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1.  Improvement of Sleep Disturbance and Insomnia Following Parathyroidectomy for Primary Hyperparathyroidism 
World journal of surgery  2014;38(3):542-548.
Background
Our aim was to investigate the incidence of sleep disturbance and insomnia in patients with primary hyperparathyroidism (PHPT), and to evaluate the effect of parathyroidectomy.
Methods
A questionnaire was prospectively administered to adult patients with PHPT who underwent curative parathyroidectomy over an 11-month period. The questionnaire, administered pre- and 6-months post-operatively, included the Insomnia Severity Index (ISI) and eight additional questions regarding sleep pattern. Total ISI scores range from 0 to 28, with >7 signifying sleep difficulties and scores >14 indicating clinical insomnia.
Results
Of 197 eligible patients undergoing parathyroidectomy for PHPT, 115 (58.3%) completed the pre- and post-operative questionnaires. The mean age was 60.0±1.2 years and 80.0% were female. Pre-operatively, 72 patients (62.6%) had sleep difficulties, and 29 patients (25.2%) met criteria for clinical insomnia. Clinicopathologic variables were not predictive of clinical insomnia. There was a significant reduction in mean ISI score after parathyroidectomy (10.3±0.6 vs 6.2±0.5, p<0.0001). Post-operatively, 79 patients (68.7%) had an improved ISI score. Of the 29 patients with pre-operative clinical insomnia, 21 (72.4%) had resolution after parathyroidectomy. Pre-operative insomnia patients had an increase in total hours slept after parathyroidectomy (5.4±0.3 vs 6.1±0.3 hours, p=0.02), whereas both insomnia and non-insomnia patients had a decrease in the number of awakenings (3.7±0.4 vs 1.9±0.2 times, p=0.0001).
Conclusion
Sleep disturbances and insomnia are common in patients with PHPT, and the majority of patients will improve after curative parathyroidectomy.
doi:10.1007/s00268-013-2285-1
PMCID: PMC3945278  PMID: 24142330
2.  Predictors of Primary Breast Abscesses and Recurrence 
World journal of surgery  2009;33(12):2582-2586.
Background
We investigated the patients and microbiological risk factors that predispose to the development of primary breast abscesses and subsequent recurrence.
Methods
Patients with a primary breast abscess requiring surgical therapy between January 1, 2000 and December 31, 2006 were reviewed. Recurrent breast abscess was defined by the need for repeated drainage within 6 months. Patient characteristics were compared to the general population and between groups.
Results
A total of 89 patients with a primary breast abscess were identified; 12 (14%) were lactational and 77 (86%) were nonlactational. None of the lactational abscesses recurred, whereas 43 (57%) of the nonlactational abscesses did so (P < 0.01). Compared to the general population, patients with a primary breast abscess were predominantly African American (64% vs. 12%), had higher rates of obesity (body mass index > 30: 43% vs. 22%), and were tobacco smokers (45% vs, 23%) (P < 0.01 for all). The only factor significantly associated with recurrence in the multivariate logistic regression analysis was tobacco smoking (P = 0.003). Compared to patients who did not have a recurrence, patients with recurrent breast abscesses had a higher incidence of mixed bacteria (20.5% vs. 8.9%), anaerobes (4.5% vs. 0%), and Proteus (9.1% vs. 4.4%) but lower incidence of Staphylococcus (4.6% vs. 24.4%) (P < 0.05 for each).
Conclusions
Risk factors for developing a primary breast abscess include African American race, obesity, and tobacco smoking. Patients with recurrent breast abscesses are more likely to be smokers and have mixed bacterial and anaerobic infections. Broader antibiotic coverage should be considered for the higher risk groups.
doi:10.1007/s00268-009-0170-8
PMCID: PMC3892669  PMID: 19669231
4.  Perioperative Immunonutrition in Surgical Cancer Patients: A Summary of a Decade of Research 
World Journal of Surgery  2013;38:803-812.
Background
Immunonutrition is assumed to enhance immune system function. In surgical patients, it is supposed to reduce postoperative complications. However, results of recent clinical trials have been puzzling and have not supported this theory.
Aim
The aim of our study was to evaluate the value of enteral and parenteral postoperative immunonutrition.
Methods
After initial evaluation of 969 patients, the intent-to-treat analysis included 776 patients (female 407, male 466, mean age 61.1 years) undergoing gastric or pancreatic resections between 2001 and 2009. All patients were randomly assigned after surgery to one of the following groups: standard enteral nutrition (SEN), immunomodulating enteral nutrition (IMEN), standard parenteral nutrition (SPN), or immunomodulating parenteral nutrition (IMPN). All malnourished patients received preoperative parenteral nutrition. Number and type of postoperative complications, length of hospitalization (length of stay [LOS]), and vital organ function were assessed.
Results
No statistically significant differences were observed in well-nourished patients, during either enteral or parenteral intervention, independent of the type of intervention (standard or immunomodulating). However, analysis of the malnourished group revealed the positive impact of enteral immunonutrition on reduction of postoperative complications (28.3 vs. 39.2 %, respectively; p = 0.043) and LOS (17.1 and 13.1 days, respectively; p < 0.05) compared with a standard enteral diet. The cross-analysis of SEN, IMEN, SPN, and IMPN was insignificant.
Conclusions
The type of postoperative nutrition was of no importance in well-nourished patients. However, in malnourished patients, enteral immunonutrition helped to improve treatment outcome. These findings suggest its use as a method of choice during the postoperative period.
doi:10.1007/s00268-013-2323-z
PMCID: PMC3956976  PMID: 24178185
5.  Preoperative Platelet Count and Survival Prognosis in Resected Pancreatic Ductal Adenocarcinoma 
World journal of surgery  2008;32(6):1051-1056.
Background
High platelet counts are associated with an adverse effect on survival in various neoplastic entities. The prognostic relevance of preoperative platelet count in pancreatic cancer has not been clarified.
Methods
We performed a retrospective review of 205 patients with ductal adenocarcinoma who underwent surgical resection between 1990 and 2003. Demographic, surgical, and clinicopathologic variables were collected. A cutoff of 300,000/μl was used to define high platelet count.
Results
Of the 205 patients, 56 (27.4%) had a high platelet count, whereas 149 patients (72.6%) comprised the low platelet group. The overall median survival was 17 (2–178) months. The median survival of the high platelet group was 18 (2–137) months, and that of the low platelet group was 15 (2–178) months (p = 0.7). On multivariate analysis, lymph node metastasis, vascular invasion, positive margins, and CA 19–9 > 200 U/ml were all significantly associated with poor survival.
Conclusions
There is no evidence to support preoperative platelet count as either an adverse or favorable prognostic factor in pancreatic ductal adenocarcinoma. Use of 5-year actual survival data confirms that lymph node metastases, positive margins, vascular invasion, and CA 19–9 are predictors of poor survival in resected pancreatic cancer.
doi:10.1007/s00268-007-9423-6
PMCID: PMC3806089  PMID: 18224462
6.  HIV Testing and Epidemiology in a Hospital-Based Surgical Cohort in Malawi 
World journal of surgery  2013;37(9):2122-2128.
Background
Despite the high prevalence of HIV in adults (11 %) in Malawi, testing among surgical patients is not routine. We examined the feasibility of universal opt-out HIV testing and counseling (HTC) on the surgical wards of Kamuzu Central Hospital in Lilongwe, Malawi, and sought to further delineate the role of HIV in surgical presentation and outcome.
Methods
We reviewed HTC and surgical admission records from May to October 2011 and compared these data to data collected prospectively on patients admitted from November 2011 through April 2012, after universal HTC implementation.
Results
Prior to universal HTC, 270 of the 2,606 (10.4 %) surgical admissions were tested; 13 % were HIV-infected. After universal HTC implementation, HTC counselors reviewed 1,961 of the 2,488 admissions (79 %): 310 (16 %) had known status (157 seropositive, 153 seronegative) and 1,651 had unknown status (81 %). Among those with unknown status, 97 % (1,598, of 64 % of all admissions) accepted testing, of whom 9 % were found to be HIV-infected. Patients with longer lengths of stay (LOS) (mean = 11 vs. 5 days, p <0.01) and those who underwent surgical intervention (odds ratio [OR] 2.5; confidence interval [CI] 2.0–3.1) were more likely to have a known status on discharge. HIV was more prevalence in patients with infection and genital/anal warts or ulcers and lower in trauma patients. HIV-positive patients received less surgical intervention (OR 0.69; CI 0.52–0.90), but there was no association between HIV status and length of stay or mortality.
Conclusions
Universal opt-out HTC on the surgical wards was well accepted and increased the proportion of patients tested. High HIV prevalence in this setting merits implementation of universal HTC.
doi:10.1007/s00268-013-2096-4
PMCID: PMC3802529  PMID: 23652356
8.  The Use of Short Segment Free Jejunal Transfer as Salvage Surgery for Cervical Esophageal and Hypopharyngeal Cancer 
World Journal of Surgery  2013;38:144-149.
Background
Salvage surgery after definitive chemoradiotherapy for cervical esophageal cancer and hypopharyngeal cancer remains a challenge because of the high rate of complications. The purpose of this study was to evaluate the safety and efficacy of free jejunal transfer as salvage surgery for cervical esophageal cancer and hypopharyngeal cancer after definitive chemoradiotherapy.
Methods
We enrolled eight patients with cervical esophageal cancer and 11 patients with hypopharyngeal cancer who underwent free jejunal transfer as salvage surgery following radiotherapy or chemoradiotherapy. In this study, we reviewed the surgical procedures, perioperative complications, and survival rates.
Results
The median duration of surgery was 514 min, and the median blood loss was 439 ml. In surgical procedures, the recipient vessels for the anastomosis of the free jejunum consisted of one artery and one vein (63 %), one artery and two veins (5 %), and two arteries and two veins (31 %). The postoperative morbidity rate was 57.9 % (11 patients), with six cases of partial necrosis of the tracheal margin and no cases of graft necrosis or postoperative in-hospital death. The overall 5-year survival rate after surgery was 58.1 %.
Conclusions
Our findings suggest that with careful attention to the potential development of necrosis of the tracheal margin, pharyngolaryngoesophagectomy and free jejunal transfer can be safely performed, even in patients who received radiotherapy or chemoradiotherapy.
doi:10.1007/s00268-013-2229-9
PMCID: PMC3868873  PMID: 24081534
9.  A Prospective Evaluation of Missed Injuries in Trauma Patients, Before and After Formalising the Trauma Tertiary Survey 
World Journal of Surgery  2013;38:222-232.
Objective
This study prospectively evaluated in-hospital and postdischarge missed injury rates in admitted trauma patients, before and after the formalisation of a trauma tertiary survey (TTS) procedure.
Methods
Prospective before-and-after cohort study. TTS were formalised in a single regional level II trauma hospital in November 2009. All multitrauma patients admitted between March–October 2009 (preformalisation of TTS) and December 2009–September 2010 (post-) were assessed for missed injury, classified into three types: Type I, in-hospital, (injury missed at initial assessment, detected within 24 h); Type II, in-hospital (detected in hospital after 24 h, missed at initial assessment and by TTS); Type III, postdischarge (detected after hospital discharge). Secondary outcome measures included TTS performance rates and functional outcomes at 1 and 6 months.
Results
A total of 487 trauma patients were included (pre-: n = 235; post-: n = 252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8 vs. 4.8 %, P = 0.61), as were postdischarge missed injury rates (Type III) at 1 month (13.7 vs. 11.5 %, P = 0.43), and 6 months (3.8 vs. 3.3 %, P = 0.84) after discharge. TTS performance was substantially higher in the post-group (27 vs. 42 %, P < 0.001). Functional outcomes for both cohorts were similar at 1 and 6 months follow-up.
Conclusions
This is the first study to evaluate missed injury rates after hospital discharge and demonstrated cumulative missed injury rates >15 %. Some of these injuries were clinically relevant. Although TTS performance was significantly improved by formalising the process (from 27 to 42 %), this did not decrease missed injury rates.
doi:10.1007/s00268-013-2226-z
PMCID: PMC3889299  PMID: 24081533
10.  Intraoperative Nerve Monitoring Can Reduce Prevalence of Recurrent Laryngeal Nerve Injury in Thyroid Reoperations: Results of a Retrospective Cohort Study 
World Journal of Surgery  2013;38:599-606.
Background
The prevalence of recurrent laryngeal nerve (RLN) injury is higher in repeat than in primary thyroid operations. The use of intraoperative nerve monitoring (IONM) as an aid in dissection of the scar tissue is believed to minimize the risk of nerve injury. The aim of this study was to examine whether the use of IONM in thyroid reoperations can reduce the prevalence of RLN injury.
Methods
This was a retrospective cohort study of patients who underwent thyroid reoperations with IONM versus with RLN visualization, but without IONM. The database of thyroid surgery was searched for eligible patients (treated in the years 1993–2012). The primary outcomes were transient and permanent RLN injury. Laryngoscopy was used to evaluate and follow RLN injury.
Results
The study group comprised 854 patients (139 men, 715 women) operated for recurrent goiter (n = 576), recurrent hyperthyroidism (n = 36), completion thyroidectomy for cancer (n = 194) or recurrent thyroid cancer (n = 48), including 472 bilateral and 382 unilateral reoperations; 1,326 nerves at risk (NAR). A group of 306 patients (500 NAR) underwent reoperations with IONM and 548 patients (826 NAR) had reoperations with RLN visualization, but without IONM. Transient and permanent RLN injuries were found respectively in 13 (2.6 %) and seven (1.4 %) nerves with IONM versus 52 (6.3 %) and 20 (2.4 %) nerves without IONM (p = 0.003 and p = 0.202, respectively).
Conclusions
IONM decreased the incidence of transient RLN paresis in repeat thyroid operations compared with nerve visualization alone. The prevalence of permanent RLN injury tended to be lower in thyroid reoperations with IONM, but statistical validation of the observed differences requires a sample size of 920 NAR per arm.
doi:10.1007/s00268-013-2260-x
PMCID: PMC3923121  PMID: 24081538
11.  The distribution of survival times after injury 
World journal of surgery  2012;36(7):1562-1570.
Introduction
The distribution of survival times after injury has been described as “trimodal”, but several studies have not confirmed this. The purpose of this study was to clarify the distribution of survival times after injury.
Methods
We defined survival time (ts) as the interval between injury time and declared death time. We constructed histograms for ts <=150 minutes from the 2004-2007 Fatality Analysis Reporting System (FARS, for traffic crashes) and National Violent Death Reporting System (NVDRS, for homicides). We estimated statistical models in which death times known only within intervals were treated as interval-censored. For confirmation, we also obtained EMS response times (tr), prehospital times (tp), and hospital times (th) for decedents in the 2008 National Trauma Data Bank (NTDB) with ts=tp+th<=150. We approximated times until circulatory arrest (tx) as tr for patients pulseless at the injury scene, tp for other patients pulseless at hospital admission, and ts for the rest; for any declared ts, we calculated mean tx / ts. We used this ratio to estimate tx for hospital deaths in FARS or NVDRS, and provide independent support for using interval-censored methods.
Results
FARS and NVDRS deaths were most frequent in the first few minutes. Both showed a second peak at 35-40 minutes after injury, corresponding to peaks in hospital deaths. Third peaks were not present. Estimated tx in FARS and NVDRS did not show second peaks, and were similar to estimates treating some death times as interval-censored.
Conclusions
Increases in frequency of survival times at 35-40 minutes are primarily artifacts created because declaration of death in hospitals is delayed until completing resuscitative attempts. By avoiding these artifacts, interval censoring methods are useful for analysis of injury survival times.
doi:10.1007/s00268-012-1549-5
PMCID: PMC3779685  PMID: 22402976
12.  Ratio of Cesarean Sections to Total Procedures as a Marker of District Hospital Trauma Capacity 
World journal of surgery  2012;36(9):2074-2079.
Background
There are few established metrics to define surgical capacity in resource-limited settings. Previous work hypothesizes that the relative frequency of cesarean sections (CS) at a hospital, expressed as a proportion of total operative procedures (%CS), may serve as a proxy measure of surgical capacity. We attempted to evaluate this hypothesis as it specifically relates to hospital capacity for emergency interventions for injury.
Methods
We conducted a WHO survey of emergency surgical capacity at 40 Rwandan district hospitals in November 2010 and extracted annual operative volume for 2010 from the Ministry of Health centralized statistical system. We dichotomized the 40 hospitals into low and high %CS groups below and above the median proportion of CS performed. We compared low and high %CS groups across self-reported capabilities related to facility characteristics, trauma supplies, procedural capacity, and surgical training using bivariate χ2 statistics with significance indicated at p ≤ 0.05. We evaluated herniorrhaphy proportion of total procedures (%Hernia) as a representative general surgery procedure in the same manner.
Results
High %CS hospitals were less likely to report capability related to blood banking (p = 0.05), amputation (p = 0.04), closed fracture repair (p = 0.04), inhalational anesthesia (p = 0.05), and chest tube insertion (p = 0.05). Availability of reliable electricity was the only measure that showed statistical significance with the %Hernia measure (p = 0.02).
Conclusions
Cesarean section proportion shows some utility as a marker for district hospital injury-care capacity in resource-limited settings.
doi:10.1007/s00268-012-1629-6
PMCID: PMC3460261  PMID: 22532310
13.  The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis 
World journal of surgery  2012;36(9):2239-2251.
Background/Purpose
In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate.
Methods
We found 3588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published.
Results
There was significant variation in the false-negative rate over time with a trend to higher rates over time. There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant. This meta-analysis also indicates a significant change over time in the false-negative rate.
Discussion/Conclusions
The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.
doi:10.1007/s00268-012-1623-z
PMCID: PMC3469260  PMID: 22569745
14.  Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway 
World Journal of Surgery  2013;37:2483-2489.
Background
The present study aims to examine the feasibility and safety of a two-day hospital stay after laparoscopic colorectal resection (LCR) under an enhanced recovery after surgery (ERAS) pathway.
Methods
Between 2003 and 2010, 882 consecutive patients undergoing LCR were analyzed. Patients were grouped and analyzed according to whether their hospital stay was 2 days (group A) or longer (group B). Demographic, surgical, and postoperative data were compared. To identify independent predictive factors related to a short hospital stay, a multivariate analysis was also performed.
Results
Group A represented 10.3 % of this series (91 patients). There were no differences regarding age, gender, BMI, ASA, and previous abdominal surgeries between groups. Group A had a lower incidence of rectal cancer and anterior resections than group B (6.6 vs. 17.7 % [p = 0.006] and 14.3 vs. 23.4 % [p = 0.048]), respectively, and a lower mean operative time (170 min vs. 192 min; p = 0.002). Group A had a lower overall morbidity rate than group B (5.5 vs. 16.9 %; p = 0.004) and a lower incidence of surgery-related complications (5.5 vs. 14.9 %; p = 0.001). The overall conversion rate was 10 % (only one patient in group A required conversion), and the difference in conversion rate between groups was statistically significant (1.2 vs. 10.7 %; p = 0.003). Group A had a lower readmission rate (0 vs. 4.9 %; p = 0.089). Multivariate analysis showed that conversion, postoperative morbidity, and rectal prolapse were independently associated with the length of hospital stay.
Conclusions
A two-day hospital stay after LCR is safe and feasible under an ERAS pathway, without compromising the readmission or complication rate.
doi:10.1007/s00268-013-2155-x
PMCID: PMC3755219  PMID: 23881088
15.  Prospective Study Examining Clinical Outcomes Associated with a Negative Pressure Wound Therapy System and Barker’s Vacuum Packing Technique 
World Journal of Surgery  2013;37:2018-2030.
Background
The open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. The method of temporary abdominal closure (TAC) may play a role in patient outcome.
Methods
A prospective, observational, open-label study was performed to evaluate two TAC techniques in surgical and trauma patients requiring open abdomen management: Barker’s vacuum-packing technique (BVPT) and the ABTheraTM open abdomen negative pressure therapy system (NPWT). Study endpoints were days to and rate of 30-day primary fascial closure (PFC) and 30-day all-cause mortality.
Results
Altogether, 280 patients were enrolled from 20 study sites. Among them, 168 patients underwent at least 48 hours of consistent TAC therapy (111 NPWT, 57 BVPT). The two study groups were well matched demographically. Median days to PFC were 9 days for NPWT versus 12 days for BVPT (p = 0.12). The 30-day PFC rate was 69 % for NPWT and 51 % for BVPT (p = 0.03). The 30-day all-cause mortality was 14 % for NPWT and 30 % for BVPT (p = 0.01). Multivariate logistic regression analysis identified that patients treated with NPWT were significantly more likely to survive than the BVPT patients [odds ratio 3.17 (95 % confidence interval 1.22–8.26); p = 0.02] after controlling for age, severity of illness, and cumulative fluid administration.
Conclusions
Active NPWT is associated with significantly higher 30-day PFC rates and lower 30-day all-cause mortality among patients who require an open abdomen for at least 48 h during treatment for critical illness.
doi:10.1007/s00268-013-2080-z
PMCID: PMC3742953  PMID: 23674252
16.  Intention to Treat Analysis: Are We Really Doing It?: Reply 
World Journal of Surgery  2013;37(5):1183-1184.
doi:10.1007/s00268-013-1984-y
PMCID: PMC3618406  PMID: 23494085
17.  Local Pain-reducing Methods after Hemorrhoidectomy 
World Journal of Surgery  2013;37(8):2007-2008.
doi:10.1007/s00268-013-1983-z
PMCID: PMC3715688  PMID: 23494084
18.  Clinical Fellowships in Surgical Training: Analysis of a National Pan-specialty Workforce Survey 
World Journal of Surgery  2013;37(5):945-952.
Background
Fellowship posts are increasingly common and offer targeted opportunities for training and personal development. Despite international demand, there is little objective information quantifying this effect or the motivations behind undertaking such a post. The present study investigated surgical trainees’ fellowship aims and intentions.
Methods
An electronic, 38-item, self-administered questionnaire survey was distributed in the United Kingdom via national and regional surgical mailing lists and websites via the Association of Surgeons in Training, Royal Surgical Colleges, and Specialty Associations.
Results
In all, 1,581 fully completed surveys were received, and 1,365 were included in the analysis. These represented trainees in core or higher training programs or research from all specialties and training regions: 66 % were male; the mean age was 32 years; 77.6 % intended to or had already completed a fellowship. Plastic surgery (95.2 %) and cardiothoracic (88.6 %) trainees were most likely to undertake a fellowship, with pediatrics (51.2 %), and urology (54.3 %) the least likely. Fellowship uptake increased with seniority (p < 0.01) and was positively correlated (p = 0.016, r = 0.767) with increasing belief that fellowships are necessary to the attainment of clinical competence, agreed by 73.1 %. Fellowship aims were ranked in descending order of importance as attaining competence, increasing confidence, and attaining subspecialist skills.
Conclusions
Over three-quarters of trainees have or will undertake a clinical fellowship, varying with gender, specialty, and seniority. Competence, confidence, and subspecialty skills development are the main aims. The findings will influence workforce planning, and perceptions that current training does not deliver sufficient levels of competence and confidence merit further investigation.
doi:10.1007/s00268-013-1949-1
PMCID: PMC3618414  PMID: 23423449
19.  The Role of Liver-directed Surgery in Patients with Hepatic Metastasis from a Gynecologic Primary Carcinoma 
World journal of surgery  2011;35(6):1345-1354.
Background
The management of patients with liver metastasis from a gynecologic carcinoma remains controversial, as there is currently little data available. We sought to determine the safety and efficacy of liver-directed surgery for hepatic metastasis from gynecologic primaries.
Methods
Between 1990 and 2010, 87 patients with biopsy-proven liver metastasis from a gynecologic carcinoma were identified from an institutional hepatobiliary database. Fifty-two (60%) patients who underwent hepatic surgery for their liver disease and 35 (40%) patients who underwent biopsy only were matched for age, primary tumor characteristics, and hepatic tumor burden. Clinicopathologic, operative, and outcome data were collected and analyzed.
Results
Of the 87 patients, 30 (34%) presented with synchronous metastasis. The majority of patients had multiple hepatic tumors (63%), with a median size of the largest lesion being 2.5 cm. Of those patients who underwent liver surgery (n = 52), most underwent a minor hepatic resection (n = 44; 85%), while 29 (56%) patients underwent concurrent lymphadenectomy and 45 (87%) patients underwent simultaneous peritoneal debulking. Postoperative morbidity and mortality were 37% and 0%, respectively. Median survival from time of diagnosis was 53 months for patients who underwent liver-directed surgery compared with 21 months for patients who underwent biopsy alone (n = 35) (p = 0.01). Among those patients who underwent liver-directed surgery, 5-year survival following hepatic resection was 41%.
Conclusions
Hepatic surgery for liver metastasis from gynecologic cancer can be performed safely. Liver surgery may be associated with prolonged survival in a subset of patients with hepatic metastasis from gynecologic primaries and therefore should be considered in carefully selected patients.
doi:10.1007/s00268-011-1074-y
PMCID: PMC3568526  PMID: 21452068
20.  Rate of Clinically Significant Postoperative Pancreatic Fistula in Pancreatic Neuroendocrine Tumors 
World journal of surgery  2012;36(7):1517-1526.
Background
In 2005, the International Study Group of Pancreatic Fistula (ISGPF) developed a definition and grading system for postoperative pancreatic fistula (POPF). The authors sought to determine the rate of POPF after enucleation and/or resection of pancreatic neuroendocrine tumors (PNET) and to identify clinical, surgical, or pathologic factors associated with POPF.
Methods
A retrospective analysis of pancreatic enucleations and resections performed from March 1998 to April 2010. We defined a clinically significant POPF as a grade B that required nonoperative intervention and grade C.
Results
One hundred twenty-two patients were identified; 62 patients had enucleations and 60 patients had resections of PNET. The rate of clinically significant POPF was 23.7 % (29/122). For pancreatic enucleation, the POPF rate was 27.4 % (17/62, 14 grade B, 3 grade C). The pancreatic resection group had a POPF rate of 20 % (12/60, 10 grade B, 2 grade C). This difference was not significant (p = 0.4). In univariate analyses, patients in the enucleation group with hereditary syndromes (p = 0.02) and non-insulinoma tumors (p = 0.02) had a higher POPF rate. Patients in the resection group with body mass index (BMI) >25 (p <0.01), multiple endocrine neoplasia type 1 (MEN-1; p <0.01) and those who underwent simultaneous multiple procedures (p = 0.02) had a higher POPF rate. Multivariate analyses revealed that hereditary syndromes were able to predict POPF in the enucleation group, while having BMI >25 and increasing lesion size were also associated with POPF in the group undergoing resection.
Conclusions
We found a clinically significant POPF rate after surgery in PNET to be 23.7 % with no difference by the type of operation. Our POPF rate is comparable to that reported in the literature for pancreatic resection for other types of tumors. Certain inherited genetic diseases—von Hippel–Lindau disease (VHL) and MEN-1—were associated with higher POPF rates.
doi:10.1007/s00268-012-1598-9
PMCID: PMC3521612  PMID: 22526042
21.  Wandering Spleen: A Medical Enigma, Its Natural History and Rationalization 
World Journal of Surgery  2012;37(3):545-550.
Introduction
Wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region because of the laxity of the peritoneal attachments. Many patients with wandering spleen are asymptomatic, hence the condition can be discovered only by abdominal examination or at a hospital emergency department if a patient is admitted to hospital because of severe abdominal pain, vomiting or obstipation.
Methods
This article aims to provide a historical overview of wandering spleen diagnostics and surgical treatment supplemented with an analyses of articles on wandering spleen included in the PubMed database.
Results
One of the first clinical descriptions of a wandering spleen was written by Józef Dietl in 1854. The next years of vital importance are 1877 when A. Martin conducted the first splenectomy and in 1895 when Ludwik Rydygier carried out the first splenopexy to immobilize a wandering spleen. Since that time various techniques of splenectomy and splenopexy have been developed.
Conclusions
Introducing medical technologies was a watershed in the development and treatment of wandering spleen, which is confirmed by the PubMed database. Despite the increased number of publications medical literature shows that a wandering spleen still remains a misdiagnosed condition, especially among children.
doi:10.1007/s00268-012-1880-x
PMCID: PMC3566390  PMID: 23238797
22.  Effect of Obesity and Decompressive Laparotomy on Mortality in Acute Pancreatitis Requiring Intensive Care Unit Admission 
World Journal of Surgery  2012;37(2):318-332.
Background
Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality.
Methods
A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS.
Result
Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052–1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012–1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000–1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients’ age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548–0.661).
Conclusions
Patients’ age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.
doi:10.1007/s00268-012-1821-8
PMCID: PMC3553416  PMID: 23052814
23.  Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low- and Middle-income Countries 
World Journal of Surgery  2012;37(2):349-355.
Background
The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.
Methods
The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.
Results
The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.
Conclusions
The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.
doi:10.1007/s00268-012-1817-4
PMCID: PMC3553402  PMID: 23052810
24.  Retrospective Analysis of Nodal Spread Patterns According to Tumor Location in Pathological N2 Non-small Cell Lung Cancer 
World Journal of Surgery  2012;36(12):2865-2871.
Background
The purpose of the present study was to determine the nodal spread patterns of pN2 non-small cell lung cancer (NSCLC) according to tumor location, and to attempt to evaluate the possible indications of selective lymph node dissection (SLND).
Methods
We retrospectively analyzed nodal spread patterns in 207 patients with NSCLC of less than 5 cm with N2 involvement.
Results
The tumor location was right upper lobe (RUL) in 79, middle lobe in 12, right lower lobe (RLL) in 40, left upper division (LUD) in 41, lingular division in 11, and left lower lobe (LLL) in 24. Both RUL and LUD tumors showed a higher incidence of upper mediastinal (UM) involvement (96 and 100 %, respectively) and a lower incidence of subcarinal involvement (15 and 10 %, respectively) than lower lobe tumors (UM; RLL 60 %, LLL 42 %; subcarinal: RLL 60 %, LLL 46 %, respectively). Among the patients with 24 right UM-positive RLL and 10 left UM-positive LLL tumors, 2 showed negative hilar, subcarinal, and lower mediastinal involvement, and cT1, suggesting that UM dissection may be unnecessary in lower lobe tumors with no metastasis to hilar, subcarinal, and lower mediastinal nodes on frozen sections according to the preoperative T status. Among the patients with 12 subcarinal-positive RUL and 4 subcarinal-positive LUD tumors, one showed negative hilar or UM involvement, suggesting that subcarinal dissection may be unnecessary in RUL or LUD tumors with no metastasis to hilar and UM nodes on frozen sections.
Conclusions
The present study appears to provide one of the supportive results regarding the treatment strategies for tumor location-specific SLND.
doi:10.1007/s00268-012-1743-5
PMCID: PMC3501158  PMID: 22948194
25.  Deferred Primary Anastomosis Versus Diversion in Patients with Severe Secondary Peritonitis Managed with Staged Laparotomies 
World journal of surgery  2010;34(1):169-176.
Background
There is inconclusive data on whether critically ill individuals with severe secondary peritonitis requiring multiple staged laparotomies may became eligible candidates for deferred primary anastomoses (DPA). We sought to compare a protocol for DPA against a protocol for diversion in severely ill critical patients with intra-abdominal sepsis.
Methods
A retrospective cohort study was performed examining 112 patients admitted through an ICU between 2002 and 2006, with diagnosis of secondary peritonitis and managed with staged laparotomies whom required small- or large-bowel segment resections. Patients were categorized and compared according to the surgical treatment necessitated to resolve the secondary peritonitis (DPA versus diversion). Outcome measures were days on mechanical ventilation, days required in ICU, days required in hospital, incidence of fistulas/leakages, acute respiratory distress syndrome (ARDS), and mortality.
Results
There were 34 patients subjected to DPA and 78 to diversion. Fistulas/leakages developed in three patients (8.8%) with DPA and four patients (5.1%) with diversion (p = 0.359). ARDS was present in 6 patients (17.6%) with DPA and 24 patients (30.8%) with diversion (p = 0.149). There were 30 patients (88.2%) with DPA and 65 patients (83.3%) with diversion discharged alive (p = 0.51). There were not statistical significant differences between groups among survivors regarding hospital length of stay, ICU length of stay, and days on mechanical ventilation.
Conclusions
We did not find significant differences in morbidity or mortality when we compared DPA versus diversion surgical treatment. It is feasible to perform a primary anastomosis in critically ill patients with severe secondary peritonitis managed with staged laparotomies.
doi:10.1007/s00268-009-0285-y
PMCID: PMC3413282  PMID: 20020299
Peritonitis; Anastomosis; Diversion; ICU length of stay; Intra abdominal sepsis

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