ten Kate FJ, Obertop H, Tilanus HW, van Lanschot JJ
Extended Transthoracic Resection Compared With Limited Transhiatal Resection for Adenocarcinoma of the Mid/Distal Esophagus: Five-Year Survival of a Randomized Clinical Trial.
Ann Surg. 2007 Dec;246(6):992-1001.
OBJECTIVE:: To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival. BACKGROUND:: A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available. METHODS:: A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy. RESULTS:: After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02). CONCLUSION:: There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy. [Abstract]

Maathuis MH, Manekeller S, van der Plaats A, Leuvenink HG, 't Hart NA, Lier AB, Rakhorst G, Ploeg RJ, Minor T
Improved Kidney Graft Function After Preservation Using a Novel Hypothermic Machine Perfusion Device.
Ann Surg. 2007 Dec;246(6):982-991.
OBJECTIVE:: To study graft function and ischemia/reperfusion injury of porcine kidneys after preservation with the new Groningen Machine Perfusion (GMP) system versus static cold storage (CS). INTRODUCTION:: The increasing proportion of marginal and nonheart beating donors necessitates better preservation methods to maintain adequate graft viability. Hypothermic machine preservation (HMP) is a promising alternative to static CS. We have therefore developed and tested an HMP device, which is portable and actively oxygenates the perfusate via an oxygenator. The aim of the present study was to examine the efficacy of the GMP system in a transplantation experiment. MATERIALS AND METHODS:: In a porcine autotransplantation model, kidneys were retrieved and either cold stored in University of Wisconsin CS for 20 hours at 4 degrees C or subjected to HMP using University of Wisconsin machine perfusion at 4 degrees C with 2 different pressure settings: 30/20 mm Hg or 60/40 mm Hg. RESULTS:: HMP at 30/20 mm Hg was found to better preserve the viability of kidneys reflected by improved cortical microcirculation, less damage to the proximal tubule, less damage mediated by reactive oxygen species, less proinflammatory cytokine expression, and better functional recovery after transplantation. However, high perfusion pressures (60/40 mm Hg) resulted in higher expression of von Willebrand factor and monocyte chemotactic peptide-1 in postpreservation biopsies and subsequent graft thrombosis in 2 kidneys. CONCLUSIONS:: It is concluded that the GMP system improves kidney graft viability and perfusion pressures are critically important for outcome. [Abstract]

Westerdahl J, Bergenfelz A
Unilateral Versus Bilateral Neck Exploration for Primary Hyperparathyroidism: Five-Year Follow-up of a Randomized Controlled Trial.
Ann Surg. 2007 Dec;246(6):976-81.
OBJECTIVE:: To compare long-term patient outcome in a prospective randomized controlled trial between unilateral and bilateral neck exploration for primary hyperparathyroidism (pHPT). SUMMARY BACKGROUND DATA:: Minimal invasive and/or focused parathyroidectomy has challenged the traditional bilateral neck exploration for pHPT. Between 1997 and 2001, we conducted the first unselected randomized controlled trial of unilateral versus bilateral neck exploration for pHPT. The results showed that unilateral exploration is a surgical strategy with distinct advantages in the early postoperative period. However, concerns have been raised that limited parathyroid exploration could increase the risk for recurrent pHPT during long-term follow-up. METHODS:: Ninety-one patients with the diagnosis of pHPT were randomized to unilateral or bilateral neck exploration. Preoperative scintigraphy and intraoperative parathyroid hormone measurement guided the unilateral exploration. Gross morphology and frozen section determined the extent of parathyroid tissue resection in the bilateral group. Follow-up was performed after 6 weeks, 1 year, and 5 years postoperatively. RESULTS:: Seventy-one patients were available for 5-year follow-up. There were no differences in serum ionized calcium and parathyroid hormone, respectively, between patients in the unilateral and bilateral group. Overall 6 patients have been found to have persistent (n = 3) or recurrent (n = 3) pHPT; 4 patients in the unilateral group (3 of these 4 patients were bilaterally explored) and 2 patients in the bilateral group. Three of 6 failures were unexpectedly found to have multiple endocrine neoplasia mutations. One patient with solitary adenoma in the bilateral group still required vitamin D substitution 5 years after surgery. CONCLUSION:: Unilateral neck exploration with intraoperative parathyroid hormone assessment provides the same long-term results as bilateral neck exploration, and is thus a valid strategy for the surgical treatment of pHPT. [Abstract]

M�ller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, B�chler MW
Is There Still a Role for Total Pancreatectomy?
Ann Surg. 2007 Dec;246(6):966-975.
OBJECTIVE:: To evaluate the perioperative and long-term results of total pancreatectomy (TP), and to assess whether it provides morbidity, mortality, and quality of life (QoL) comparable to those of the pylorus-preserving (pp)-Whipple procedure in patients with benign and malignant pancreatic disease. SUMMARY BACKGROUND DATA:: TP was abandoned for decades because of high peri- and postoperative morbidity and mortality. Because selected pancreatic diseases are best treated by TP, and pancreatic surgery and postoperative management of exocrine and endocrine insufficiency have significantly improved, the hesitance to perform a TP is disappearing. PATIENTS AND METHODS:: In a prospective study conducted from October 2001 to November 2006, all patients undergoing a TP (n = 147; 100 primary elective TP [group A], 24 elective TP after previous pancreatic resection [group B], and 23 completion pancreatectomies for complications) were included, and perioperative and late follow-up data, including the QoL (EORTC QLQ-C30 questionnaire), were evaluated. A matched-pairs analysis with patients receiving a pp-Whipple operation was performed. RESULTS:: Indications for an elective TP (group A + B) were pancreatic and periampullary adenocarcinoma (n = 71), other neoplastic pancreatic tumors (intraductal papillary mucinous neoplasms, neuroendocrine tumors, cystic tumors; n = 34), metastatic lesions (n = 8), and chronic pancreatitis (n = 11). There were 73 men and 51 women with a mean age of 60.9 +/- 11.3 years. Median intraoperative blood loss was 1000 mL and median operation time was 380 minutes. Postoperative surgical morbidity was 24%, medical morbidity was 15%, and mortality was 4.8%. The relaparotomy rate was 12%. Median postoperative hospital stay was 11 days. After a median follow-up of 23 months, global health status of TP patients was comparable to that of pp-Whipple patients, although a few single QoL items were reduced. All patients required insulin and exocrine pancreatic enzyme replacements. The mean HbA1c value was 7.3% +/- 0.9%. CONCLUSION:: In this cohort study, mortality and morbidity rates after elective TP are not significantly different from the pp-Whipple. Because of improvements in postoperative management, QoL is acceptable, and is almost comparable to that of pp-Whipple patients. Therefore, TP should no longer be generally avoided, because it is a viable option in selected patients. [Abstract]

Gertsch P, Vandoni RE, Pelloni A, Krpo A, Alerci M
Localized Hepatic Ischemia After Liver Resection: A Prospective Evaluation.
Ann Surg. 2007 Dec;246(6):958-965.
OBJECTIVE:: To prospectively assess the frequency, severity, and extension of localized ischemia in the remaining liver parenchyma after hepatectomy. BACKGROUND:: Major blood loss and postoperative ischemia of the remnant liver are known factors contributing to morbidity after liver surgery. The segmental anatomy of the liver and the techniques of selective hilar or suprahilar clamping of the Glissonian sheaths permit identification of ischemia on the surface of the corresponding segments for precise section of the parenchyma. Incomplete resection of a segment, or compromised blood supply to the remaining liver, may result in ischemia of various extension and severity. METHODS:: Patients undergoing hepatectomy received enhanced computerized tomodensitometry with study of the arterial and venous phases within 48 hours after resection. We defined hepatic ischemia as reduced or absent contrast enhancement during the venous phase. We classified the severity of ischemia as hypoperfusion, nonperfusion, or necrosis. The extension of ischemia was identified as marginal, partial, or segmental. Factors that may influence postoperative ischemia were analyzed by univariate and multivariate analyses. RESULTS:: One hundred fifty consecutive patients (70 F, 80 M, mean age 62 +/- 12 years) underwent 64 major and 81 minor hepatectomies and 5 wedge resections. We observed radiologic signs of ischemia in 38 patients (25.3%): 33 hypoperfusions (17 marginal, 12 partial, and 4 segmental), 3 nonperfusions (1 marginal, 1 partial, and 1 segmental), and 2 necroses (1 partial, 1 segmental). One patient with a segmental necrosis underwent an early reoperation. In all other cases, the evolution was spontaneously favorable. Postoperative peak levels of serum aspartate aminotransferase and alanine aminotransferase were significantly higher in patients with ischemia. Patients with ischemia had a significantly higher risk of developing a biliary leak (18.4% vs. 2.6%, P < 0.001). There was no correlation between liver ischemia and mortality (2%). None of the following factors were associated with ischemia after univariate and multivariate analysis: age, preoperative bilirubin level, liver fibrosis, malignant tumor, type of hepatectomy, surface of transection, weight of resected liver, Pringle maneuver, blood loss, and number of transfusions. CONCLUSIONS:: Some form of localized ischemia after hepatectomy was detected in 1 of 4 of our patients. Its clinical expression was discreet in the large majority of cases, even if it might have been one of the underlying causes of postoperative biliary fistulas. Clinical observation is sufficient to detect the rare patient with suspected postoperative liver ischemia that will require active treatment. [Abstract]

Lerut JP, Orlando G, Adam R, Schiavo M, Klempnauer J, Mirza D, Boleslawski E, Burroughs A, Sell�s CF, Jaeck D, Pfitzmann R, Salizzoni M, S�derdahl G, Steininger R, Wettergren A, Mazzaferro V, Le Treut YP, Karam V
The Place of Liver Transplantation in the Treatment of Hepatic Epitheloid Hemangioendothelioma: Report of the European Liver Transplant Registry.
Ann Surg. 2007 Dec;246(6):949-957.
BACKGROUND:: Hepatic epitheloid hemangioendothelioma (HEHE) is a rare low-grade vascular tumor. Its treatment algorithm is still unclear mainly due to a lack of larger clinical experiences with detailed long-term follow-up. MATERIAL AND METHODS:: Fifty-nine patients, reported to the European Liver Transplant Registry, were analyzed to define the role of liver transplantation (LT) in the treatment of this disease. Eleven (19%) patients were asymptomatic. Eighteen (30.5%) patients had pre-LT surgical [hepatic (7 patients) and extrahepatic (3 patients)] and/or systemic or locoregional (10 patients) medical therapy. Ten (16.9%) patients had extrahepatic disease localization before or at the time of LT. Follow-up was complete for all patients with a median of 92.5 (range, 7-369) from moment of diagnosis and a median of 78.5 (range, 1-245) from the moment of LT. RESULTS:: HEHE was bilobar in 96% of patients; 86% of patients had more than 15 nodules in the liver specimen. Early (<3 months) and late (>3 months) post-LT mortality was 1.7% (1 patient) and 22% (14 patients). Fourteen (23.7%) patients developed disease recurrence after a median time of 49 months (range, 6-98). Nine (15.3%) patients died of recurrent disease and 5 are surviving with recurrent disease. One-, 5-, and 10- year patient survival rates from moment of transplantation for the whole series are 93%, 83%, 72%. Pre-LT tumor treatment (n = 18) (89%, 89%, and 68% 1-, 5-, and 10-year survival rates from moment of LT vs. 95%, 80%, and 73% in case of absence of pre-LT treatment), lymph node (LN) invasion (n = 18) (96%, 81%, and 71% 1-, 5-, and 10-year survival rates vs. 83%, 78%, and 67% in node negative patients) and extrahepatic disease localization (n = 10) (90%, 80%, and 80% 1-, 5-, and 10-year survival rates vs. 94%, 83%, and 70% in case of absence of extrahepatic disease) did not significantly influence patient survival whereas microvascular (n = 24) (96%, 75%, 52% 1-, 5-, and 10-year survival vs. 96%, 92%, 85% in case of absence of microvascular invasion) and combined micro- and macrovascular invasion (n = 28) (90%, 72%, and 54% 1-,5-, and 10-year survival vs. 96%, 92%, and 85% in case of absence of vascular invasion, P = 0.03) did. Disease-free survival rates at 1, 5, and 10 years post-LT are 90%, 82%, and 64%. Disease-free survival is not significantly influenced by pre-LT treatment, LN status, extrahepatic disease localization, and vascular invasion. CONCLUSIONS:: The results of the largest reported transplant series in the treatment of HEHE are excellent. Preexisting extrahepatic disease localization as well as LN involvement are not contraindications to LT. Microvascular or combined macro-microvascular invasion significantly influence survival after LT. LT therefore should be offered as a valid therapy earlier in the disease course of these, frequently young, patients. Recurrent (allograft) disease should be treated aggressively as good long-term survivals can be obtained. Long-term prospective follow-up multicenter studies as well as the evaluation of antiangiogenic drugs are necessary to further optimize the treatment of this rare vascular hepatic disorder. [Abstract]

McCormack L, Petrowsky H, Jochum W, Mullhaupt B, Weber M, Clavien PA
Use of Severely Steatotic Grafts in Liver Transplantation: A Matched Case-Control Study.
Ann Surg. 2007 Dec;246(6):940-948.
BACKGROUND:: Although there is a worldwide need to expand the pool of available liver grafts, cadaveric livers with severe steatosis (>60%) are discarded for orthotopic liver transplantation (OLT) by most centers. METHODS:: We analyzed patients receiving liver grafts with severe steatosis between January 2002 and September 2006. These patients were matched 1:2 with control patients without severe steatosis according to status the waiting list, recipient age, recipient body mass index (BMI), and model for end-stage liver disease (MELD) score. Primary end points were the incidence of primary graft nonfunction (PNF), and graft and patient survival. Secondary end points included primary graft dysfunction (PDF), the incidence of postoperative complications, and histologic assessment of steatosis in follow-up biopsies. We also conducted a survey on the use of grafts with severe steatosis among leading European liver transplant centers. RESULTS:: During the study period, 62 patients dropped out of the waiting list and 45 of them died due to progression of disease. Of 118 patients who received transplants 20 (17%) received a graft with severe steatosis during this period. The median degree of total liver steatosis was 90% (R = 65%-100%) for the steatotic group. The steatotic (n = 20) and matched control group (n = 40) were comparable in terms of recipient age, BMI, MELD score, and cold ischemia time. The steatotic group had a significantly higher rate of PDF and/or renal failure. Although the median intensive care unit (ICU) and hospital stay were not significantly different between both groups, the proportion of patients with long-term ICU (>/=21 days) and hospital (>/=40 days) stay was significantly higher for patients with a severely steatotic graft. Sixty-day mortality (5% vs. 5%) and 3-year patient survival rate (83% vs. 84%) were comparable between the control and severe steatosis group. Postoperative histologic assessment demonstrated that the median total amount of liver steatosis decreased significantly (median: 90% to 15%, P < 0.001). Our survey showed that all but one of the European centers currently reject liver grafts with severe steatosis for any recipient. CONCLUSION:: Due to the urgent need of liver grafts, severely steatotic grafts should be no longer discarded for OLT. Maximal effort must be spent when dealing with these high-risk organs but the use of severely steatotic grafts may save the lives of many patients who would die on the waiting list. [Abstract]

Sperti C, Bissoli S, Pasquali C, Frison L, Liessi G, Chierichetti F, Pedrazzoli S
18-Fluorodeoxyglucose Positron Emission Tomography Enhances Computed Tomography Diagnosis of Malignant Intraductal Papillary Mucinous Neoplasms of the Pancreas.
Ann Surg. 2007 Dec;246(6):932-939.
OBJECTIVE:: To assess the reliability of 18-fluorodeoxyglucose positron emission tomography (18-FDG PET) in distinguishing benign from malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas and its contribution to surgical decision making. SUMMARY BACKGROUND DATA:: Pancreatic IPMNs are increasingly recognized, often as incidental findings, especially in people over age 70 and 80. Computed tomography (CT) and magnetic resonance (MR) are unreliable in discriminating a benign from a malignant neoplasm. 18-FDG PET as imaging procedure based on the increased glucose uptake by tumor cells has been suggested for diagnosis and staging of pancreatic cancer. METHODS:: From January 1998 to December 2005, 64 patients with suspected IPMNs were prospectively investigated with 18-FDG PET in addition to conventional imaging techniques [helical-CT in all and MR and magnetic resonance cholangiopancreatography (MRCP) in 60]. 18-FDG PET was analyzed visually and semiquantitatively using the standard uptake value (SUV). The validation of the diagnosis was made by a surgical procedure (n = 44), a percutaneous biopsy (n = 2), main duct cytology (n = 1), or follow-up (n = 17). Mean and median follow-up times were 25 and 27.5 months, respectively (range, 12-90 months). RESULTS:: Twenty-seven patients (42%) were asymptomatic. Forty-two patients underwent pancreatic resection, 2 palliative surgery, and 20 did not undergo surgery. An adenoma was diagnosed in 13 patients, a borderline tumor in 8, a carcinoma in situ in 5, and an invasive cancer in 21; in 17 patients a tumor sampling was not performed and therefore the histology remained undetermined. Positive criteria of increased uptake on 18-FDG PET was absent in 13 of 13 adenomas and 7 of 8 borderline IPMNs, but was present in 4 of 5 carcinoma in situ (80%) and in 20 of 21 invasive cancers (95%). Conventional imaging technique was strongly suggestive of malignancy in 2 of 5 carcinomas in situ and in 13 of 21 invasive carcinomas (62%). Furthermore, conventional imaging had findings that would be considered falsely positive in 1 of 13 adenomas (8%) and in 3 of 8 borderline neoplasms (37.5%). Therefore, positive 18-FDG PET influenced surgical decision making in 10 patients with malignant IPMN. Furthermore, negative findings on 18-FDG PET prompted us to use a more limited resection in 15 patients, and offered a follow-up strategy in 18 patients (3 positive at CT scan) for the future development of a malignancy. CONCLUSIONS:: 18-FDG PET is more accurate than conventional imaging techniques (CT and MR) in distinguishing benign from malignant (invasive and noninvasive) IPMNs. 18-FDG PET seems to be much better than conventional imaging techniques in selecting IPMNs patients, especially when old and asymptomatic, for surgical treatment or follow-up. [Abstract]

Recent Articles in American Journal of Transplantation : Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons

Mueller TF, Reeve J, Jhangri GS, Mengel M, Jacaj Z, Cairo L, Obeidat M, Todd G, Moore R, Famulski KS, Cruz J, Wishart D, Meng C, Sis B, Solez K, Kaplan B, Halloran PF
The Transcriptome of the Implant Biopsy Identifies Donor Kidneys at Increased Risk of Delayed Graft Function.
Am J Transplant. 2007 Nov 16;
Improved assessment of donor organ quality at time of transplantation would help in management of potentially usable organs. The transcriptome might correlate with risk of delayed graft function (DGF) better than conventional risk factors. Microarray results of 87 consecutive implantation biopsies taken postreperfusion in 42 deceased (DD) and 45 living (LD) donor kidneys were compared to clinical and histopathology-based scores. Unsupervised analysis separated the 87 kidneys into three groups: LD, DD1 and DD2. Kidneys in DD2 had a greater incidence of DGF (38.1 vs. 9.5%, p < 0.05) than those in DD1. Clinical and histopathological risk scores did not discriminate DD1 from DD2. A total of 1051 transcripts were differentially expressed between DD1 and DD2, but no transcripts separated DGF from immediate graft function (adjusted p < 0.01). Principal components analysis revealed a continuum from LD to DD1 to DD2, i.e. from best to poorest functioning kidneys. Within DD kidneys, the odds ratio for DGF was significantly increased with a transcriptome-based score and recipient age (p < 0.03) but not with clinical or histopathologic scores. The transcriptome reflects kidney quality and susceptibility to DGF better than available clinical and histopathological scoring systems. [Abstract]

Harbell JW, Dunn TB, Fauda M, John DG, Goldenberg AS, Teperman LW
Transmission of Anaplastic Large Cell Lymphoma via Organ Donation After Cardiac Death.
Am J Transplant. 2007 Nov 16;
Recently, donation after cardiac death (DCD) has been encouraged in order to expand the donor pool. We present a case of anaplastic T-cell lymphoma transmitted to four recipients of solid organ transplants from a DCD donor suspected of having bacterial meningitis. On brain biopsy, the donor was found to have anaplastic central nervous system T-cell lymphoma, and the recipient of the donor's pancreas, liver and kidneys were found to have involvement of T-cell lymphoma. The transplanted kidneys and pancreas were excised from the respective recipients, and the kidney and pancreas recipients responded well to chemotherapy. The liver recipient underwent three cycles of chemotherapy, but later died due to complications of severe tumor burden. We recommend transplanting organs from donors with suspected bacterial meningitis only after identification of the infectious organism. In cases of lymphoma transmission, excision of the graft may be the only chance at long-term survival. [Abstract]

Schaub S, Scornik JC
High-Tech Detection of HLA Antibodies and Complement: Prospects and Limitations.
Am J Transplant. 2007 Nov 16; [Abstract]

Ulrich C, Heine GH, Gerhart MK, K�hler H, Girndt M
Proinflammatory CD14+CD16+ Monocytes Are Associated With Subclinical Atherosclerosis in Renal Transplant Patients.
Am J Transplant. 2007 Nov 16;
Atherosclerotic cardiovascular disease is a major cause of death in renal transplant (TX) recipients. Atherosclerotic lesions are characterized by monocytic infiltration. Circulating monocytes can be divided into functionally distinct subpopulations, among which CD14++CD16+ and CD14+CD16+ monocytes (summarized as CD16+ monocytes) are proinflammatory cells. We hypothesized that the frequency of circulating CD16+ monocytes is associated with subclinical atherosclerosis in TX patients. Monocyte subpopulations were quantified in 95 TX and 31 hemodialysis patients (HD). In TX patients, subclinical atherosclerosis was determined by carotid intima media thickness (IMT) measurement. TX patients had lower frequencies of CD16+ monocytes than HD patients. When stratifying by immunosuppressive treatment, patients on methylprednisolone (MP) therapy had fewer CD14+CD16+ monocytes than patients not receiving MP. CD14+CD16+ monocytes decrease very shortly after transplantation. CD14+CD16+ monocyte frequency correlated with IMT in TX recipients (r = 0.34, p < 0.001). This correlation was most pronounced among patients without MP treatment (r = 0.55, p = 0.02). In a multivariate regression analysis, the association of CD14+CD16+ monocytes with IMT was independent from traditional cardiovascular risk factors. The frequency of proinflammatory CD14+CD16+ monocytes is independently associated with subclinical atherosclerosis in transplant recipients. Further studies on the association between circulating leukocytes and atherosclerosis should take monocyte heterogeneity into account. [Abstract]

Setoguchi K, Ishida H, Shimmura H, Shimizu T, Shirakawa H, Omoto K, Toki D, Iida S, Setoguchi S, Tokumoto T, Horita S, Nakayama H, Yamaguchi Y, Tanabe K
Analysis of Renal Transplant Protocol Biopsies in ABO-Incompatible Kidney Transplantation.
Am J Transplant. 2007 Nov 16;
Numerous studies have shown that protocol biopsies have predictive power. We retrospectively examined the histologic findings and C4d staining in 89 protocol biopsies from 48 ABO-incompatible (ABO-I) transplant recipients, and compared the results with those of 250 controls from 133 ABO-compatible (ABO-C) transplant recipients given equivalent maintenance immunosuppression. Others have shown that subclinical rejection (borderline and grade I) in ABO-C grafts decreased gradually after transplantation. In our study, however, subclinical rejection in the ABO-I grafts was detected in 10%, 14% and 28% at 1, 3 and 6-12 months, respectively. At 6-12 months, mild tubular atrophy was more common in the ABO-C grafts whereas the incidence of transplant glomerulopathy did not differ between the two groups (ABO-C: 7%; ABO-I: 15%; p = 0.57). In the ABO-I transplants, risk factors for transplant glomerulopathy in univariate analysis were positive panel reactivity (relative risk, 45.0; p < 0.01) and a prior history of antibody-mediated rejection (relative risk, 17.9; p = 0.01). Furthermore, C4d deposition in the peritubular capillaries was detected in 94%, with diffuse staining in 66%. This deposition, however, was not linked to antibody-mediated rejection. We conclude that, in the ABO-I kidney transplantation setting, detection of C4d alone in protoc