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Background: This study aimed to assess the efficacy of a method for avoiding conversion to laparotomy in patients considered for laparoscopic colectomy. Patients deemed to be at high risk for conversion to laparotomy were initially approached via an 8-cm midline incision ("peek port") with the laparoscopic equipment unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy. If intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. Patients deemed to be at low risk for conversion to laparotomy were approached laparoscopically from the outset.Methods: Data from 241 consecutive patients brought to the operating room for intended laparoscopic colectomy were retrieved from a prospective database.Results: The study population consisted of 132 men and 109 women with a mean age of 62 years and a mean body mass index (BMI) of 28. Prior abdominal surgery had been performed in 49% of these patients. Inflammatory conditions accounted for 38% of the diagnoses, and enteric fistulas were present in 7% of the cases. Of the 25 patients who underwent the initial "peek port," 8 (32%) underwent immediate incision extension to formal laparotomy. Hand-assisted laparoscopic colectomy was performed in 17 (68%) of these 25 patients, with one subsequent conversion to formal laparotomy. Of the 216 patients initially approached laparoscopically, 5 (2%) required conversion to laparotomy. The laparotomy rate for the "peek port" group (9/25, 36%) was higher than for the initial laparoscopy group (5/216, 2%) (p < 0.0001). Of the 233 patients from both groups who underwent laparoscopy, the overall rate for conversion to laparotomy was 3% (6/233).Conclusions: The "peek port" approach to the patient with a potentially hostile abdomen allows for rapid assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy. This technique should reduce overall cost by avoiding the use of laparoscopic equipment as well as potential complications related to trocar placement and laparoscopic dissection in patients who will ultimately require formal laparotomy. [ABSTRACT FROM AUTHOR]

Purpose: Tangential excision of burns is complicated by blood loss. Tourniquet use decreases blood loss, but adequacy of excision has been questioned. An attempt was made to assess the value of not exsanguinating the limb prior to tourniquet inflation to improve visualization of bleeding points and subsequent engraftment.Methods: Eleven excisions of bilateral extremity wounds were performed. One limb was excised without the benefit of a tourniquet, the other with tourniquet but without exsanguination. Tangential excision was performed, hemostasis achieved, and blood loss quantified. Engraftment of skin was assessed at first dressing change and at initial follow-up after discharge.Results: Area of burn was the same, 4.8% with tourniquet, 5.1% without (P=0.38). Overall blood loss was less with tourniquet control, 100-259 cm(3) (P=0.002); as was blood loss per area, 0.19-0.58 cc/cm(2) (P=0.04). Graft take was similar, 98.2% early and 98.1% later with tourniquet, with 98.2 and 96.8% take without (P>0.1).Conclusions: Tourniquet use in the unexsanquinated extremity reduced blood loss without affecting engraftment. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess the incidence of diagnosed sinusitis and the effect of diagnosis and treatment on the outcome in critically ill burn victims. Chart analysis of 84 consecutive burn victims requiring mechanical ventilation for greater than 7 days was performed. Sinusitis was diagnosed in 13/84 patients (15%). There was no difference in age or total body surface area burned, or the incidence of inhalation injury, ARDS, pneumonia and sepsis (P>0.05). Co-morbid disease was similar in both the groups. The number of ventilator-dependent days and hospital length of stay were higher in the sinusitis group (P<0.05). The hospital mortality in those diagnosed and treated for sinusitis was 23% (3/13) as opposed to 48% (34/71) in those not diagnosed with sinusitis (P<0.05). Increased number of ventilator-dependent days and longer hospital stay are associated with the diagnosis of sinusitis. Our findings suggest an improved survival in those diagnosed and treated for sinusitis. [ABSTRACT FROM AUTHOR]

Purpose: Rectal cancer treatment has a wide range of possible approaches from radical extirpative surgery to nonoperative watchful waiting following chemoradiotherapy, with or without, additional chemotherapy. Our goal was to assess the personal opinion of active practicing surgeons on rectal cancer treatment if he/she was the patient., Methods: A panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) selected 10 questions that were included in a questionnaire that included other items including demographics. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in our database and remained open from April 16 to 28, 2020., Results: One hundred sixty-three specialists completed the survey. The majority of surgeons (n=65, 39.9%) chose the minimally invasive (laparoscopic) surgery for their personal treatment of rectal cancer. For low-lying rectal cancer T1 and T2, the treatment choice was standard chemoradiation+local excision (n=60, 36.8%) followed by local excision±chemoradiotherapy if needed (n=55, 33.7%). In regards to locally advanced low rectal cancer T3 or greater, the preference of the responders was for laparoscopic surgery (n=65, 39.9%). We found a statistically significant relationship between surgeons' age and their preference for minimally invasive techniques demonstrating an age-based bias on senior surgeons' inclination toward open approach., Conclusion: Our survey reveals an age-based preference by surgeons for minimally invasive surgical techniques as well as organ-preserving techniques for personal treatment of treating rectal cancer. Only 1/4 of specialists do adhere to the international guidelines for treating early rectal cancer.

Background: The novel severe acute respiratory syndrome coronavirus 2 virus that emerged in December 2019 causing coronavirus disease 2019 (COVID-19) has led to the sudden national reorganization of health care systems and changes in the delivery of health care globally. The purpose of our study was to use a survey to assess the global effects of COVID-19 on colorectal practice and surgery., Materials and Methods: A panel of International Society of University Colon and Rectal Surgeons (ISUCRS) selected 22 questions, which were included in the questionnaire. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in the ISUCRS database and was advertised on social media sites. The questionnaire remained open from April 16 to 28, 2020., Results: A total of 287 surgeons completed the survey. Of the 287 respondents, 90% were colorectal specialists or general surgeons with an interest in colorectal disease. COVID-19 had affected the practice of 96% of the surgeons, and 52% were now using telemedicine. Also, 66% reported that elective colorectal cancer surgery could proceed but with perioperative precautions. Of the 287 respondents, 19.5% reported that the use of personal protective equipment was the most important perioperative precaution. However, personal protective equipment was only provided by 9.1% of hospitals. In addition, 64% of surgeons were offering minimally invasive surgery. However, 44% reported that enough information was not available regarding the safety of the loss of intra-abdominal carbon dioxide gas during the COVID-19 pandemic. Finally, 61% of the surgeons were prepared to defer elective colorectal cancer surgery, with 29% willing to defer for ≤ 8 weeks., Conclusion: The results from our survey have demonstrated that, globally, COVID-19 has affected the ability of colorectal surgeons to offer care to their patients. We have also discussed suggestions for various practical adaptation strategies for use during the recovery period., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Hypothermia has been associated with an increase in the rate of infectious complications following colectomy. We hypothesized that a substantial fraction of temperature loss in patients undergoing elective colectomy occurs prior to operation., Methods: Temperature data were collected from 105 consecutive patients undergoing elective colectomy at a single institution., Results: The study population consisted of 105 patients; 67(64%) male, median age 59 years (range 17-95 years), median body mass index 27 kg/m 2 (range 15-48 kg/m 2 ). Median preoperative temperature was 36.7 °C (range 35.2-39.2 °C), dropping to 35.7 °C (range 34.0-37.3 °C) immediately following intubation and then rising to 36.2 °C (range 34.0-38.0 °C) prior to leaving the operating room. The median first postoperative temperature was 36.3 °C (range 34.4-37.7 °C). Temperatures were significantly different from one another (p < 0.05, ANOVA), except for the last operative and first postoperative temperature. A first postoperative temperature of ≥ 36.0 °C (meeting Surgical Care Improvement criteria Inf-10) was achieved in 78 (74%) of patients. A preoperative temperature of ≥ 36.5 °C was associated with a first postoperative temperature of ≥ 36.0 °C, but operative approach (laparoscopic versus open) was not., Conclusions: Most temperature loss occurs prior to operation in patients undergoing colectomy. Patients are rewarmed during the operative procedure. The time period prior to operation should be the focus of efforts designed to ensure normothermia.

Background: Auscultation for bowel sounds has been advocated by some clinicians as a method to determine the resolution of postoperative ileus., Objective: Our primary aim was to prospectively evaluate the relationships between bowel sounds and the ability to tolerate oral intake in patients after major abdominal surgery. Secondarily we aimed to evaluate relationships among bowel sounds, flatus and bowel movement, and oral intake., Design: This was a prospective, blinded observational study., Settings: The study was conducted at Western Pennsylvania Hospital., Patients: A total of 124 adult patients undergoing major abdominal surgery were included., Main Outcome Measures: Data were collected by medical students blinded to the purpose of the study for 10 days postoperatively or until discharge, including the presence of bowel sounds (auscultation for 1 minute), flatus, bowel movement, and tolerance of oral intake (defined as ingestion of ≥1000 mL/24 h and each subsequent day without vomiting). Associations between paired variables were determined using ϕ coefficient testing., Results: The study population consisted of 51 men and 73 women, with a mean age of 64 years (range, 20-92 y). The majority of patients (78/124 (63%)) underwent colorectal resection. The median length of hospital was 6 days. Bowel sounds were not associated with flatus, bowel movement, or tolerance of oral intake throughout the study period. The positive predictive value of bowel sounds in predicting flatus and bowel movement was low in the early postoperative period and remained <25% in predicting tolerance of oral intake throughout the study period. The analysis was repeated, including only those patients undergoing colorectal procedures, and was essentially unchanged. Flatus correlated with bowel movement in the first 6 days postoperation, but neither flatus nor bowel movement was associated with tolerance of oral intake., Limitations: The rate of tolerance of oral intake was relatively modest throughout the study period., Conclusions: Bowel sounds are not associated with flatus, bowel movement, or tolerance of oral intake after major abdominal surgery.

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using chi2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (nonsurvivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.

Background: Immunocompromised patients are at high risk of medical complications. Immunosuppression might be a relative contraindication to bariatric surgery. We describe our experience with immunosuppressed patients undergoing bariatric surgery and review the safety, efficacy, results, and outcomes., Methods: We performed a retrospective review of prospectively collected data. All patients taking long-term immunosuppressive medications or with a diagnosis of an immunosuppressive condition were included in this study. Data on weight loss, co-morbidities, complications, and postoperative immunosuppression were collected., Results: From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 61 (3.9%) were taking immunosuppressive medications or had an immunosuppressive condition. Of these 61 patients, 49 were taking immunosuppressive medications for asthma, autoimmune disorders, endocrine deficiency, or chronic inflammatory disorders. The medications included oral, inhaled, and topical glucocorticoids for 39 patients and other immunosuppressive or disease-modifying antirheumatic drugs for 24 patients. The bariatric procedures included laparoscopic Roux-en-Y gastric bypass in 55, laparoscopic revisional procedures in 5, and laparoscopic sleeve gastrectomy in 1. No patient died perioperatively. A total of 26 complications occurred in 20 patients. The average percentage of excess weight loss was 72% (range 20-109%) at 1 year postoperatively. At a median postoperative follow-up of 18 months (range 2-68.6), 25 (51%) of 49 patients no longer required immunosuppressive medications owing to improvement of their underlying disease. Obesity-related health problems (diabetes mellitus, hypertension, obstructive sleep apnea, gastroesophageal reflux disease, asthma) had resolved or improved in 80-100% of patients., Conclusion: The results of our study have shown that immunocompromised patients can safely undergo bariatric surgery with good weight loss results and improvement in co-morbidities. A large percentage of patients were able to discontinue immunosuppressive medications postoperatively.

Background: Obesity is a risk factor for cancer and is associated with increased mortality from a number of malignancies. We describe our experience with bariatric surgery patients with a history of malignancy and review the safety and outcomes of bariatric surgery in patients with a history of cancer., Methods: We performed a retrospective review of prospectively collected data from all patients diagnosed with a malignancy before, during, or after bariatric surgery. Data on weight loss, co-morbidities, and recurrence were collected., Results: From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 36 (2.3%) had a history of malignancy before they underwent bariatric evaluation and surgery, 4 (0.26%) were diagnosed with a malignancy during their preoperative evaluation, 2 of whom subsequently underwent bariatric surgery, and 2 had intraoperative findings suspicious for malignancy; bariatric surgery was completed in both cases. The evaluation revealed renal cell carcinoma and low-grade lymphoma, respectively. No procedures were aborted because of a suspicion of malignancy. Postoperatively, 16 patients (0.9%) were diagnosed with cancer, 3 of whom had a history of malignancy: 1 with metastatic renal cell, 1 with recurrent melanoma, and 1, who had had prostate cancer, with bladder cancer., Conclusion: A history of malignancy does not appear to be a contraindication for bariatric surgery as long as the life expectancy is reasonable. Screening for bariatric surgery might reveal the malignancy. Bariatric surgery does not seem to have a negative effect on the treatment of malignancies that are discovered in the postoperative period.

Introduction: Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates' technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice., Materials and Methods: Prospective study. Eight surgeons, applying for a fellowship position in minimally invasive surgery (MIS), performed a previously validated assessment curriculum using a Virtual-Reality Laparoscopic Trainer (LapSim 3.0, Surgical Science, Gothenburgh, Sweden). Technical performance was evaluated using criteria registered by the simulator, i.e., time, error score, and efficiency of movements score. Candidates performed all the tasks in easy end medium level until reaching predefined criteria. If proficiency criteria were not achieved on easy or medium level after nine repetitions the test was considered as failed. Additionally, all applicants underwent an interview by two independent attending surgeons. Each applicant received a grade on a ten-point scale., Results: Five out of the eight candidates failed the technical skills assessment test. One candidate failed to achieve proficiency criteria on easy level, one on medium, and three on difficult level. Evaluation scores, based on the interview of the candidates showed a good interrater reliability (Cronbach's alpha = 0.8). There was no significant correlation between the interviewers rating, and the applicants technical skills demonstrated during the test on the VR trainer (Spearman's rho = 0.182, p = 0.696)., Conclusions: Evaluations by senior surgeons are reproducible and reliable. The introduction of technical skills assessment has the potential to improve the current method of candidate selection, making it more valid, objective, and transparent.

Aim: To review trends in incidence and treatment of thermal injuries among the elderly., Method: A 3-year retrospective review of medical records of people aged 65 years and older admitted to our burn centre over July 2003-June 2006., Results: Elderly people with burns continued to have significant comorbidities. They were often burned because they were inappropriately trying to live alone. Thus discharge was often complicated., Conclusions: At our burn centre, survival among elderly people with burns has increased, probably as a result of more sophisticated medical, surgical and nursing care, as well as more extensive rehabilitation.

Background: Previous studies have reported a high prevalence of Helicobacter pylori infection in patients undergoing Roux-en-Y gastric bypass (RYGB) and a greater incidence of anastomotic ulcer in patients positive for H. pylori, leading to recommendations for routine preoperative screening. Our hypotheses were that the prevalence of H. pylori in patients undergoing RYGB is similar to that of the general population and that preoperative H. pylori testing and treatment does not decrease the incidence of anastomotic ulcer or pouch gastritis., Methods: A retrospective analysis of H. pylori serology, preoperative and postoperative endoscopy findings, and the development of anastomotic ulcer or erosive pouch gastritis was performed. All patients positive for H. pylori received treatment. Univariate parametric and nonparametric statistical tests, as well as multiple logistic regression analyses, were performed., Results: A total of 422 LRYGB patients were included in the study. Of these patients, 259 (61.4%) were tested for H. pylori and 163 (38.6%) were not. Of the 259 patients, 58 (22.4%) tested positive for H. pylori, 197 (76.1%) tested negative, and 4 (1.5%) had an equivocal result. Postoperatively, 53 patients (12.6%) underwent upper endoscopy. Of these 53 patients, 19 (4.5%) had positive endoscopy findings for anastomotic ulcer (n = 16) or erosive pouch gastritis (n = 3). Five patients underwent biopsy at endoscopy; all biopsies were negative for H. pylori. No difference was found in the rate of positive endoscopy between patients tested preoperatively for H. pylori (5%) and patients not tested (3.7%)., Conclusion: The results of our study have shown that the prevalence of H. pylori infection in patients undergoing RYGB is similar to that of the general population. Our study has shown that H. pylori testing does not lower the risk of anastomotic ulcer or pouch gastritis.

Purpose: Endoscopically unresectable apparently benign colorectal polyps are considered by some surgeons as ideal for their early laparoscopic colectomy experience. Our hypotheses were: (1) a substantial fraction of patients undergoing laparoscopic colectomy for apparently benign colorectal neoplasia will have adenocarcinoma on final pathology; and (2) in our practice, we perform an adequate laparoscopic oncological resection for apparently benign polyps as evidenced by margin status and nodal retrieval., Methods: Data from a consecutive series of patients undergoing laparoscopic colectomy (on an intention-to-treat basis) for endoscopically unresectable neoplasms with benign preoperative histology were retrieved from a prospective database and supplemented by chart review., Results: The study population consisted of 63 patients (mean age 67, mean body mass index 29). Two out of 63 cases (3%) were converted to laparotomy because of extensive adhesions (n = 1) and equipment failure (n = 1). Colectomy type: right/transverse (n = 49, 78%); left/anterior resection (n = 10, 16%); subtotal (n = 4, 6%). Invasive adenocarcinoma was found on histological analysis of the colectomy specimen in 14 out of 63 cases (22%), standard error of the proportion 0.052. Staging of the 14 cancers were I (n = 6, 43%), II (n = 3, 21%), III ( = 4, 29%), and IV (n = 1, 7%). The median nodal harvest was 12 and all resection margins were free of neoplasm. Neither dysplasia on endoscopic biopsy nor lesion diameter was predictive of adenocarcinoma. Eight out of 23 (35%) patients with dysplasia on endoscopic biopsy had adenocarcinoma on final pathology versus 6/40 (15%) with no dysplasia (p = 0.114, Fisher's exact test). Mean diameter of benign tumors was 3.2 cm (range 0.5-10.0cm) versus 3.9cm (range 1.5-7.5cm) for adenocarcinomas (p = 0.189, t - test)., Conclusion: A substantial fraction of endoscopically unresectable colorectal neoplasms with benign histology on initial biopsy will harbor invasive adenocarcinoma, some of advanced stage. This finding supports the practice of performing oncological resection for all patients with endoscopically unresectable neoplasms of the colorectum. The inexperienced laparoscopic colectomist should approach these cases with caution.

Thrombotic thrombocytopenic purpura (TTP) is an uncommon disorder characterized by a pentad of microangiopathic hemolytic anemia, thrombocytopenia, renal dysfunction, fever, and a fluctuating neurologic syndrome. Splenectomy is performed for patients who are refractory to plasma therapy and for relapsing TTP. We describe a case of a patient who died due to intramyocardial hemorrhage after undergoing laparoscopic splenectomy for TTP resistant to treatment with plasmapheresis. A 52-year-old woman was admitted with ecchymoses, low platelet count, weakness of left face and upper extremity, and a presumptive diagnosis of TTP. Vital signs were stable. White blood count was 7800/microL, hemoglobin 7.9 g/dL, and platelet count of 13,000/microL. Her basic metabolic panel and liver function tests were normal. Further laboratory workup confirmed the diagnosis of TTP. The patient was initially treated with plasmapheresis and high dose steroid therapy but underwent an emergent laparoscopic splenectomy due to refractory TTP. At the end of the uneventful procedure, the patient suffered a cardiac arrest and died. Autopsy concluded that the death was from myocardial failure due to extensive myocardial hemorrhage secondary to TTP. There are several published case reports of sudden death due to cardiac involvement in TTP. However, intraoperative mortality is not reported. We conclude that TTP-related acute heart failure may represent an extremely important clinical risk in these patients who are undergoing surgery.

Background: Isolated perineal endometrioma is a rare entity and often causes diagnostic uncertainty., Cases: Three premenopausal women, none with a prior history of endometriosis, presented with vague perineal pain 3-6 months following obstetric delivery with episiotomy. The latency periods between the onset of symptoms and definitive diagnosis were 3 months, 18 months and 3 years despite multiple physician evaluations in the interim. Patient presentation and management were virtually identical in all cases. Detailed questioning revealed that the pain was located adjacent to the episiotomy incision and waxed and waned with menses. Physical examination revealed a vague fullness adjacent to the episiotomy incision. Endoanal ultrasound revealed a mass of mixed echogenicity adjacent to the external anal sphincter. Transperineal exploration revealed a tumor with the gross appearance of an endometrioma, which was confirmed histologically. Excision of the mass with preservation of the anal sphincter muscle resulted in resolution of symptoms in all patients without the need for hormonal manipulation. No patient suffered diminution of fecal continence., Conclusion: Occult perineal endometriosis should be considered when a woman presents with cyclic pain in the perineum following delivery and episiotomy. Endoanal ultrasound can assist with the diagnosis. Transperineal excision with sparing of the anal sphincter can be curative, without compromising continence.

Tourniquets are routinely used during the excising and grafting of burn wounds located on the limbs in order to decrease blood loss. It has been postulated that the exsanguination of extremities by using Esmarch bandages might further reduce blood loss. However, there are concerns about a decrease in graft quality when Esmarch bandages are applied. The purpose of this prospective, double-blinded randomized study was to compare Esmarch application in addition to tourniquet (exsanguinated extremities) with the application of tourniquet alone. Thirty-eight excisions of bilateral extremity wounds were performed. Both limbs were tangentially excised after tourniquet application with one limb randomly chosen for prior Esmarch exsanguination. Blood loss was estimated during this procedure. Graft take was assessed twice: on post-operative days 3 and 7. The burn surface area and total area grafted were equivalent in the extremities with Esmarch bandages when compared to the extremities without them. Total blood loss was less in the extremities where Esmarch was applied. Graft take was similar in the two groups. Statistical analysis was performed with a two-tailed paired T-test. It is concluded that the use of Esmarch exsanguination in addition to tourniquet further reduces blood loss without affecting the quality of the engraftment.

Background: Access and endoscopic evaluation of the bypassed stomach is difficult after laparoscopic Roux-en-Y gastric bypass. We propose a minimally invasive technique to access the bypassed stomach after Roux-en-Y gastric bypass for endoscopic diagnosis and treatment., Methods: First, we established carbon dioxide pneumoperitoneum to a pressure of 12-15 mm Hg. Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm left upper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of the stomach. A gastrotomy was made using ultrasonic shears and the 15-mm trocar was placed into the stomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneum was decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with a running suture or linear stapler., Results: Ten patients at our institution have undergone laparoscopic transgastric endoscopy. Five patients had biliary pathologic findings. Four of these patients underwent successful endoscopic retrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was unsuccessful because stone impaction at the ampulla. Three patients were evaluated for gastrointestinal bleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleeding duodenal ulcer, requiring surgical exploration; and the third had negative endoscopy findings. Two patients evaluated for chronic abdominal pain had negative endoscopy findings. No complications developed., Conclusions: Laparoscopic transgastric endoscopy is a safe and minimally invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en-Y gastric bypass.

Background: The bypassed portion of the stomach is difficult to access and evaluate after Roux-en-Y gastric bypass. Access to the excluded stomach may be needed for nutritional support or decompression owing to acute distension and obstruction. We report our experience with percutaneous, computed tomography (CT)-guided gastrostomy tube placement into the gastric remnant after laparoscopic Roux-en-Y gastric bypass (LRYGB)., Methods: Of 569 consecutive LRYGB procedures performed, 9 patients underwent successful percutaneous, CT-guided gastrostomy placement. One additional patient was referred from another facility. We reviewed the indications, interval from surgery to the intervention, interval to removal, complications, and success or outcome of the procedure in our patient population., Results: Ten patients underwent percutaneous, CT-guided gastric remnant gastrostomy tube placement. The indications included distended gastric remnant in 6, nutritional access in 4, and remnant drainage after leak in 1. Of the 10 patients, 2 had undergone previous gastric operations. The attempt at percutaneous gastrostomy was unsuccessful in 1 additional patient, who subsequently required laparoscopic gastrostomy (success rate 91%)., Conclusion: In selected patients after LRYGB, CT-guided gastrostomy tube placement is safe and efficient. It may be used to manage complications of LRYGB, serve as a bridge to definitive surgery, or offer a convenient route for enteral nutritional support.

We describe an unusual case of sarcoidosis in which the patient presented with a discrete solitary parotid mass and no other manifestation of the disease. The diagnosis was based on the unexpected pathologic findings during examination of a superficial parotidectomy specimen. To the best of our knowledge, no such presentation has been previously reported in the English-language literature.

Gastric diverticula are extremely rare and may be congenital or acquired. Postgastrectomy formation of gastric diverticula has been attributed to outpouching through the weakened wall of the stomach. When symptomatic, gastric diverticula may cause pain, nausea, dysphagia, and vomiting. Gastric diverticula may also be associated with ectopic mucosa, ulcers, and neoplastic changes. We report a case of gastric cardia diverticulum that became symptomatic after laparoscopic Roux-en-Y gastric bypass. The patient was successfully treated with laparoscopic resection.

Women undergoing breast conservation therapy (BCT) for stage 1 breast cancer have adjuvant external beam radiotherapy (EBR). In addition, the use of brachytherapy radiation is being used. We present two local tumor recurrences for review. Our first patient underwent BCT, sentinel lymph node biopsy (SLNBx) and MammoSite brachytherapy for a T1N0M0 infiltrating ductal carcinoma (IDC) of the right breast. Pathology: 0.6 cm poorly differentiated ER, PR, and Her-2/ Neu negative IDC. At 18 months, she had palpable axillary lymph nodes. Fine needle aspiration and ultrasound-guided core biopsy of a nodule showed IDC. She underwent modified radical mastectomy (MRM) and EBR. Our second patient underwent BCT, SLNBx, and MammoSite brachytherapy for a T1N0M0 IDC of the left breast. Pathology: 0.8 cm poorly differentiated, ER+, PR-, and Her-2/Neu negative tumor. At 18 months, a retroareolar mass was detected. Ultrasound guided core needle biopsy showed recurrent IDC. She chose a re-excision and EBR and not MRM. Pathology: 1.3 cm poorly differentiated, ER+, PR-, and Her-2/Neu negative tumor. Our 2 recurrences were >2 cm away from the lumpectomy site and therefor outside the 1 cm treatment plan of the MammoSite catheter. Both recurrences were biologically identical to the initial tumors and are felt to be local failures rather than new primaries.

Two cases of small-bowel perforation secondary to Clostridium difficile enteritis are described and compared with the 8 cases of C difficile enteritis reported in the medical literature. The cause of small-bowel involvement with C difficile is unknown, but prior antibiotic use, prior colectomy, chronic alterations in small-bowel flora, and other host factors are discussed.

Background: Management of the gallbladder in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) is controversial. We reviewed our experience in patients undergoing LRYGBP without routine gallbladder screening., Methods: The data of 644 patients who underwent LRYGBP at our institution were analyzed. Preoperative ultrasonography was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy at LRYGBP was performed in symptomatic patients with positive ultrasound findings. Postoperatively, patients with intact gallbladders were prescribed ursodiol for 6 months., Results: Of the 644 patients, 155 (24%) had history of cholecystectomy. A total of 104 patients underwent preoperative ultrasonography. Of the 104 patients, 20 had positive ultrasound findings and symptoms consistent with biliary disease and underwent concomitant cholecystectomy. Twelve patients had positive ultrasound findings and no biliary symptoms and did not undergo cholecystectomy. At a mean follow-up of 26.4 months, only 1 (8.3%) of the 12 patients had required cholecystectomy. Of the 104 patients, 72 had negative ultrasound findings. At a mean follow-up of 21.2 months, 5 of them (6.9%) had required cholecystectomy. The remaining 385 patients did not undergo any gallbladder screening. At a mean follow-up of 14 months, 32 (8.3%) of 385 patients had required cholecystectomy. Compliance with ursodiol for >4 months was only 39%. A time-to-event analysis did not reveal a significant difference in the cholecystectomy rate between asymptomatic patients with preoperative gallbladder screening and patients with no screening., Conclusion: Omission of gallbladder screening in asymptomatic patients undergoing LRYGBP is a reasonable approach that spares the patient a potentially unnecessary procedure with all its associated risks.

In the past, many patients were admitted for a minimum of 72 h for split-thickness skin grafting (STSG). Several factors have caused us to discharge burn patients on the same day or within 24 h following STSG. We have reviewed outcomes of such patients to determine whether early discharge has an adverse effect on graft outcome and to determine patient acceptance of this new procedure. We retrospectively reviewed charts of patients consecutively treated at our hospital. Two hundred patients were identified. All patients were found to have successful grafts. From our results, we can conclude that patient discharge in less than 24 h following STSG does not predispose patients to poor graft take or other adverse outcomes.

Introduction: Blood loss and high rates of transfusion in burn centers remains an area of ongoing concern. Blood use brings the risk of infection, adverse reaction, and immunosuppression., Methods: A protocol to reduce blood loss and blood use was implemented. Analysis included 3-year periods before and after institution of the protocol. All patients were transfused for a hemoglobin below 8.0 gm/dL., Results: Operations per admission did not change during the two time periods (0.78 in each). Overall units transfused per operation decreased from 1.56+/-0.06 to 1.25+/-0.14 units after instituting the protocol (p<0.05). Also, units transfused per admission decreased from 1.21+/-0.15 to 0.96+/-0.06 units of blood (p<0.05). This was noticed particularly in burns of less than 20% surface area, declining from 386 to 46 units after protocol institution, from 0.37 to 0.04 units per admission, and from 0.79 to 0.08 units per operation in this group of smallest burns. There was no change noted in the larger burns., Conclusions: This study suggests that a defined protocol of hemostasis, technique, and transfusion trigger should be implemented in the process of burn excision and grafting. This will help especially those patients with the smallest burns, essentially eliminating transfusion need in that group.

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed operation for the treatment of morbid obesity in the USA. Complications related to the jejuno-jejunal (J-J) anastomosis include postoperative leak, staple-line bleeding and obstruction. We present 3 cases of perforation at the J-J anastomosis occurring more than 30 days after surgery. 3 morbidly obese patients underwent laparoscopic RYGBP. The side-to-side J-J anastomosis was created with a linear stapler, and the anastomotic defect was closed with a running absorbable suture. All 3 patients had uneventful recoveries, but presented 7 to 8 weeks postoperatively with acute abdominal pain and peritoneal signs. Exploratory laparoscopy in these patients revealed a perforation at the J-J anastomosis. No apparent reason for the perforation was found in 2 patients. These perforations were repaired laparoscopically with absorbable suture. The third patient had an obstruction at the J-J anastomosis from an phytobezoar and required conversion to open technique due to limited pneumoperitoneum. All 3 patients recovered uneventfully. Late perforation of the J-J anastomosis is a very rare complication. Primary laparoscopic repair is a feasible and safe choice of treatment.

Background: The volume of resuscitation in burn patients has been shown to correlate with intra-abdominal pressure (IAP). Limiting volume may reduce consequences of IAP and abdominal compartment syndrome. Colloid resuscitation has been previously shown to limit the volume required initially after burn., Methods: Thirty-one patients were prospectively followed. Inclusion criteria were a burn of 25% total body surface area with inhalation injury or 40% total body surface area without. Patients received crystalloid (Parkland formula) or plasma resuscitation. IAP was measured by means of urinary bladder transduction., Results: Mean age, area of burn, and baseline IAP were not different. Urine output was maintained. There was a greater increase in IAP with crystalloid (26.5 vs. 10.6 mmHg, p < 0.0001). Two patients in the plasma group developed IAP greater than 25 mmHg; only one patient in the crystalloid group maintained IAP less than 25 mmHg. More fluid volume was required with crystalloid resuscitation, 0.26 L/kg, versus 0.21 L/kg (p < 0.005). Correlation was seen in both groups between volume of fluid and IAP (crystalloid, r = 0.351; plasma, r = 0.657; all patients, r = 0.621)., Conclusion: Plasma-resuscitated patients maintained an IAP below the threshold of complications of intra-abdominal hypertension. This appears to be a direct result of the decrease in volume required. Lower fluid volume regimens should be given consideration as the incidence and consequences of intra-abdominal hypertension in burn patients continue to be defined.

Background: Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass (LRYGBP) present with dysphagia, nausea, and vomiting. Diagnosis is made by endoscopy and/or radiographic studies. Therapeutic options include endoscopic dilation and surgical revision., Methods: Of 369 LRYGBP performed, 19 patients developed anastomotic stricture (5.1%). One additional patient was referred from another facility. Pneumatic balloons were used for initial dilation in all patients. Savary-Gilliard bougies were used for some of the subsequent dilations., Results: Flexible endoscopy was diagnostic in all 20 patients allowing dilation in 18 (90%). Two patients did not undergo endoscopic dilation because of anastomotic obstruction and ulcer. The median time to stricture development was 32 days (range: 17-85). Most patients (78%) required more than two dilations. The complication rate was 1.6% (one case of microperforation). At a mean follow-up of 21 months, all patients were symptom-free., Conclusions: Gastrojejunostomy stricture following LRYGBP is associated with substantial morbidity and patient dissatisfaction. Based on our experience, we propose a clinical grading system and present our strategy for managing gastrojejunal strictures.

Background: Coronary artery disease represents a significant cause of morbidity and mortality in patients with connective tissue disease. Few reports exist on the results of surgical management of coronary artery disease in these patients., Methods: The medical records of patients with connective tissue diseases who underwent coronary artery bypass grafting at our institution between 1995 and 2002 were reviewed for demographic data, perioperative variables, and postoperative complications. The results were compared with data from The Society of Thoracic Surgeons database., Results: Forty-four patients were identified from a total of 5,496 cases during the study period (0.8%). There were 35 patients with rheumatoid arthritis, 8 with systemic lupus erythematosus, and 1 with scleroderma. Patients with connective tissue diseases were more likely to be women and use immunomodulating agents. They also had a higher incidence of Canadian Cardiovascular Society class IV angina, need for inotropic agents, need for intraaortic balloon pulsation, use of blood transfusions, and leg wound infections. The use of steroids or other immunomodulating agents was associated with increased postoperative complications. Mean follow-up was 35 months. The overall survival and freedom from reintervention at 3 years were 89% and 75%, respectively., Conclusions: Coronary artery bypass grafting is a safe treatment modality in patients with connective tissue diseases, with acceptable early results. Wound complications may be a problem in this patient population. Midterm results are less favorable, and reinterventions are frequently required.

Purpose: This study was designed to: determine the efficacy of sentinel lymph node mapping in patients with intraperitoneal colon cancer; and create an algorithm to predict potential survival benefit by using best-case estimates in favor of sentinel node mapping and lymph node ultraprocessing techniques., Methods: Forty-one patients with intraperitoneal colon cancer undergoing colectomy with curative intent were studied prospectively. After mobilization of the colon and mesentery, 1 to 2 ml of isosulfan blue dye was injected subserosally around the tumor. The first several nodes highlighted with blue dye were identified as sentinel nodes. Additional nodes were identified by the pathologist in routine fashion by manual dissection of the mesentery. All nodes were processed in routine fashion by bivalving and hematoxylin and eosin staining. To create an algorithm to predict potential survival benefit of sentinel node mapping and lymph node ultraprocessing techniques, assumptions were made using data from the literature. All bias was directed toward success of the techniques., Results: Three of 41 patients (7 percent) did not undergo injection of dye and were excluded from further analysis. Stage of disease in the remaining 38 patients was: I, n = 10 (26 percent); II, n = 15 (39 percent); III, n = 11 (29 percent); IV, n = 2 (5 percent). At least one sentinel node was identified in 30 of 38 patients (79 percent). The median number of sentinel nodes identified was two (range, 1-3). Median total nodal retrieval was 14 (range, 7-45). All nodes were negative in 26 of 38 patients (68 percent). Sentinel nodes and nonsentinel nodes were positive in 2 of 38 patients (5 percent). Sentinel nodes were the only positive nodes in 1 of 38 patients (3 percent). Sentinel nodes were negative and nonsentinel nodes were positive in 9 of 38 patients (24 percent). Thus, sentinel node mapping would have potentially benefited only 3 percent, and failed to accurately identify nodal metastases in 24 percent of the patients in our study. To create a survival benefit algorithm, we assumed the following: combined fraction of Stage I and II disease (0.5); fraction understaged by bivalving and hematoxylin and eosin staining that would have occult positive nodes by more sophisticated analysis (0.15); fraction of occult positive nodes detected by sentinel node mapping (0.9); and survival benefit from chemotherapy (0.33). Thus, the fraction of patients benefiting from sentinel lymph node mapping and lymph node ultraprocessing techniques would be 0.02 (2 percent)., Conclusions: Sentinel node mapping with isosulfan blue dye and routine processing of retrieved nodes does not improve staging accuracy in patients with intraperitoneal colon cancer. Even using best-case assumptions, the percentage of patients who would potentially benefit from sentinel lymph node mapping is small.

Standard therapy for abdominal compartment syndrome is laparotomy. In many patients, laparotomy involves a recent incision; for others, volume of resuscitation may be the cause. The components separation technique allows difficult abdominal closure. The authors studied the effect of a modified separation of parts on abdominal compartment syndrome in an animal model. Eight pigs were instrumented for measurement of central venous pressure, mean arterial pressure, peak airway pressure, and intraabdominal pressure. Intraabdominal hypertension to 25 mmHg was established with intraperitoneal fluid infusion. Modified separation of parts was performed by sequential release of the abdominal wall layers. With increased intraabdominal pressure, mean arterial pressure (55.3 +/- 12.0 to 65.3 +/- 11.0), central venous pressure (7.7 +/- 2.4 to 13.3 +/- 6.9), and peak airway pressure (20.2 +/- 2.4 to 25.3 +/- 4.1; p < 0.05) also increased. Maximum intraabdominal pressure was 26.0 +/- 1.2 mmHg. Skin incision resulted in a decrease in intraabdominal pressure to 21.7 +/- 4.5, external oblique release to 18.3 +/- 3.9, internal oblique release to 13.2 +/- 4.0, and transversus muscle incision to 7.0 +/- 2.5 mmHg (p < 0.05). With completion of components separation, mean arterial pressure remained increased (63.2 +/- 16.9), central venous pressure decreased (6.8 +/- 3.6; p < 0.05), and peak airway pressure decreased (22.7 +/- 3.9; p < 0.05). Modified separation of parts technique effectively releases intraabdominal hypertension and reverses the physiologic derangements associated with abdominal compartment syndrome in the animal model.

Background: Standard therapy for abdominal compartment syndrome (ACS) is laparotomy and temporary abdominal wall closure with significant morbidity. The component separation technique allows for difficult abdominal closure. We studied a modified extraperitoneal endoscopic separation of parts technique on an animal model of ACS., Methods: Twelve anesthetized pigs were instrumented for measurement of central venous pressure, arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, and intraabdominal pressure (IAP). ACS to 25 mmHg was created by infusing saline into an intraabdominally placed bag. Animals were divided in two equal groups. Pigs in group A underwent minimally invasive resection of the nerves supplying the rectus muscles bilaterally. Pigs in group B underwent minimally invasive modified component separation technique bilaterally. Change in IAP and other physiological parameters were recorded., Results: (Group A) IAP increased significantly from 7.3 mmHg +/- 3.8 to 25.2 mmHg +/- 1.5 with infusion of saline. Following nerve transection on the right side there was a nonsignificant decrease in IAP from 25.2 mmHg +/- 1.5 to 22.3 mmHg +/- 1.4 and following nerve transection on the left side there was a further decrease in IAP to 20.3 mmHg +/- 1.9. (Group B) IAP increased significantly from 3.8 mmHg +/- 0.4 to 24.7 mmHg +/- 0.5 with infusion of saline. Following separation of parts on the right side there was a significant decrease in IAP from 24.7 mmHg +/- 0.5 to 15.0 mmHg +/- 1.7 and there was a further decrease in IAP to 11.3 mmHg +/- 1.4 following separation of parts on the left side. The only significant change in the physiological parameters measured was observed in CVP in both groups., Conclusion: We present a porcine model of extraperitoneal endoscopic release of abdominal wall components as a treatment option for ACS.

Background: Obtaining tumor-negative margins when performing breast-conserving surgery is the standard of care to prevent local recurrence. We believe two-view specimen mammography is a useful method for intraoperative determination of adequacy of excision., Methods: A retrospective review was performed on patients who underwent wire-localized partial mastectomy for invasive cancer in our Breast Center from 2000 to 2001. Two-view specimen mammography reports were compared to the pathologic evaluation., Results: Eighty-eight of 93 patients (95%) had complete primary excision. Sixteen patients had additional margins excised at the time of the initial operation based on specimen mammogram. Six patients would have had positive margins had additional excision at the primary surgery not been performed., Conclusions: Specimen mammography can help reduce reoperation rate by identifying patients who need additional margin excision at the time of initial surgery for breast conservation therapy. Using two-view specimen mammography, our reoperation rate was reduced from 12% to 5%.

Objective: This study was undertaken to determine the safety and efficacy of reoperative laparoscopic fundoplication for patients with failed fundoplication., Methods: Thirty-nine of 612 consecutive patients who had undergone fundoplication underwent laparoscopic reoperative fundoplication for recurrent symptoms, persistent dysphagia, or gas bloat. An additional 15 patients were referred from outside facilities for reoperation. Preoperative evaluation included barium swallow (n = 54), esophagogastroduodenoscopy (n = 54), esophageal manometry (n = 34), and 24-hour ambulatory pH measurement (n = 32). Symptom severity before and after surgery was evaluated with a visual analog scoring scale. The mean follow-up was 22.5 months., Results: The primary symptoms that led to reoperation in the 54 patients were heartburn (n = 26), dysphagia (n = 23), and gas bloat (n = 5). Average time from initial operation to reoperation was 22.7 months. There were 3 conversions to open technique. An anatomic reason for the failure of the initial fundoplication was found in 69% of cases: slipped or misplaced fundoplication (n = 14), disrupted fundoplication (n = 8), transdiaphragmatic herniation (n = 7), achalasia (n = 1), and tight fundoplication (n = 7). Fourteen patients had 15 perioperative complications. Mean hospital stay was 2.3 days. Symptoms such as heartburn, dysphagia, and gas bloat improved significantly after reoperation; 40% to 50% of patients had scores 0 to 2, 21% to 45% had scores 3 to 7, and 9% to 29% had scores 8 to 10. Proton-pump inhibitor use after operation decreased from 88% to 36%. Fifty-two percent of patients completely discontinued any antireflux medications. Three patients had failure of the reoperation and required additional procedures., Conclusion: Laparoscopic reoperation for failed fundoplication is feasible and can achieve resolution of symptoms for a significant percentage of patients.

Background: Bariatric surgery in patients >50 years has been controversial. We investigated the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients >55 years of age., Methods: Prospective data on 71 patients (54 females and 17 males) undergoing LRYGBP were reviewed. The patients were followed for a mean of 17 months (range 2-35 months)., Results: The mean age was 59 years (range 55-67 years), and the mean preoperative BMI was 50.2 kg/m2 (range 37-65 kg/m2). There were no conversions to open technique. Mean percent of excess weight loss (%EWL) was 20%, 48%, 64% and 67% at 1, 6, 12 and 24 months respectively. 89% of patients had at least a 50% EWL at 1 year postoperatively. There was a significant decrease in the number of patients requiring medical treatment for co-morbidities associated with morbid obesity: diabetes mellitus 87%, hypertension 70% and sleep apnea 86%. There was no inpatient mortality. 1 patient died suddenly 2 weeks postoperatively of possible myocardial infarction or pulmonary embolism. 16 patients developed 22 complications. The median length of hospital stay was 3 days., Conclusion: LRYGBP is a safe and well-tolerated surgical option for the treatment of morbid obesity in patients >55 years old. These patients demonstrate a satisfactory weight loss and resolution of co-morbidities.

Objective: Deep vein thrombosis (DVT) represents a major cause of morbidity in surgical patients. Controversial reports exist on the incidence of DVT in burn patients. We report our experience over a 10-year period., Methods: Patients admitted to our Burn Unit over the period 1991-2001 and diagnosed with DVT were identified. Their records were retrospectively reviewed for demographic factors, extent and severity of burn injury and outcome., Results: A total of 4102 patients were admitted to the WPH Burn unit during the study period. All patients received routine subcutaneous heparin prophylaxis. Ten patients were diagnosed with DVT (0.25%). Compared to our total burn population, these patients were older (mean age 47 +/- 22.7 years versus 35 +/- 22 years P = 0.14) and had more extensive burns (mean total body surface area (TBSA) 34.7 +/- 25.3% versus 12 +/- 15.7% P = 0.02). Two patients developed non-fatal pulmonary embolism (PE). There were three deaths, none due to thromboembolic disease. There were no complications from the routine administration of subcutaneous heparin., Conclusion: The incidence of DVT in our study is much less than the incidence reported in other critically ill patients and less than that of most reports on burn patients. In our experience, routine heparin prophylaxis is effective for the prevention of DVT in burn patients.

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.

Purpose: This study was designed to compare histologic T and N stages in patients with rectal adenocarcinoma undergoing various neoadjuvant radiotherapy regimens and proctectomy, in an attempt to determine if final histologic stage of the mural tumor predicts nodal status., Methods: Data were collected from computerized databases at two institutions on 649 consecutive patients who underwent neoadjuvant radiotherapy or chemoradiotherapy and proctectomy for primary adenocarcinoma of the rectum from 1990 to 2002., Results: Five patients were excluded because of incomplete pathology data sets, leaving a study population of 644. Patients underwent neoadjuvant radiotherapy alone (2000 cGy in 5 fractions, n = 191; or 4500 cGy in 25 fractions, n = 259) or chemoradiation (4500 cGy in 25 fractions with concurrent 5-fluorouracil, n = 194). Histologic stage of the remaining mural tumor (ypT) correlated with nodal status (ypN). Lymph nodes harboring metastatic tumor were found in 1 of 42 (2 percent) ypT0 patients, 2 of 45 (4 percent) ypT1 patients, 43 of 186 (23 percent) ypT2 patients, 158 of 338 (47 percent) ypT3 patients, and 16 of 33 (48 percent) ypT4 patients ( P < 0.001, chi-squared test). The probability of finding ypN+ disease was 3 of 87 (3 percent) in patients with ypT0-1 residual primary tumors vs. 220 of 557 (39 percent) in patients with ypT2-4 residual primary tumors ( P < 0.0001; Fisher's exact test)., Conclusions: Nodal metastases are rare in patients whose mural tumor burden shrinks to ypT0-1 after neoadjuvant radiotherapy. If transanal excision is offered to select patients with distal rectal cancer, it is reasonable to select those who have an excellent clinical response to neoadjuvant therapy for transanal excision, and then reserve proctectomy for patients proven to have residual ypT2-4 disease.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been very effective in managing a broad range of morbid obesity-related co-morbidities. We report a beneficial effect of LRYGBP that has not been previously observed., Methods: Between December 1999 and September 2002, 224 patients underwent LRYGBP. Preoperative assessment for hypothyroidism and follow-up data were prospectively collected in our database. Improved thyroid function (ITF) or unchanged thyroid function (UTF) was determined by comparison of preoperative and postoperative thyroxine requirements., Results: 23 of 224 patients (10.3%) were treated preoperatively for hypothyroidism. During a median follow-up of 17 months, hypothyroidism was improved in 10/23 patients (43.5%). 2 patients had complete resolution, and the remaining 8 had reduction (14%-50%) of their thyroxine requirements. ITF occurred at a mean follow-up of 8.9 months and at a mean excess weight loss (EWL) of 57%. 6 of the 8 patients (75%) with ITF >or= 25% had EWL >90% at last follow-up, compared to 1 out of 15 patients (6.6%) with UTF or <25% improvement (P =0.001). Comparison of patients with ITF and UTF over time during a 20-month follow-up, showed no significant difference in mean body mass index (BMI) and mean percentage of EWL., Conclusion: Improvement of hypothyroidism may be an additional benefit of bariatric surgery that has not been previously reported. Reduction of thyroxine requirements is most likely the result of the decrease in the BMI.

Objectives: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients., Methods: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded., Results: There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%., Conclusions: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.

Background: Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair., Methods: We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Student's t-test., Results: A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II ( n = 43), type III ( n = 104), and type IV ( n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months., Conclusion: LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic.

Abdominal compartment syndrome is a well-documented entity arising from multiple and various causes. The rise of intra-abdominal pressure by the increase in volume of the peritoneal and retroperitoneal contents has been shown in the resuscitation and evaluation of surgical patients. However, the incidence of constriction of the abdomen causing intra-abdominal hypertension is unknown. Previously limited to burn eschar and externally applied devices (such as MAST trousers), external compression leading to abdominal compartment syndrome has been a limited entity. We report the first documented case of an expansive abdominal wall mass, a rectus sheath hematoma, leading to impending abdominal compartment syndrome.