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BACKGROUND Merkel cell polyomavirus (MCPyV) is associated with the development of Merkel cell carcinoma (MCC). Antibody (MCPyV-Ab) titers may have prognostic implications. This study evaluated the impact of the presence or absence of MCPyV-Ab on the 2-year overall survival (OS) and disease-free survival (DFS) of MCC patients. METHODS This single-center, IRB-approved, retrospective cohort study evaluated 51 adult patients with MCC from 2014 to 2021 using a prospectively maintained database. Patients were compared by MCPyV-Ab status, and Kaplan-Meier analysis was used to evaluate 2-year OS and DFS. RESULTS Of the 51 patients, 13 (25.4%) were seropositive, 41 (80.4%) underwent wide excision, 40 (80.0%) received radiotherapy, and 43 (84.3%) received multimodal therapy. The median follow-up period was 15.5 months (range 1-69.5 months). The median 2-year OS of the entire cohort was not reached. The median 2-year OS was not reached for either the seronegative or the seropositive patients. The difference in 2-year OS between the groups was not statistically significant (p = 0.37). Eight patients, all seronegative, were never rendered disease-free and were removed from recurrence analysis. The seropositive patients experienced no recurrences. Of the 30 seronegative patients, 9 (30.0%) experienced recurrence. The median 2-year DFS of the entire cohort was not reached. The median 2-year DFS of the seronegative group was 22.2 months. The 2-year DFS was not reached for the seropositive cohort. Seropositivity conferred a significantly better 2-year DFS than seronegativity (p = 0.04). CONCLUSION The MCPyV-Ab seropositive patients demonstrated improved 2-year DFS. The seropositive patients showed a strong trend toward improved 2-year OS, although the difference not statistically significant. This study substantiated the value of MCPyV-Ab assessment for MCC.

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR

Background:The differential diagnosis for retroperitoneal masses is broad, and includes pancreatic lipomatous hamartoma, a rare but benign disease process. Hamartoma describes outgrowth of tissue native to the organ in which it occurs and is considered a malformation rather than a true neoplasm. Pancreatic hamartomas consist of less than 1% of all hamartomas, and few cases of pancreatic lipomatous tumors with distinct components of pancreatic hamartoma have been described. These tumors are difficult to diagnose on imaging and biopsy alone and can appear malignant with potential for significant mass effect on surrounding organs, leading to surgical intervention for definitive diagnosis. Case Presentation:A 57-year-old male presented with right upper quadrant pain radiating to his left side and back. Ultrasound demonstrated cholelithiasis and an incidentally discovered large retroperitoneal mass. Computed tomography (CT) imaging demonstrated a 14.4 x 4.6 x 16 cm heterogenous, fatty-appearing retroperitoneal mass displacing the colon and small bowel, while abutting the aorta and inferior vena cava (IVC) with no obvious invasion of surrounding structures. He underwent laparoscopic cholecystectomy with biopsy of the mass. Biopsy demonstrated benign adipose tissue and no evidence of malignancy, and his care was transferred to our facility. His postoperative course was complicated by acute congestive heart failure that ultimately delayed definitive surgical intervention for nine months. Progressive growth of the mass was noted on serial imaging as his cardiopulmonary status was optimized. Preoperative CT revealed a 20.2 x 28.2 x 14.1 cm with worsened mass effect on surrounding structures.The patient underwent open resection of the retroperitoneal mass with en bloc resection of the third and fourth portions of the duodenum and the uncinate process of the pancreas. The final pathologic diagnosis was benign lipomatous proliferation with features most consistent with pancreatic lipomatous hamartoma (PLH), with specimen weight of 3810g and overall dimensions of 35 x 27 x 14 cm.Conclusions:PLH is an extremely rare benign tumor, which is notoriously difficult to diagnose with imaging and biopsy alone. This case highlights the difficulty delineating benign from malignant tumors of the pancreas and retroperitoneum.

Appendiceal neoplasms are uncommon tumors. Optimal treatment for patients with perforation or high-grade pathology after initial resection is unknown. This study evaluated patients with increased risk for peritoneal dissemination after primary resection, but no evidence of peritoneal disease, who underwent adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC). This multi-institutional cohort study evaluated 56 patients with high-risk (HR) appendiceal neoplasms with a peritoneal carcinomatosis index of 0 who underwent HIPEC. The patients were divided into two groups: perforated low-grade appendiceal (LGA) carcinoma and HR neoplasms, which included perforated high-grade appendiceal carcinoma, positive margins after initial resection, minimal macroscopic peritoneal disease that was previously resected or completely responded to systemic chemotherapy prior to HIPEC, goblet cell carcinoma, and adenocarcinoma with signet ring cell features. Overall survival (OS) and recurrence-free survival (RFS) were estimated by Kaplan–Meier analysis. Thirty-eight percent of patients had perforated LGA and 68% had HR features. Five-year OS probability was 82.1% for the entire cohort, and 100% and 70.1% for patients with perforated LGA and HR features, respectively (p = 0.024). Five-year RFS probability was 79.3% for the entire cohort, and 90.0% and 72.4% for patients with perforated LGA and HR features, respectively (p = 0.025). Eight patients recurred after HIPEC and their OS was significantly worse (p

Malignant peritoneal mesothelioma (MPM) is a rare, aggressive malignancy that typically presents with vague symptoms, ascites, and/or diffuse peritoneal studding. Despite findings of advanced disease within the peritoneal cavity, spread beyond the abdomen is uncommon. Although advances in systemic chemotherapy have been made, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remain the mainstay of treatment. Median overall survival of approximately 50 months with CRS/HIPEC has been demonstrated, with age, gender, histologic subtype, peritoneal carcinomatosis index, comorbidities, nodal and extra-abdominal metastases, and completeness of cytoreduction all playing a role in prognosis. In patients with refractory malignant ascites and unresectable disease, complete resolution of ascites and improvement in quality of life have been demonstrated with palliative HIPEC. In appropriately selected patients, CRS/HIPEC plays a critical role in the treatment and palliation of MPM.

Care of pancreatic cancer patients has become increasingly complex, which has led to delays in the initiation of therapy. Nurse navigators have been added to care teams, in part, to ameliorate this delay. This study investigated the difference in time from first oncology visit to first treatment date in patients with any pancreatic malignancy before and after the addition of an Oncology Navigator. A single-institution database of patients with any pancreatic neoplasm evaluated by a provider in radiation, medical, or surgical oncology between 1 October 2015 and 30 September 2017 was analyzed. After 1 October 2016, an Oncology Navigator met patients at their initial visit and coordinated care throughout treatment. The cohort was divided into two groups: patients evaluated prior to the implementation of an Oncology Navigator and patients evaluated after implementation. Patient demographics and time from first visit to first intervention were compared. Overall, 147 patients with a new diagnosis of pancreatic neoplasm were evaluated; 57 patients were seen prior to the start of the Oncology Navigator program and 79 were evaluated after the navigation program was implemented. On univariate analysis, time from first contact by any provider to intervention was 46 days prior to oncology navigation and 26 days after implementation of oncology navigation (p = 0.005). While controlling for other covariates, employment of the Oncology Navigator decreased the time from first contact by any provider to intervention by almost 16 days (p = 0.009). Implementing an oncology navigation program significantly decreased time to treatment in patients with pancreatic malignancy.

Merkel cell polyomavirus (MCPyV) is associated with the development of Merkel cell carcinoma (MCC). Antibody (MCPyV-Ab) titers may have prognostic implications. This study evaluated the impact of the presence or absence of MCPyV-Ab on the 2-year overall survival (OS) and disease-free survival (DFS) of MCC patients.This single-center, IRB-approved, retrospective cohort study evaluated 51 adult patients with MCC from 2014 to 2021 using a prospectively maintained database. Patients were compared by MCPyV-Ab status, and Kaplan-Meier analysis was used to evaluate 2-year OS and DFS.Of the 51 patients, 13 (25.4%) were seropositive, 41 (80.4%) underwent wide excision, 40 (80.0%) received radiotherapy, and 43 (84.3%) received multimodal therapy. The median follow-up period was 15.5 months (range 1-69.5 months). The median 2-year OS of the entire cohort was not reached. The median 2-year OS was not reached for either the seronegative or the seropositive patients. The difference in 2-year OS between the groups was not statistically significant (p = 0.37). Eight patients, all seronegative, were never rendered disease-free and were removed from recurrence analysis. The seropositive patients experienced no recurrences. Of the 30 seronegative patients, 9 (30.0%) experienced recurrence. The median 2-year DFS of the entire cohort was not reached. The median 2-year DFS of the seronegative group was 22.2 months. The 2-year DFS was not reached for the seropositive cohort. Seropositivity conferred a significantly better 2-year DFS than seronegativity (p = 0.04).The MCPyV-Ab seropositive patients demonstrated improved 2-year DFS. The seropositive patients showed a strong trend toward improved 2-year OS, although the difference not statistically significant. This study substantiated the value of MCPyV-Ab assessment for MCC.

Synchronous intra-parenchymal hepatic involvement (HI) in patients with peritoneal disease (PD) has traditionally served as a contraindication for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). However, several studies have demonstrated the feasibility and safety of combined liver resection with CRS/HIPEC in well-selected patients with synchronous HI and PD. In patients with low-grade appendiceal (LGA) primaries, HI is generally superficial peritoneal surface disease and functions as a marker for greater volume of disease, rather than contraindication to resection. In patients with colorectal or high-grade appendiceal (HGA) primaries, HI is associated with decreased disease-free survival (DFS) and overall survival (OS), but with the addition of preoperative systemic chemotherapy, a meaningful survival benefit can still be achieved with CRS/HIPEC. In patients with colorectal primaries, major complication rates range from 31% to 47% in patients with HI and 11% to 31% in patients without HI. Thirty-day mortality in patients with HI ranges from 0 to 3%, and 0.6% to 5% in patients without HI. Median OS is 13 to 35.3 months in patients with HI, and from 21 to 45.5 months in patients without HI. In all cases, well-selected patients may benefit from CRS/HIPEC when a complete cytoreduction can be achieved.

First described over a century ago, malignant peritoneal mesothelioma (MPM) is a rare, aggressive malignancy typically presenting with diffuse peritoneal studding and/or ascites. Although usually advanced disease is found within the peritoneal cavity, spread beyond the abdomen is uncommonly encountered. Although advances in systemic chemotherapy have been made, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have emerged as the mainstay of treatment. Median overall survival of approximately 50 months with CRS/HIPEC has been demonstrated, with age, gender, histologic subtype, peritoneal carcinomatosis index (PCI), comorbidities, nodal and extra-abdominal metastases, and completeness of cytoreduction all playing a role in prognosis. Similarly, urachal-derived peritoneal carcinomatosis, a clinical condition involving extensive spread of intraperitoneal mucin from a urachal primary, is an exceedingly rare disease whose pathophysiologic characteristics have mainly been determined by case series. As there is no standard systemic therapy for urachal carcinomatosis, CRS/HIPEC provides a useful treatment strategy, with a median overall survival approaching 60 months. The completeness of cytoreduction during CRS/HIPEC for urachal-derived carcinomatosis significantly influences prognosis, with increasing PCI trending toward poorer overall survival. For both of these rare diseases, CRS/HIPEC offers durable, long-term survival in appropriately selected patients.

Complete surgical resection of metastatic melanoma has a known survival benefit. Treatment of metastatic melanoma, however, has become increasingly complex with the introduction of targeted treatments and immune checkpoint inhibitors. Integration of systemic medical therapy and surgical resection has shown promising results, with significantly improved long-term survivals. Results from current clinical trials are awaited to help further delineate the sequence and combination of systemic therapy and surgery.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving strategy in the locoregional management of peritoneal surface malignancies, and the role of laparoscopy is expanding. Staging laparoscopy is routinely used to obtain tissue for diagnosis and assess extent of tumor burden. Laparoscopic CRS and HIPEC with curative intent is safe and effective in patients with a low disease burden. In patients with refractory malignant ascites, complete resolution of ascites and improvement in quality of life have been demonstrated with palliative laparoscopic HIPEC. Laparoscopic CRS and HIPEC has an expanding role in the treatment of peritoneal surface disease.

Cysts of the liver are common and generally asymptomatic and benign. Large cysts may cause symptoms including abdominal pain, distension, or early satiety. Patients may also, rarely, present with jaundice. Radiographic imaging and patient history can often help determine the diagnosis. Treatment is geared toward the underlying nature of the cyst, the presenting symptoms (if any), and the risk of degeneration to malignancy.

The incidence of oropharyngeal squamous cell carcinoma (SCCa) has increased in the United States despite a decrease in tobacco usage, and it may be driven by an increase in oral human papilloma virus (HPV) infection. We studied the incidence of tongue base and tonsillar SCCa over time to understand the changing epidemiology of oropharyngeal SCCa.Large national tumor registry.We studied patients diagnosed with oropharyngeal SCCa in SEER data (Surveillance, Epidemiology, and End Results) from 1973 to 2009. Age-adjusted incidence rates standardized to the 2000 US population were computed, with stratifications for age, sex, race, and stage.The sample included 10,061 tongue base and 11,515 tonsillar oropharyngeal cancers. When stratified by age, the incidence of oropharyngeal SCCa in patients ≤55 years of age more than doubled over 30 years. While the incidence rate in females remained stable, the rate in males more than doubled, from 2 per 100,000 persons in 1973 to4 per 100,000 persons in 2009. The age-adjusted incidence of oropharyngeal SCCa in patients of black race/ethnicity remained consistently elevated, but the incidence in patients of white race/ethnicity rose from 1.3 per 100,000 persons to2.5 per 100,000 persons, surpassing the incidence in black patients starting in 2002.The observation that the incidence of oropharyngeal SCCa is increasing among younger white males, despite a reduction in tobacco usage in the United States, is consistent with HPV as the source. Primary and secondary prevention strategies may be warranted in this population.

Breastfeeding can reduce breast cancer risk; however, unknown factors modify this protective effect. Zinc (Zn) modulates an array of cellular functions including oxidative stress, cell proliferation, motility and apoptosis. Marginal Zn intake is common in women and is associated with breast cancer. We reported that marginal Zn intake in mice leads to mammary gland hypoplasia and hallmarks of pre-neoplastic lesions. In the present study, we tested the hypothesis that marginal Zn intake confounds the protective effect of lactation on breast cancer. Nulliparous mice fed control (ZA, 30 mg Zn/kg) or a marginal Zn diet (ZD, 15 mg Zn/kg), were bred and offspring were weaned naturally. Post-involution, mice were gavaged with corn oil or 7,12-dimethylbenz(a)anthracene (DMBA, 1 mg/wk for 4 weeks) and tumor development was monitored. A ZD diet led to insufficient involution, increased fibrosis and oxidative stress. Following DMBA treatment, mice fed ZD had higher oxidative stress in mammary tissue that correlated with reduced levels of peroxiredoxin-1 and p53 and tended to have shorter tumor latency and greater incidence of non-palpable tumors. In summary, marginal Zn intake creates a toxic mammary gland microenvironment and abrogates the protective effect of lactation on carcinogenesis.

Despite similar appearances on imaging studies, emphysematous gastritis (EG) and gastric emphysema (GE) are rare clinical entities encountered in surgical practices. The purpose of this review is to clarify the presentation, natural history, and optimal treatment strategies for these two disorders. We conducted a comprehensive literature review for reported adult cases of EG and GE in MEDLINE. Two cases from our institution were also included. Patient with demographics, diagnostic and therapeutic data, and outcomes were compared between patients with EG and GE. A total of 75 cases were included for our review. The finding of intramural air in the stomach was often associated with portal vein gas, pneumatosis intestinalis, or pneumoperitoneum in both groups. Surgical removal of the stomach was performed in 23.1 % of EG patients, but only one patient in the GE group. In the EG group, overall mortality (55 %) appeared to be driven by sepsis and its complications, whereas in the GE group, mortality (29 %) was attributable to comorbid conditions and the underlying illness. Prompt surgical intervention is more commonly indicated for severe EG and is directed at removal of the septic organ, while the primary indication for surgical intervention in GE is the uncertainty of the diagnosis.

This study compared postoperative complications of patients who underwent pancreaticoduodenectomy (PD) recorded in the National Surgical Quality Improvement Program (NSQIP) to patients who underwent PD recorded in the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Data included 8,822 PD cases recorded in NSQIP and 9,827 PD cases recorded in NIS performed between 2005 and 2010. Eighteen postoperative adverse outcomes were identified in NSQIP and then matched to corresponding International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in NIS. Using logistic regression, the relationship between database and postoperative complications was determined while accounting for patient factors. Patients undergoing PD in the NIS were more likely to have several adverse outcomes, including urinary tract infection (odds ratio (OR) = 1.42, p

Background Carotid endarterectomy (CEA) has been performed since the 1950s and remains one of the most common surgical procedures in the United States. The procedure is performed by cardiothoracic, general, neurologic, and vascular surgeons. This study uses data from the National Surgical Quality Improvement Program (NSQIP) to examine the outcomes after CEA when performed by general or vascular surgeons. Materials and methods Data included 34,493 CEAs from years 2005 to 2010 recorded in the NSQIP database. Primary outcomes measured were length of stay, 30-d mortality, surgical site infection, cerebrovascular accident, myocardial infarction, and blood transfusion requirement. Secondary outcomes measured were the remaining intraoperative outcomes from the NSQIP database. Results After controlling for patient and surgical characteristics, patients treated by general surgeons did not have a significantly different LOS or 30-d mortality than those treated by vascular surgeons. Patients of general surgeons had nearly twice the risk of acquiring a surgical site infection (odds ratio [OR] = 1.94; P = 0.012), >1.5 times the risk of cerebrovascular accident (OR = 1.56; P = 0.008), and >1.8 times the risk of blood transfusion (OR = 1.85; P = 0.017) than those of vascular surgeons. Patients of general surgeons had less than half the risk of having a myocardial infarction (OR = 0.34; P = 0.031) than those of vascular surgeons. Conclusions Surgical specialty is associated with a wide range of postoperative outcomes after CEA. Additional research is needed to explore practice and cultural differences across surgical specialty that may lead to outcome differences.

Robotic surgery is experiencing a rapidly-increasing presence in the field of general surgery. The adoption of any new technology carries the challenge of training current and future surgeons in a safe and effective manner. We report our experience with the initiation of a robotic general surgery program at an academic institution while simultaneously incorporating surgical trainees. The initial procedure performed was robotic-assisted cholecystectomy (RAC). Concurrent with the introduction of a robotic general surgical program, our institution implemented a progressive surgical trainee curriculum for all active residents and fellows. Immediately after being credentialed to perform RAC, attending surgeons began incorporating surgical trainees into robotic procedures. We retrospectively reviewed our first 50 RACs and compared them with our previous 50 standard laparoscopic cholecystectomies (SLC) to determine the impact of rapid integration of surgical trainees on developing technologies. Despite new technology and novice surgeons, there was no difference in mean operative time between the SLC and RAC groups (75.3 vs. 84.1 min, p = 0.077). Two patients in the robotic-assisted group required intraoperative conversion. Hospital length of stay was similar between groups, with the majority of patients leaving the same day. There were no postoperative complications in either group. A robotic general surgery program can be initiated while concurrently instructing surgical trainees on robotic surgery in a safe and efficient manner. We report our initial experience with the adoption of this rapidly advancing technology and describe our training model.

Background Risk of readmission is elevated in patients congestive heart failure (CHF), and clinical decision makers need to better understand risk factors for 30-day readmissions. Objective To identify risk factors for readmission in patients with CHF. Methods We studied all admissions for patients with CHF during 2011 using a statewide discharge data set from Pennsylvania. The primary outcome was readmission to any Pennsylvania hospital within 30 days of discharge. Results Of 155,146 CHF patients admitted, 35,294 (22.8%) were readmitted within 30 days. Male sex, black race, coverage by Medicare, comorbidities, discharge to a skilled nursing facility or with a home nurse, a longer length of stay (LOS), admission from another facility, and emergent admission (all p Conclusions Comorbidities, sociodemographic factors including male sex, age, black race and Medicare coverage, and prolonged length of stay are associated with increased risk of readmission in patients with CHF.

Patients with type 2 diabetes mellitus (type 2 DM) are at greater risk of poor hospital outcomes. The purpose of this study was to determine the impact of type 2 DM on 30-day hospital readmission and length of stay (LOS).We studied all inpatient admissions in Pennsylvania during 2011 using data from the Pennsylvania Health Care Cost Containment Council. Outcomes included 30-day readmission and inpatient LOS. We estimated the impact of type 2 DM on readmission and LOS, and identified risk factors for readmission and prolonged LOS.Among inpatient admissions, patients with diabetes were more likely to be readmitted (AOR=1.17, P0.001) and have longer LOS (0.19days, P0.001) compared to patients without diabetes. Among those with diabetes, several factors were associated with readmission, including demographics, source of admission, and comorbidities. Patients with diabetes were more likely to be readmitted for infectious complications (9.4% vs. 7.7%), heart failure (6.0% vs. 3.1%), and chest pain/MI (5.5% vs. 3.3%) than patients without diabetes.Diabetes is associated with risk of 30-day readmission and LOS, and several patient-specific factors are associated with outcomes for patients with diabetes. Future studies may target risk factors to develop strategies to reduce readmissions and LOS.

This study evaluates the short-term impact of fluid administration during gastrectomy for cancer.A multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed.205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95-691 min). Median intraoperative crystalloid administration was 2901 ml (range 500-10,700 ml). Median colloid administration was 0 (range 0-3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition.Restricting intra-operative fluid resuscitation to10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.

To define the effect of estrogen and progesterone concentrations achieved during hormonal contraceptive therapy (HCT) on cell-mediated immunity (CMI) of HIV-infected and uninfected subjects, peripheral blood mononuclear cells (PBMCs) from varicella-zoster virus (VZV)-seropositive individuals were treated with 0.1 ng/mL of estradiol, 33 ng/mL of norgestrel, and 13 ng/mL of dexamethasone and tested for VZV CMI. Estrogen and progesterone decreased VZV lymphocyte proliferation and T helper (Th) 1/inflammatory cytokine secretion, albeit less than dexamethasone. Progesterone decreased the expression of CD69 activation marker on CD8 and CD14 cells and increased the expression of Fas ligand (CD178) on CD14 monocytes, suggesting that induction of apoptosis may contribute to the inhibitory effect of this hormone. Cytokine production of separated CD4, CD8, and CD14 cells confirmed the effect of progesterone on all 3 cellular types, whereas the effect of estrogen was restricted to CD14 monocytes. The estrogen- and progesterone-mediated inhibition of Th1/inflammatory cytokines was greater in HIV-infected subjects (35% decrease for both hormones) compared with uninfected subjects (12% and 19% for estrogen and progesterone, respectively), whereas the effect on proliferation and PBMC phenotype did not differ by HIV status. Overall, HCT concentrations of estrogen and progesterone downregulated ex vivo VZV CMI of HIV-infected and uninfected subjects.

Intraoperative assessment of pancreatic parenchymal margin during pancreatectomies is challenging and misinterpretation by the pathologist is a cause of incorrect frozen section (FS) diagnosis. Although the current literature supports that pancreatic margin FS diagnosis and its accuracy has no impact on the patient outcome for pancreatic ductal adenocarcinoma (PDAC) patients and reexcision in an attempt to achieve a negative intraoperative pancreatic margin after positive FS is not associated with increased overall survival; still it remains a routine practice in many institutions. To this end, we sought to assess the interobserver variation and accuracy of FS diagnosis between subspecialized gastrointestinal/pancreatobiliary (GI) and general pathologists. Seventy seven consecutive pancreatic parenchymal margin FSs performed on pancreatectomies for PDAC from 2010 to 2013 were retrieved at our institution. These were retrospectively evaluated by 2 GI and 2 general pathologists independently without knowledge of the original FS diagnosis or the final diagnosis. The specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of GI versus general pathologist was 97.8% versus 87.5%, 61.1% versus 66.7%, 78.6% versus 41.4%, 95% versus 95.2%, and 93.5% versus 85.1%, respectively. The interobserver agreement between GI and general pathologists was fair (κ = .337, P < .001). The interobserver agreement between 2 GI pathologists was fair (κ = .373, P = .0005) and between 2 general pathologists was slight (κ = .195, P = .042). Although overall accuracy of subspecialized GI pathologists was higher than that of general pathologists, none had an accuracy of 100%. Our study reaffirms the challenging nature of these FSs.

Improved mortality rates following pancreaticoduodenectomy by high-volume surgeons and hospitals have been well documented, but less is known about the impact of such volumes on length of stay and cost. This study uses data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) to examine the effect of surgeon and hospital volume on mortality, length of stay, and cost following pancreaticoduodenectomy while controlling for patient-specific factors. Data included 3,137 pancreaticoduodenectomies from the NIS performed between 2004 and 2008. Using logistic regression, the relationship between surgeon volume, hospital volume, and postoperative mortality, length of stay, and cost was estimated while accounting for patient factors. After controlling for patient characteristics, patients of high-volume surgeons at high-volume hospitals had a significantly lower risk of mortality compared to low-volume surgeons at low-volume hospitals (OR 0.32, p

Improvements in outcomes after pancreatoduodenectomy (PD) have permitted more complex resections. Complete extirpation at PD may require multivisceral resection (MVR-PD); however, descriptions of morbidity of MVR-PD are limited to small, single-institution series.The National Surgical Quality Improvement Project database (2005-2011) was used to compare 30-day postoperative morbidity of PD with MVR-PD. Concurrent resection of colon, small bowel, stomach, kidney, or adrenal gland defined MVR-PD.Of 9,927 PDs, MVR-PD was performed in 273 patients (3%). MVR included colon (58%), small bowel (30%), and gastric (12%) resections. Preoperative comorbidities were similar between groups. Pancreatic, duodenal, or periampullary cancer was present in 75% of patients. Mortality (8.8% vs 2.9%) and major morbidity (56.8% vs 30.8%) were much greater for MVR-PD versus PD alone (P.001). MVR-PD patients also experienced greater rates of wound, pulmonary, cardiac, thromboembolic, renal, and septic complications. On multivariable regression, MVR was an independent predictor of death (odds ratio [OR], 3.4; P.001), overall morbidity (OR, 3.01; P.001), major morbidity (OR, 3.21; P.001), and minor morbidity (OR, 1.65; P = .03). Among patients undergoing PD+MVR, colectomy was an independent predictor of increased overall morbidity (OR, 1.96; P = .03) and major morbidity (OR, 1.90; P = .02).Margin-negative resection may require MVRs at the time of PD. MVR at is associated with 3-fold mortality and substantial morbidity after adjusting for comorbidities. Colectomy independently predicted major morbidity. At PD, the morbidity of MVR should be approached with caution when attempting margin-negative resection.

Inflammatory bowel disease (IBD) patients are at increased risk for venous thromboembolism (VTE) compared to the general population. Practice guidelines recommend pharmacologic prophylaxis for IBD inpatients.Our aim was to determine the rates of pharmacologic VTE prophylaxis in ulcerative colitis (UC) inpatients at a tertiary referral center. We also assessed potential predictors of pharmacologic prophylaxis.We conducted a retrospective cohort study of 377 UC patients between January 1st, 2007 and December 31st, 2011. The medical record of each patient was examined to determine whether pharmacologic VTE prophylaxis was ordered and administered. We conducted multiple logistic regression to determine predictors of pharmacologic prophylaxis.The overall VTE pharmacologic prophylaxis rate was 67.6%. The rate of patients admitted to the medical service was 57.4% compared to 93.5% for those admitted to surgery. In medical patients who received pharmacologic VTE prophylaxis, 34.0% of ordered doses were not given compared to 17.4% of doses in surgical patients (P0.001). In the multiple logistic regression analysis, having an additional VTE risk factor (OR 2.46, 95% CI 1.41-4.30), extensive colitis (OR 2.26, 95% CI 1.32-3.87) or being admitted to a surgical service (OR 12.03, 95% CI 5.29-27.38) was associated with VTE pharmacologic prophylaxis.A substantial proportion of medical patients admitted with UC were not ordered for VTE pharmacologic prophylaxis despite current guidelines. Even in patients who were ordered for pharmacologic prophylaxis, one third of doses were not given. Inappropriate prophylaxis may lead to unnecessary morbidity and mortality.

INTRODUCTION: High hospital volume has a protective effect on surgical outcomes, however, it is not known whether the effect is different depending on the patient population studied. We sought to analyze the treatment effect with regard to in-hospital mortality in different patient populations who undergo gastric resection for cancer, based on hospital volume.METHODSAND PROCEDURES: The Nationwide Inpatient Sample (NIS) database was used and data was extracted using ICD-9 codes. Adults were included if they had a diagnosis of gastric cancer and underwent a potentially curative partial or total gastrectomy. Multivariate logistic regression analyses were used with in-hospital mortality as the dependent variable to evaluate the effect of low, intermediate, and high hospital volume (average of ≤5, 6-20, and >20 gastric resections for cancer per year, respectively). Multivariate analyses were repeated in different subsets of patients to determine if hospital volume had variable effects on mortality depending on the subset evaluated. RESULTS: From 1998-2011, a total of 24,538 patients were included. The overall perioperative mortality rate was 5.5%, and multivariate analysis demonstrated that patients who received an operation in a center that performed a high-volume of gastric resections was protective (OR 0.64, 95% CI 0.500.81) when compared to patients who underwent surgery in a low-volume hospital. Other independent risk factors included male gender, age ≥65 years, Caucasian race, and Charlson Comorbidity Index (CCI) ≥3. Upon subset analyses, there were no cohorts of patients that had a significantly lower risk of mortality if they received their operation in a low or intermediate-volume center when compared to a high-volume center. The risk of mortality for those undergoing surgery in low-volume hospitals was statistically significantly elevated in certain subsets (age ≥75, male, Caucasian, Asian, CCI ≥6) when compared to high-volume hospitals. Similarly, in intermediate-volume hospitals, mortality risk was significantly elevated in males, Caucasians, and those with CCI 0-2 and CCI ≥6. There were no significant differences in mortality between subgroups as evidenced by overlapping confidence intervals. (Figures 1A,B). CONCLUSION(S): There was no heterogeneity of treatment effect observed in gastric cancer patients undergoing surgery at low, intermediate, or high volume centers. These data support the current recommendation that all patients with gastric cancer should receive treatment at high-volume centers. This recommendation is particularly important for high-risk subgroups such as elderly patients and those with medical comorbidities.

Cord blood (CB) progenitor cells are increasingly used for transplantation in children because of the lower risk of graft-versus-host disease compared with unrelated bone marrow and comparable rates of disease-free survival. There is concern that CB might carry a higher risk of opportunistic infections. Human herpesviruses (HHV) are common pathogens in transplant recipients. CB donors are routinely tested for the presence of anti-cytomegalovirus (CMV) immunoglobulin M to reduce the risk of collecting CMV-infected CB. To assess the incidence of β and γ HHV infection of CB collected under standard procedures, we tested 362 CB samples for the presence of CMV; HHV-6, -7, and -8; and Epstein-Barr virus DNA by polymerase chain reaction. HHV-6 DNA was found in 2 samples, yielding an incidence of 0.55% (95% confidence interval, 0.1%-2%). None of the other viral DNAs was found, resulting in a 95% confidence interval of 0% to 1% for the incidence of CMV, Epstein-Barr virus, HHV-7, and HHV-8. Because the seroprevalence of HHV-8 among the CB donors in this study was only 4%, these findings cannot be extended to HHV-8-endemic areas. Our data show that screening prospective CB donors with anti-CMV immunoglobulin M practically eliminates the risk of CB CMV transmission, but HHV-6 warrants CB testing by polymerase chain reaction.

Recently, we have adapted IMCD3 cell cultures to survive under increasing hypertonic conditions (i.e., 600 and 900 mOsmol/kg H(2)O). In adapted cells, ATPase activity is increased by one order of magnitude, while the expression of the alpha and beta subunit is increased by a factor of 4 to 5 over controls (300 mOsmol/kg H(2)O). Corresponding increases in mRNAs were also detected. The gamma subunit has been described as being uniquely expressed in some areas of the kidney, but never in cell cultures (even those derived from kidney tissues). However, the gamma subunit was detected at the protein and mRNA levels in the adapted IMCD3 cells. In contrast to the alpha and beta subunits, the levels of gamma protein and mRNA expression continue to increase as a function of the media ion concentration. We have also demonstrated that signaling pathways that upregulate the alpha, beta, and gamma subunits are very different. Increasing concentrations of the PI3 kinase inhibitor, LY294002, resulted in a dose-dependent reduction in the expression of the gamma subunit, with total abolition at 10 micro M. However, LY294002 had no significant effect on the expression of the alpha subunit. Inhibition of the JNK2 (but not of the JNK1) pathways by dominant negative transfections abolished the upregulation of the gamma, but not the a subunit. Failure to upregulate the expression of the gamma subunit was associated with a marked decrease in cell viability upon stress.

BackgroundIn pancreatitis, total pancreatectomy (TP) is an effective treatment for refractory pain. Islet cell auto-transplantation (IAT) may mitigate resulting endocrinopathy. Short-term morbidity data for TP + IAT and comparisons with TP are limited.MethodsThis study, using 2005–2011 National Surgical Quality Improvement Program data, examined patients with pancreatitis or benign neoplasms. Morbidity after TP alone was compared with that after TP + IAT.ResultsIn 126 patients (40%) undergoing TP and 191 (60%) patients undergoing TP + IAT, the most common diagnosis was chronic pancreatitis. Benign neoplasms were present in 46 (14%) patients, six of whom underwent TP + IAT. Patients in the TP + IAT group were younger and had fewer comorbidities than those in the TP group. Despite this, major morbidity was more frequent after TP + IAT than after TP [n = 79 (41%) versus n = 36 (29%); P = 0.020]. Transfusions were more common after TP + IAT [n = 39 (20%) versus n = 9 (7%); P = 0.001], as was longer hospitalization (13 days versus 9 days; P < 0.0001). There was no difference in mortality.ConclusionsThis study is the only comparative, multicentre study of TP and TP + IAT. The TP + IAT group experienced higher rates of major morbidity and transfusion, and longer hospitalizations. Better data on the longterm benefits of TP + IAT are needed. In the interim, this study should inform physicians and patients regarding the perioperative risks of TP + IAT.