Design  Prospective study.

Setting  Academic research.

Patients  Using a pentaplex polymerase chain reaction assay, MSI status was determined prospectively for 135 operative patients.

Main Outcome Measures  Mismatch repair defects were investigated by immunohistochemistry on tumors demonstrating MSI.

Results  Among 82 stage I or II colorectal carcinomas, 11 had MSI, and 71 had MSS, with a mean (SD) number of 23.6 (3.1) and 13.7 (1.0) negative lymph nodes, respectively (P = .001). The mean number of lymph nodes for all resected stage I or II colorectal carcinomas analyzed at our hospital was 15. The prevalence of MSI among tumors with more than 15 lymph nodes in the specimen was 25% (9 of 36), and 82% (9 of 11) of MSI tumors belonged to this group.

Conclusions  A high number of isolated lymph nodes in stage I or II colorectal carcinomas was associated with the MSI phenotype. Good prognosis that is usually associated with tumors having a high number of uninvolved lymph nodes might reflect the high prevalence of MSI among these tumors. The number of examined lymph nodes as a quality criterion should be used with caution. For stage I or stage II colorectal carcinomas, restricting MSI phenotyping to tumors with more than the mean number of lymph nodes identifies almost all MSI tumors.

Design  Single-institutional retrospective review.

Setting  Tertiary referral center.

Patients  All consecutive patients undergoing total laparoscopic pancreaticoduodenectomy from July 2007 through July 2009 at a single center (n = 62).

Main Outcome Measures  Blood loss, operative time, postoperative morbidity, length of hospital stay, and 30-day or in-hospital mortality.

Results  Of 65 patients undergoing laparoscopic resection, 62 patients with a mean age of 66 years (SD, 12 years) underwent total laparoscopic pancreaticoduodenectomy. The pancreaticojejunostomy consisted of a duct-to-mucosa anastomosis with interrupted suture. Median operative time was 368 minutes (range, 258-608 minutes) and median blood loss was 240 mL (range, 30-1200 mL). Diagnosis was pancreatic adenocarcinoma (n = 31), intraductal papillary mucinous neoplasm (n = 12), periampullary adenocarcinoma (n = 8), neuroendocrine tumor (n = 4), chronic pancreatitis (n = 3), cholangiocarcinoma (n = 1), metastatic renal cell carcinoma (n = 1), cystadenoma (n = 1), and duodenal adenoma (n = 1). Median tumor size was 3 cm (range, 0.9-10.0 cm) and the median number of lymph nodes harvested was 15 (range, 6-31). Perioperative morbidity occurred in 26 patients and included pancreatic fistula (n = 11), delayed gastric emptying (n = 9), bleeding (n = 5), and deep vein thrombosis (n = 2). There was 1 postoperative mortality. Median length of hospital stay was 7 days (range, 4-69 days).

Conclusions  Laparoscopic pancreaticoduodenectomy is feasible, safe, and effective. Outcomes appear comparable with those via the open approach; however, controlled trials are needed. Despite this series representing experience within the learning curve, laparoscopic pancreaticoduodenectomy holds promise for providing advantages seen with minimally invasive approaches in other procedures.

Design  Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique.

Setting  Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California.

Patients  We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed.

Interventions  Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE.

Main Outcome Measures  The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores.

Results  The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD], $4820 [1637] vs $6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups.

Conclusions  Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE.

Trial Registration  clinicaltrials.gov Identifier: NCT00807729

Design  Retrospective study.

Setting  Rikshospitalet University Hospital.

Patients  One hundred thirty-nine patients who underwent 177 laparoscopic liver resections in 149 procedures from August 18, 1998, through October 14, 2008. One hundred thirteen patients had malignant lesions, of whom 96 had colorectal metastases.

Intervention  Laparoscopic liver resection for malignant and benign lesions.

Main Outcome Measures  Perioperative and oncologic outcomes and survival.

Results  Five procedures (3.4%) were converted to laparotomy and 1 (0.7%) to laparoscopic radiofrequency ablation. The remaining 143 procedures were completed laparoscopically, during which 177 liver resections were undertaken, including 131 nonanatomic and 46 anatomic resections. The median operative time and blood loss were 164 (50-488) minutes and 350 (<50-4000) mL, respectively. There were 10 intraoperative (6.7%) and 18 postoperative (12.6%) complications. One patient (0.7%) died. The median postoperative stay and opioid requirement were 3 (1-42) and 1 (0-11) days, respectively. Tumor-free resection margins determined by histopathologic evaluation were achieved in 140 of 149 malignant specimens (94.0%). The 5-year actuarial survival for patients undergoing procedures for colorectal metastases was 46%.

Conclusions  In experienced hands, laparoscopic liver resection is a favorable alternative to open resection. Perioperative morbidity and mortality and long-term survival after laparoscopic resection of colorectal metastases appear to be comparable to those after open resections.

Design  Retrospective record review.

Setting  Tertiary academic medical center.

Patients  All patients who underwent primary laparoscopic ileocolectomy for terminal ileal Crohn disease between April 28, 1994, and August 3, 2006, at the Mayo Clinic, Rochester, Minnesota.

Main Outcome Measures  All patients were reviewed for follow-up, recurrence, risk factors for recurrence, and use of postoperative immunosuppressive prophylaxis.

Results  One hundred nine patients were identified, of whom 89 were followed up postoperatively at Mayo Clinic with a median follow-up of 3.5 years (range, 1.8 months to 11.9 years). Recurrence was discovered in 54 patients (61%) at a median of 13.1 months (range, 1.3 months to 8.7 years). Forty-four patients (49%) received postoperative immunosuppressive prophylaxis (37 [42%] received azathioprine, 8 [9%] received 6-mercaptopurine, and 3 [3%] received infliximab). In a multivariate model of various risk factors for recurrence, presence of granulomas was the only significant predictor of recurrence (P = .01). The 2-year cumulative recurrence rates in the prophylaxis and nonprophylaxis groups were 37.5% and 52.6%, respectively (log-rank test, P = .87).

Conclusions  Recurrence occurred in more than half of the patients with Crohn disease after primary laparoscopic ileocolectomy. In this highly selected patient population, use of immunosuppressive prophylaxis was not associated with a delay in recurrence. Presence of granulomas was the only significant predictor of recurrence. These findings should be further explored in larger and less selected patient populations.

Objective  To identify the additional benefit of adjuvant therapy by retrospectively examining a large population-based registry of patients who underwent definitive surgical resection for pancreatic adenocarcinoma.

Design and Setting  The Florida cancer registry and state inpatient and outpatient hospital data records were queried for pancreatic adenocarcinoma diagnosed between 1998 and 2002.

Patients  A total of 2877 patients who underwent surgical resection with curative intent for pancreatic adenocarcinoma were identified.

Main Outcome Measure  Overall survival time.

Results  Overall, 58.7% of patients were older than 65 years. Most patients were white (90.7%), were non-Hispanic (86.7%), and did not consume alcohol abusively (89.2%). Approximately half of the patients (51.9%) did not receive chemotherapy or chemoradiotherapy. Approximately 25.0% of the patients underwent chemoradiotherapy, and 10.0% received chemotherapy alone. Patients were more frequently treated at low-volume centers (57.6%) and nonteaching facilities (72.8%). Multivariate analysis correcting for patient comorbidities demonstrated that postoperative chemoradiotherapy (hazard ratio = 0.69, P = .04) and treatment at high-volume centers (hazard ratio = 0.85, P < .001) and teaching facilities (hazard ratio = 0.84, P < .001) were independent predictors of improved survival.

Conclusions  Adjuvant chemoradiotherapy was found to provide a significant additional survival benefit to surgical resection for patients with pancreatic adenocarcinoma. Furthermore, this benefit is independent of the additional survival advantage when patients are treated at teaching facilities or high-volume centers. Although selection bias may be contributing to the observed differences, these data nonetheless support the use of adjuvant chemoradiotherapy for pancreatic cancer.

Design  Decision analytic Markov state transition model with multiple logistic regression models as inputs. Data from the 2005 National Inpatient Survey were used to calculate in-hospital mortality risk associated with bariatric surgery and then adjusted for 30-day mortality. To calculate excess mortality associated with obesity, we used the 1991-1996 National Health Interview Survey linked to the National Death Index. Bariatric surgery was assumed to influence mortality only through its impact on the excess mortality associated with obesity, and the efficacy of surgery was estimated from a recent large observational trial.

Intervention  Gastric bypass surgery.

Main Outcome Measure  Life expectancy.

Results  Our base case, a 42-year-old woman with a body mass index of 45, gained an additional 2.95 years of life expectancy with bariatric surgery. No surgical treatment was favored in our base case when the 30-day surgical mortality exceeded 9.5% (baseline 30-day mortality, 0.2%) or when the efficacy of bariatric surgery for reducing mortality decreased to 2% or less (baseline efficacy, 53%).

Conclusions  The optimal decision for individual patients varies based on the balance of risk between perioperative mortality, excess annual mortality risk associated with increasing body mass index, and the efficacy of surgery; however, for the average morbidly obese patient, gastric bypass improves life expectancy.

Design  Epidemiologic study.

Setting  The National Hospital Discharge Survey

Patients  Estimated US hospitalized population.

Main Outcome Measures  International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis codes of the National Hospital Discharge Survey were queried from 1970 to 2006 to identify admissions for appendicitis, influenza, rotavirus, and enteric infections. Cointegration analysis of time series data was used to determine if the disease incidence trends for these various disease entities varied over time together.

Results  Rates of influenza and nonperforating appendicitis declined progressively from the late 1970s to 1995 and rose thereafter, but influenza rates exhibited more distinct seasonal variation than appendicitis rates. Rotavirus infection showed no association with the incidence of nonperforating appendicitis. Perforating appendicitis showed a dissimilar trend to both nonperforating appendicitis and viral infection. Hospital admissions for enteric infections substantially increased over the years but were not related to appendicitis cases.

Conclusions  Neither influenza nor rotavirus are likely proximate causes of appendicitis given the lack of a seasonal relationship between these disease entities. However, because of significant cointegration between the annual incidence rates of influenza and nonperforated appendicitis, it is possible that these diseases share common etiologic determinates, pathogenetic mechanisms, or environmental factors that similarly affect their incidence.

Design  Analysis of the University HealthSystem Consortium database from October 1, 2004, through September 31, 2007.

Setting  A total of 102 academic medical centers and approximately 150 of their affiliated hospitals, representing more than 90% of the nation's nonprofit academic medical centers.

Patients  Medicare and Medicaid patients who underwent bariatric surgery to treat morbid obesity.

Main Outcome Measures  Demographics, length of stay, 30-day readmission, morbidity, observed-to-expected mortality ratio, and costs.

Results  A total of 3196 bariatric procedures were performed before and 3068 after the NCD. After the implementation of the NCD, the volume of gastric banding doubled and the proportion of laparoscopic gastric bypass increased from 60.0% to 77.2%. Patients who underwent bariatric surgery after the NCD benefited from a shorter length of stay (3.5 vs 3.1 days, P < .001) and lower overall complication rates (12.2% vs 10.0%, P < .001), with no significant differences in the in-hospital mortality rates (0.28% vs 0.20%). Among Medicare patients, there was a 29.3% reduction in the number of bariatric procedures performed within the first 2 quarters after the NCD. However, the number of procedures returned to baseline volume within 1 year and exceeded baseline volume after 2 years of the NCD.

Conclusion  The bariatric surgery NCD resulted in improved outcomes for Medicare beneficiaries without limiting access to care for individuals with medical disability.

Design  Observational study from January 1, 1993, through December 31, 2006.

Setting  Bellvitge University Hospital, Barcelona, Spain.

Patients  A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS).

Main Outcome Measures  Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables.

Results  Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence.

Conclusions  Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Data Sources  We conducted a review of the medical literature by the use of PubMed and OVID MEDLINE databases.

Study Selection  We identified all published series that describe the use of cricothyrotomy, with the inclusion of the subset of patients who require an emergency airway after trauma, from January 1, 1978, to January 1, 2008.

Data Extraction  Only 20 published series of cricothyrotomy were identified: 17 retrospective reports and 3 prospective, observational series.

Data Synthesis  Considerable variance in methods and follow-up periods were noted between examinations. Published experiences documented the results of 1134 total patients for whom cricothyrotomy was performed, including 368 trauma patients who underwent emergent cricothyrotomy. The rate of chronic subglottic stenosis among survivors after cricothyrotomy was 2.2% (11/511) overall and 1.1% (4/368) among trauma patients for follow-up periods with a range from 2 to 60 months. Only 1 (0.27%) of the 368 trauma patients in whom an emergent cricothyrotomy was performed required surgical treatment for chronic subglottic stenosis. Although the literature that documents complications of surgical airway conversion is scarce, rates of severe complications of up to 43% were reported.

Conclusions  Cricothyrotomy after trauma is safe for initial airway access among patients who require the establishment of an emergent airway. The prolonged use of a cricothyrotomy tube, however, remains controversial. Although no study to date has demonstrated any benefit of routine conversion to tracheostomy, considerable deficiencies in existing studies highlight the need for further investigations of this practice.