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Background: Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication., Methods: All patients undergoing laparoscopic fundoplication in the authors' series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from "very satisfying" to "very unsatisfying." Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported., Results: Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication., Conclusions: Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.

Introduction: There is increasing focus on disease-specific outcomes. This study was undertaken to analyze early mortality after pancreaticoduodenectomy as part of a strategy to improve long-term outcome., Methods: One thousand thirty-one patients who underwent pancreaticoduodenectomy from 1992 to 2010 were studied. Median data are reported., Results: Fifty-eight (5.6%) patients died within 90 days after pancreaticoduodenectomy. All patients had at least one significant comorbidity, commonly cardiorespiratory in nature (76%). Sixty percent of patients had depressed serum albumin levels, and 43% were jaundiced. The American Society of Anesthesiologists class was: 17% class II, 72% class III, and 10% class IV. Seventy-four percent had malignant disease. Twenty-two percent of patients underwent a major vascular resection at the time of pancreaticoduodenectomy. Causes of death were vascular/bleeding related (26%), cardiorespiratory causes (17%), multiorgan failure (12%), leak/perforation (10%), cancer progression (9%), infection (7%), or indeterminate (19%)., Conclusions: Death within 90 days after pancreaticoduodenectomy is uncommon, occurs in relatively older deconditioned patients, and is generally not causally related to underlying malignancy. Early death is generally associated with vascular or bleeding complications. Strategies to minimize early death should focus on careful patient selection and prompt recognition and management of herald bleeding or vascular thrombosis, as it can often result in perioperative death following pancreaticoduodenectomy.

Background: Altered expression of specific microRNAs (miRNA) is known to occur during colorectal carcinogenesis. However, little is known about the genome-wide alterations in miRNA expression during the neoplastic progression of primary colorectal cancers., Methods: Using a miRNA array platform, we evaluated the expression of 668 miRNA in primary colonic adenocarcinomas. Biological functions of selected miRNA were evaluated with in vitro invasion assays., Results: RNA was extracted for miRNA analysis from 65 primary colon cancers. We identified a seven-miRNA expression signature that differentiated stage I and stage IV primary colon cancers. We then demonstrated this signature was able to discriminate between stage II and III primary colon cancers. Six differentially expressed miRNA were downregulated in association with the development of metastases, and all 7 miRNA were complementary strand miRNA. We transfected HCT-116, a highly invasive colon cancer cell line, with corresponding downregulated miRNA and demonstrated that overexpression of three miRNA (miR200c*, miR143*, and miR424*) significantly abrogated invasive potential., Conclusion: We have identified a seven-miRNA signature that is associated with metastatic potential in the primary tumor. Forced overexpression of three downregulated miRNA resulted in attenuation of in vitro invasion, suggesting direct tumor suppressive function and further supporting the biological importance of complementary strand miRNA.

This study was undertaken to report variceal rebleeding and survival after small-diameter prosthetic H-graft portacaval shunts (HGPCS) and to compare actual to predicted survival after shunting. Since 1987 we have prospectively followed patients after undergoing HGPCS to treat bleeding varices failing/not amenable to sclerotherapy/banding. One hundred and seventy patients underwent shunting. Cirrhosis was because of alcohol in 56%, hepatitis in 12%, both in 11%, and other causes in 21%. Child class was A for 10%, B for 28%, and C for 62%. Thirty-three patients died by 6 months, 54 by 24 months, 87 by 60 months, and 112 by 10 years, generally because of liver failure. Fifty-one patients are alive at a median of 48.3 months, 76 months +/- 57.8 (mean +/- SD). Variceal rehemorrhage was documented in 3 (2%) patients. By child class, 5-year/10-year survival rates were as follows: A 66.7/33.3%, B 48.6/15.6%, and C 29.2/7.0%. Actual survival was superior to predicted survival (Model for End-Stage Liver Disease [MELD]), (p < 0.001). Variceal rehemorrhage in patients undergoing small-diameter prosthetic H-graft portacaval shunting was very uncommon. Actual survival was superior to predicted survival (MELD). Long-term survival paralleled degree of hepatic function, although long-term survival was possible even with very advanced cirrhosis. Application of HGPCS is encouraged.

Objective: This study was undertaken to evaluate the ability to predict survival after 8 mm prosthetic H-graft portacaval shunts (HGPCS)., Methods: Since 1988, 170 patients have been prospectively followed after HGPCS. Using preshunt data, predictors of survival after shunting [MELD Score, Emory Score, Child Pugh Score, Discriminant Function (DF), and Child Class] were determined and related to actual survival., Results: Child Class was: (a) 10%, (b) 28%, and (c) 62%. Actual 5- and 10-year survival by Child Class was: (a) 67% and 33%, (b) 49% and 16%, (c) 29% and 7%. Survival correlated with all predictors of survival (p < 0.01 for each). Actual survival was better than predicted by MELD (p < 0.001). By Multiple Variable Regression Analysis--Computed Model, explained variation in survival was greatest for Child Class (18%), followed by MELD (14%), with DF, Emory Score, and Child Pugh Score not significantly contributing., Conclusions: After HGPCS, actual survival is better than predicted by MELD. Child Class explains only a minor variation in survival, although it better explains survival than MELD, Emory Score, Child Pugh Score, or DF. Conventional predictors of survival poorly and underpredict survival after HGPCS and should be used with caution.