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Highlights • Primary gastrointestinal lymphomas rarely present as a single colonic mass. • This is a case report of a single mass colonic mantle cell lymphoma causing a colon-colonic intussusception. • Timely diagnosis and treatment of mantle cell lymphoma is critical. • Case represents a patient whose treatment plan was unexpectedly altered from surgery after a biopsy., Introduction Mantle Cell Lymphoma (MCL) is a non-Hodgkin lymphoma accounting for 2.5% of lymphoid neoplasms in the United States. Primary gastrointestinal (GI) lymphomas account for 1–4% of all GI malignancies, with few reports of primary mantle cell lymphoma presenting as a single colonic mass and none to our knowledge with colon-colonic intussusception as the presenting finding. Accurate and timely diagnosis is imperative because MCL has rapid progression and early chemotherapeutic intervention results in improved patient outcomes. This work is reported in line with the SCARE criteria [1] for case report publication. Presentation of case A 61-year-old male presented with 1 month history of nonspecific right sided abdominal pain. Computed Tomography (CT) of the abdomen identified an intussuscepting mass in the proximal ascending colon and an additional 8 mm hepatic lesion. Colonoscopy identified a large mass in the corresponding area of colon identified on CT. Histology and immunohistochemistry of biopsied specimen diagnosed MCL. Discussion Planned surgical intervention was deferred and the patient was referred for oncologic treatment. We report the first case to our knowledge of MCL presenting as colon-colonic intussusception and discuss the work-up of this rare lymphoma that clinicians may be required to diagnose and manage. Conclusion This report serves as a reminder to maintain a broad differential inclusive of uncommon diseases and unanticipated pathology. Practicing with a thorough understanding of medical principles and clinical acumen is essential for optimal patient care and, as demonstrated in this case, preventing a potentially unnecessary surgical intervention thus delaying appropriate chemotherapy.

Purpose Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field. Materials and Methods A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008–2016) and recent graduates (2017–2019). Results We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5–10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01). Conclusions The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons’ bariatric case volumes.

Background Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB. Methods Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY). Results Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m2. The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention. Conclusions LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

Obesity is a major risk factor for obstructive sleep apnea patients. In obese patients the severity of this risk can be reduced by bariatric surgery. This pilot study investigates the perioperative effects of bariatric surgery on obstructive sleep apnea and on the physical and biomechanical characteristics of the upper airway. Polysomnography and computer tomography data for 10 morbid obese patients promoted for bariatric surgery were conducted before surgery and at 6 and 12 months postoperatively for assessment of the oropharyngeal anatomy, and subsequent three-dimensional modelling of the airway. Mean values for the apnea/hypopnea index and body mass index significantly reduced after surgery. To combine the effect of changes in the upper airway volume and body mass index, a new volume body mass index is introduced. This index increases with a successful bariatric surgery. Although bariatric surgery leads to an effective weight reduction for all age groups, for obstructive sleep apnea patients it may be effective for middle age, less effective for 50-60 years, and further less effective for patients over the age of 60 years.

Self-fixating mesh has been introduced to further improve the quality results already seen with laparoscopic inguinal hernia repair. An observational study was undertaken to evaluate the technical learning curve and mid-term outcomes associated with the use of ProGrip (Medtronic, Minneapolis, MN, USA) laparoscopic self-fixating mesh in transabdominal preperitoneal (TAPP) inguinal herniorrhaphy.Patients who underwent elective laparoscopic TAPP inguinal herniorrhaphy by a single surgeon using ProGrip laparoscopic self-fixating mesh within a one-year period were studied. The primary outcome measures included the time from mesh introduction to the final position (MI-FP), surgical complications, and pain scores. Demographic and other perioperative outcome data were collected and analyzed.Forty hernias were repaired in 29 patients with a laparoscopic TAPP approach. The average MI-FP was 249.4 seconds for the first 20 repairs, and 118.6 seconds (p0.001) for the final 20. Minor post-operative surgical complications were reported by 13.8% of patients; there were no major surgical complications. The average pain score on a scale of 0 to 5 was 0.9 (SD = 0.67, range 0-3).Surgeons with reasonable laparoscopic experience can expect to become fully proficient in the manipulation of self-fixating mesh after 15 to 20 repairs. Use of this product yielded low intraoperative and mid-term postoperative complication rates as well as low postoperative pain.

Background Peritoneal dialysis (PD) is a widely employed renal replacement modality. A prospective study was conducted to determine the short-term and midterm outcomes and complication rates associated with a standardized optimal laparoscopic peritoneal dialysis catheter placement technique. Methods All patients undergoing laparoscopic PD catheter placement by one surgeon using our standardized method over a 5-year period were entered into a prospective database. Patients were evaluated preoperatively and postoperatively through office visits. Development of complications was assessed using follow up telephone or mail surveys. Results A total of 100 patients with a mean age of 56 years underwent laparoscopic PD catheter placement over the 5-year study period. In total, 103 laparoscopic PD catheter placement attempts were made in 100 patients. Placement was successful in 98 (95.1%) attempts and no placement required conversion to an open operation. Omentopexy was performed in 82 (83.7%) patients. There was no mortality reported within 30 days of the index operation. For patients who successfully underwent laparoscopic PD placement, early complications developed in 9 (9.2%) patients, of which 6 (6.1%) complications were directly related to the PD catheter. Midterm complications developed in 25 (25.5%) patients. Complication-related catheter repositioning was required for 12 (12.2%) catheters and catheter-related complication removal was required for 18 (18.4%) catheters. Conclusion Laparoscopic placement of PD catheters can be successfully performed using a combination of described standardized laparoscopic maneuvers for optimal placement resulting in acceptable perioperative and short and midterm complication rates with negligible mortality rates.

Obesity is a global epidemic with multiple associated comorbid conditions. The laparoscopic Roux-en-Y gastric bypass is the gold standard operation in the fight against obesity. This review outlines the common technical aspects of the procedure, as well as the evidence based recommendations for preoperative and postoperative care.

Background and objectives The preoperative work up for bariatric surgery is variable and not all centers perform a preoperative upper gastrointestinal endoscopy. A study was undertaken to determine the frequency of clinically significant gross endoscopic and pathological diagnoses in a large sample of patients with obesity undergoing work-up for bariatric surgery. Methods Routine endoscopy was performed on all preoperative bariatric patients. A retrospective chart review of 1000 consecutive patients was performed. Patients were divided into three groups: Group A (no endoscopic findings), Group B (clinically insignificant findings), Group C (clinically significant findings). Results Patients had a mean body mass index (BMI) of 49 kg/m2 and 79% were female. In this sample one finding was found on preoperative EGD in 95.2% of patients, 33.9% had at least two diagnoses, and 29.9% had three or more diagnoses. Group A (no findings) consisted of 4.8% of patient, 52.5% in Group B (clinically insignificant findings), and 42.7% were in Group C (clinically significant findings). Clinically significant findings included hiatal hernia 23.5%, esophagitis 9.5%, H. pylori 7.1%, gastric erosions 5.7%, duodenitis 3.7%, Barrett's esophagus 3.1%, and Schatzki ring 1.2%. There was no significant correlation between preoperative BMI and any endoscopic findings (all p-value 0.05). Patients in Group C were statistically older than Groups A and B. Conclusion Upper gastrointestinal pathology is highly common in patients with obesity. There is a significant rate of clinically significant endoscopy findings and all bariatric surgery patients should undergo preoperative endoscopy.

Background and Objectives: Synthetic mesh reinforcement during laparoscopic hiatal hernia repair (LHHR) reduces recurrence. Biologically derived mesh is also associated with reduced recurrence. Urinary bladder matrix (UBM), a biologically derived extracellular matrix mesh, has shown clinical success. We wanted to determine the safety and efficacy of LHHR with porcine UBM reinforcement. Methods: This retrospective, single-surgeon study reviewed clinical data on patients who underwent LHHR from August 2009 through May 2014, with diaphragmatic reinforcement with porcine UBM mesh. Primary outcomes were (1) recurrence—a >2-cm defect above the diaphragm at 3 months; (2) intra- and postoperative complications; (3) pre- and postoperative esophageal reflux (GERD) or dysphagia; and (4) cessation of proton pump inhibitor (PPI). Results: Sixty-two patients who had LHHR with UBM mesh were studied (mean age, 62 years, 53 women, mean body mass index 32.7 kg/m2) Before surgery 98% had GERD, 19% had dysphagia, and 98% were on PPI. Postoperative UGIS was performed on 66% 3 months after surgery, and 19% had a recurrence of >2 cm; 56% remained on PPI, and 16% (P < .001) remained symptomatic. Dysphagia improved in 75% (P = .05). No intraoperative complications were recorded. One postoperative mortality occurred secondary to an unrelated cardiac event. Conclusions: UBM mesh was effective and safe for LHHR. In addition to reducing the rate of recurrence compared to unreinforced primary repair, the properties of UBM, including site-specific constructive tissue remodeling, may add benefits over other biologic products. This study represents an evaluation of UBM mesh in a large cohort of patients who underwent LHHR.

Results of this study suggest that strategic laparoscopy for improved cosmesis cholecystectomy is feasible, safe, and decreases the cumulative incision length as well as the number of incisions in patients with favorable body habitus and previous surgical history., Background and Objectives: Until the advent of single-incision laparoscopic surgery, few advances were aimed at improving cosmesis with laparoscopic cholecystectomy. Criticisms of the single-incision laparoscopic surgery technique include a larger incision and increased incidence of wound-related complications. We present our initial experience with a novel technique aimed at performing strategic laparoscopy for improved cosmesis (SLIC) for cholecystectomy. Methods: Twenty-five patients with biliary symptoms were selected for SLIC cholecystectomy. Access to the abdomen was obtained with a 5-mm optical trocar in the left upper quadrant and a 5-mm trocar in the umbilicus. Retraction was performed by a transabdominal suture in the dome of the gallbladder and a needlescopic grasper. Age, American Society of Anesthesiologists score, body mass index, operative time, length of stay, pathology results, and short-term complications at follow-up were prospectively recorded. Results: The 25 female patients had a mean age of 34.3 years and mean body mass index of 24 kg/m2. American Society of Anesthesiologists scores ranged from 1 to 3. The mean operative time was 51.3 minutes. Pathology revealed chronic cholecystitis in all patients. All procedures were performed on an outpatient basis. The only complication was one ultrasonography-documented deep vein thrombosis. All 25 planned SLIC cholecystectomies were successfully completed. Conclusions: SLIC cholecystectomy is feasible and safe. This technique decreases the cumulative incision length, as well as the number of incisions, leading to very desirable cosmetic results in patients with a favorable body habitus and surgical history.

Obesity is a global epidemic with multiple associated comorbid conditions. The laparoscopic Roux-en-Y gastric bypass is the gold standard operation in the fight against obesity. This review outlines the common technical aspects of the procedure, as well as the evidence based recommendations for preoperative and postoperative care.

Atypical complications of gastric bypass surgery include the Roux-en-O configuration: an improper connection of the bilio-pancreatic limb to the gastric pouch. Four cases of Roux-en-O, which occurred at institutions not affiliated with the authors, were reviewed for issues related to causation and patient outcomes. One case was diagnosed intraoperatively (patient 1), while the time of diagnosis in the remaining three patients was postoperative days 2, 52, and 230 (patients 2–4). The delay resulted in two computed tomography scans, two endoscopies, and four contrast studies per patient. These patients presented with protracted biliary emesis and a clinical picture of bowel obstruction. Irrespective of time to diagnosis, all patients endured significant postoperative sequelae—numerous surgeries (n = 10, 3, 1, and 3, respectively) and increased length of stay (97, 86, 49, and 125 days, respectively). Patients 2 and 3 were diagnosed by repeat laparotomy, and patient 4 was diagnosed by HIDA scan. Nevertheless, surgery remains the most effective means by which to diagnose the problem, as well as correct the complication. Maneuvers that should be employed to prevent this rare complication include keeping the bilio-pancreatic limb short, identifying the ligament of Treitz and marking the Roux limb shortly after jejunal transection.

The advent of sentinel lymph node mapping (SLNM) has had a profound impact on the surgical management of breast cancer and melanoma over the past decade. However, SLNM in gastrointestinal malignancies is still in its infancy. The role of SLNM in gastrointestinal malignancies is to increase staging accuracy and to reduce the understaging associated with standard surgical and pathological techniques. Numerous authors have described the successful use of SLNM in colon, rectal, gastric, esophageal, and anal canal malignancies, with a high degree of accuracy and upstaging by detailed pathological analysis of the sentinel nodes. Over the past 2 years, research and publications related to gastrointestinal lymphatic mapping have dramatically increased worldwide.

Bariatric and metabolic surgery has blossomed over the last 60 years from its experimental origin to become one of the most astounding weapons in the arsenal of modern medicine. The evolution has taken place in a stepwise fashion through the inventive efforts of surgeons who were farsighted enough to envision the potential utility of altering gastrointestinal anatomy to change physiology. A multitude of procedures have come and gone, but with the dedication of pioneers studying the effectiveness, drawbacks, and safety, our knowledge of the field has grown immensely. This has led to the sound and unrivaled surgical treatments for obesity that we can offer today.

Background Liver disease among the morbidly obese is increasingly prevalent, contributing to significant morbidity. Obesity-related liver pathologies including nonalcoholic steatohepatitis (NASH) have become a leading cause for liver transplant. However, risk factors for developing severe liver disease in the morbidly obese remain unknown. The objective of this study was to determine the frequency of abnormal liver pathology and any relationship to patient-related factors. Methods One thousand consecutive patients undergoing weight loss surgery were reviewed. All patients had a liver biopsy at the time of surgery. Frequency of benign pathology, steatosis, NASH, and fibrosis on pathologic examination of liver biopsy specimens were recorded. Pathologic findings were compared and analyzed to age and body mass index (BMI) of all patients. Results All patients in the study population had a BMI>35 kg/m 2 . Of these patients, 80.2% had liver disease related to obesity on pathology, including 65.9% with steatosis (grade 1–3), and 14.3% with NASH and/or fibrosis. Mean BMI of patients with liver disease was 48.1 compared to a BMI of 47.7 with benign pathology ( P = .523). Mean age of patients with and without abnormal pathology was 48.3 and 47.3, respectively ( P = .294). Conclusion Liver disease is highly prevalent in the obese, but is not associated with increased age or BMI. Although all morbidly obese patients appear at significant risk for developing severe liver pathology, further risk factors are unknown.

The present study compares flow parameters (pressure drop, velocity, and shear stress) in the upper airway between pre- and post-bariatric surgery obstructive sleep apnea (OSA) patients. CT images of the upper airway were obtained prior to and six months post bariatric surgery in patients with a comorbid OSA. In-house software was used to reconstruct 3D geometric models of the upper airway, and fluid flow simulations were conducted using commercial computational fluid dynamics (CFD) software. Results show that pressure drop in the upper airway and velocity at the throat decrease post-surgery. Shear stress on the airway walls also decreased markedly. These trends were expected, however more patients must be analyzed and correlations must be drawn between these fluid dynamic parameters and the pathophysiology of the upper airway in OSA.

Background: Presence of depression and /or a lack of appropriate social support may exert deleterious effects on postoperative weight loss in bariatric surgery patients. The purpose of this study was to investigate the interactive effects of surgical procedure and marital status on weight loss in these patients, and to assess the impact of depression on these effects. Methods: A retrospective review was performed of patients who underwent laparoscopic gastric bypass or banding surgery (LRYGB or LAGB) at a single institution from 2005-2007. Our sample included 62 patients who had values for all time points for percent excess weight loss (%EWL) preoperatively, and 1, 3, 6, 12, and 18 months postoperatively. Data were analyzed using SAS 9.1, where %EWL was tested in mixed models for effects of marital status, surgical procedure, time, and all interactions of the three. Correlation analyses were used to examine the relationship between baseline depression and %EWL within categories of marital status. Results: Interactions were found between surgery-type and time, and marital status and time. LRYGB patients had greater %EWL compared to LAGB at all postoperative time points, and %EWL for Married patients was less than that of Singles at 12 and 18 months. There was a marked, inverse relationship between depression and %EWL for the Single group, but not the others. Conclusions: Interactions between these variables suggests that the effects of marital status on %EWL may be modulated by depression. Further studies are needed in order to examine these relationships in samples including more even distributions of sex and marital status.

Background Although bariatric surgery is known to exert favorable effects on dyslipidemia, few studies have systematically considered how the demographic variables might modulate the outcomes. The aim of the present study was to examine the interactive effects of gender, age, and surgery type on dyslipidimia in bariatric surgery patients at a tertiary hospital in the United States. Methods In a retrospective review of 294 patients who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic adjustable gastric bypass (LAGB), we examined the changes in lipid profiles and antihyperlipidemic use for ≤4 years postoperatively. The data were analyzed using longitudinal mixed modeling methods, in which the effects on lipid concentrations and medication use were tested in models with gender, surgery type, age, postoperative duration, and all possible interactions entered as factors. Results Significant 2-way interactions of surgery type*time were found for total cholesterol and high-density lipoprotein cholesterol, gender*time for high-density lipoprotein cholesterol, and age*time for triglycerides. A 3-way interaction of surgery type*age*time was noted for low-density lipoprotein cholesterol. For older patients, low-density lipoprotein cholesterol was reduced by 20% from baseline in the LRYGB group but did not lessen significantly in the LAGB group. In the younger patients, however, decreases from the preoperative concentrations were not evident in either surgery group. An interaction of surgery type*time on antihyperlipdemic medication use, in which values changed significantly from baseline was found in both groups. However, the pattern in the LRYGB patients opposed that in the LAGB patients. Conclusion Our results have demonstrated that bariatric surgery imparts a pronounced improvement in the blood lipid profile of recipients; however, these effects might be moderated by other factors, such as age and gender, independently of the baseline weight status of the patients.

Sentinel lymph node (SLN) mapping has been widely applied in the staging of solid neoplasms including colon and rectal cancer. Since the first reported feasibility study in 1997, there have been numerous publications validating SLN mapping as a highly accurate and powerful upstaging technique for colon and rectal cancer. In addition to refining the technical aspects of this procedure, these studies have investigated the use of other tracers and operative techniques, while determining the indications, limitations, and pitfalls of SLN mapping in patients with colorectal cancers. This chapter reviews the rationale for performing SLN mapping for the accurate staging of colon and rectal cancers, and provides a brief review of the historical background of the development of the procedure. Landmark publications, which have contributed to the current status of the technique, are discussed. We will focus on the technical details of the procedure, and on the pathological evaluation of the specimen and the SLNs. The various tracers and techniques of SLN mapping in colon and rectal cancer will be discussed. We have performed SLN mapping in more than 240 consecutive patients over the past 7 years. The success rates for identifying at least one SLN for colon and rectal cancer were 100% and 90.6%, respectively. The accuracy rates were 95.8% and 100%, respectively. In terms of upstaging, 32.3% of colon cancer patients with nodal metastases and 16.7% of rectal patients with nodal metastases were upstaged by the detection of micrometastases found in the SLNs only. Finally, we will also discuss the current role as well as the future research directions for SLN mapping in colon and rectal cancer.

Sentinel lymph node (SLN) mapping has been widely applied in the staging of solid neoplasms including colon and rectal cancer. Since the first reported feasibility study in 1997, there have been numerous publications validating SLN mapping as a highly accurate and powerful upstaging technique for colon and rectal cancer. In addition to refining the technical aspects of this procedure, these studies have investigated the use of other tracers and operative techniques, while determining the indications, limitations, and pitfalls of SLN mapping in patients with colorectal cancers. This chapter reviews the rationale for performing SLN mapping for the accurate staging of colon and rectal cancers, and provides a brief review of the historical background of the development of the procedure. Landmark publications, which have contributed to the current status of the technique, are discussed. We will focus on the technical details of the procedure, and on the pathological evaluation of the specimen and the SLNs. The various tracers and techniques of SLN mapping in colon and rectal cancer will be discussed. We have performed SLN mapping in more than 240 consecutive patients over the past 7 years. The success rates for identifying at least one SLN for colon and rectal cancer were 100% and 90.6%, respectively. The accuracy rates were 95.8% and 100%, respectively. In terms of upstaging, 32.3% of colon cancer patients with nodal metastases and 16.7% of rectal patients with nodal metastases were upstaged by the detection of micrometastases found in the SLNs only. Finally, we will also discuss the current role as well as the future research directions for SLN mapping in colon and rectal cancer.

Sentinel lymph node mapping accurately predicts nodal status in >90 percent of melanoma and breast and colorectal cancers. However, because of anatomic differences, sentinel lymph node mapping of rectal cancers has been considered inaccurate and difficult relative to colon. A prospective study was undertaken to identify differences in sentinel lymph node mapping between patients with colon cancer and those with rectal cancer. At operation 1 to 3 ml of 1 percent isosulfan blue dye was injected subserosally around colon cancers. The first to fourth blue-staining nodes seen within ten minutes of injection were marked as sentinel lymph nodes. For cancer of the mid-rectum to low rectum, the dye was injected submucosally via rigid scope and spinal needle. The mesorectum was dissected ex vivo to identify blue nodes nearest the tumor as sentinel lymph nodes. Multilevel microsections of sentinel lymph nodes were stained with hematoxylin and eosin and immunostained for cytokeratin, and standard examination of the entire specimen was performed. There were 407 consecutive patients (336 with colon and 71 rectum). The sentinel lymph nodes were identified in 99.1 percent of colon and 91.5 percent of rectal patients (P < 0.0001). Skip metastases were found in 3.6 percent of colon vs. 2.8 percent of rectal patients (P = 0.16). Occult micrometastases were found in 13.4 percent of colon vs. 7.0 percent of rectal patients (P = 0.24). Except for success rates, no other parameters were statistically different between colon and rectum. Lower success in sentinel lymph node identification in rectal cancer may have been related to neoadjuvant chemoradiation received in all six of the patients with sentinel lymph node mapping failures. Despite higher success rates in sentinel lymph node identification for colon patients, sentinel lymph node mapping was highly successful (91.5 percent) in rectal patients. Nodal upstaging, skip metastases, and occult metastases were similar.

Current conventional surgical and pathological techniques substantially understage colon cancer. This is evidenced by the fact that a significant subset of patients who are stage I and II at the time of colectomy return with distant metastases and ultimately succumb to the disease within the next 5 years. The identification of more nodes within a specimen and the detailed analysis of lymph nodes with advanced pathological techniques such as immunohistochemistry and reverse-transcriptase polymerase chain reaction (RT-PCR) can improve the staging of colon cancer, but are also associated with tremendous financial, time, and labor constraints. Sentinel lymph node (SLN) mapping has provided an avenue of staging colon cancer with high success rates and accuracy rates, while maintaining cost- and time-effectiveness. The ability to reproduce these results is dependent on adherence to the technical details of the procedure, and thereby providing the pathologist with the true SLNs, upon which the advanced pathological studies can be applied. We report our experience of SLN mapping for colon tumors in 209 patients, elaborating on the materials used, technical details, pitfalls, and results of the procedure. Our results show a success rate of 100% (209/209) and an overall accuracy rate for predicting positive or negative metastatic disease of 96.2% (201/209). Nodal metastases were identified in 46.2% (85/184) of patients with invasive disease (stage T1 to T4). The SLN was the exclusive site of metastases in 38.8% (33/85) of these patients, and the nodal disease was detected only as micrometastases in 22.4% (19/85). The skip metastases rate (false negatives) was 9.4% (8/85). SLN mapping is a powerful tool for accurate staging of colon cancer with a high success rate. The upstaging associated with this procedure may reveal disease that might otherwise go undetected by conventional surgical and pathological methods. Those patients who are upstaged can then benefit from adjuvant chemotherapy, which has been shown to improve survival of colon cancer patients with nodal disease by at least 33%.

The combination of isosulfan blue (Lymphazurin) 1% and 99(m)Tc sulfur colloid (TSC) may improve the feasibility and accuracy of lymphatic mapping for colorectal cancer.At laparotomy, 1 to 2 mL of isosulfan blue and 1 mCi of TSC were injected subserosally. Sentinel lymph node (SLN) designation was based on blue staining for isosulfan blue and increased radioactivity for TSC. Focused pathologic analysis of the SLNs and standard pathologic examination of the remaining specimen were performed.A total of 57 consecutive patients were studied (median age, 71 years; 27 men and 30 women). Mapping was successful in 100% of patients with isosulfan blue and in 89% with TSC (P =.47). Lymphatic mapping was accurate in 93% of patients with isosulfan blue versus 92% with TSC (P =.53). The combined accuracy was 95%. A total of 709 lymph nodes were found (12.4 per patient): 553 non-SLNs (5.6% nodal positivity) versus 156 SLNs (16.7% nodal positivity; P.0001). Isosulfan blue detected 152 SLNs, TSC detected 100, and both modalities detected 96. Of the SLNs detected by isosulfan blue only, 10.7% had nodal metastases, whereas 19.8% of SLNs detected with both modalities had nodal metastases (P =.028). Nodal disease was detected in 41% of patients with invasive carcinoma. Metastases were detected only in the SLNs in 26% and only by micrometastases in 11% of these patients.These data confirm the efficacy of isosulfan blue and TSC for SLN mapping in colorectal tumors. No significant difference with respect to feasibility or accuracy exists between isosulfan blue and TSC. The metastatic yield is significantly higher in SLNs identified by both modalities compared with isosulfan blue only.

3567 Background: CS and pathology understages 20% of patients (pts) with Cca. Adjuvant chemotherapy (CRx) is highly effective in pts with nodal mets. SLNM upstages up to 20% of Cca pts for nodal me...

5177 Background: PSC of the uterus (Ut) and ovary (Ov) are often treated similarly because of known similarities in their histology, biological aggressiveness and poor outcomes. In order to identify the need for more standardized treatment, the outcome of PSC of the Ut and Ov were compared in regard to their clinical presentation, treatment, stage at diagnosis, recurrence pattern and survival within the same institution. Methods: From 1991–2004, 327 consecutive patients (pts) were treated for Ut and Ov malignancy by a single oncologic surgeon. Of these, 46 pts were diagnosed as PSC (Ut =14 pts and Ov = 32 pts). The data were obtained from medical records, tumor registry, and follow-up reports. Comparisons were made in regard to age, stage at diagnosis, presentation, treatment, recurrence pattern and disease-free and overall survival. Results: See table. Conclusions: Ovarian PSC presents at a much more advanced stage, recurs more often and has much poorer disease-free and overall survival than uterine PSC....

Hypothesis Ten percent fluorescein may be successfully used as an alternative to 1% Lymphazurin (1% isosulfan blue; US Surgical Corp, North Haven, Conn) in sentinel lymph node (SLN) mapping for the accurate staging of colorectal tumors. Design Review of prospectively gathered data. Setting University-affiliated regional medical center. Patients Sentinel lymph node mapping was performed in 120 consecutive patients with colorectal malignancies. Interventions The first 1 to 4 blue nodes detected within 5 minutes were designated as Lymphazurin-detected SLNs. The first 1 to 4 fluorescent nodes seen under the Wood light were designated as fluorescein-detected SLNs. Multilevel serial sections for hematoxylin-eosin and immunohistochemistry studies for cytokeratin were performed on all SLNs. Main Outcome Measures Successful mapping, accuracy, skip metastasis, adverse reactions, occult micrometastases detection, and cost. Results Mapping was successful using Lymphazurin in 99% of the patients vs 97% of the patients using fluorescein ( P =.89). The accuracy of predicting nodal metastases with each tracer was 95.8% vs 93.1%, respectively ( P =.82). The skip metastases rate was 4.2% for Lymphazurin vs 6.9% for fluorescein ( P =.37). The 5 patients in whom nodal disease was only identified as occult micrometastasis in the SLNs had a total of 5 SLNs, all of which were identified by both tracers. No adverse reactions occurred. The cost for Lymphazurin was $99.00, while the cost for fluorescein was $2.10. Conclusions With the exception of cost, there were no statistically significant differences between the 2 dyes. While easy availability and lower cost remain distinct advantages of fluorescein, Lymphazurin remains the gold standard. In patients with known hypersensitivity to Lymphazurin and when availability and cost are an issue, fluorescein may be used effectively for SLN mapping in colorectal tumors.