Background As compared with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) affords improved perioperative outcomes. The role of LDP for patients with pancreatic ductal ...adenocarcinoma (PDAC) is not defined. Study Design Records from patients undergoing distal pancreatectomy (DP) for PDAC from 2000 to 2008 from 9 academic medical centers were reviewed. Short-term (node harvest and margin status) and long-term (survival) cancer outcomes were assessed. A 3:1 matched analysis was performed for ODP and LDP cases using age, American Society of Anesthesiologists (ASA) class, and tumor size. Results There were 212 patients who underwent DP for PDAC; 23 (11%) of these were approached laparoscopically. For all 212 patients, 56 (26%) had positive margins. The mean number of nodes (± SD) examined was 12.6 ±8.4 and 114 patients (54%) had at least 1 positive node. Median overall survival was 16 months. In the matched analysis there were no significant differences in positive margin rates, number of nodes examined, number of patients with at least 1 positive node, or overall survival. Logistic regression for all 212 patients demonstrated that advanced age, larger tumors, positive margins, and node positive disease were independently associated with worse survival; however, method of resection (ODP vs. LDP) was not. Hospital stay was 2 days shorter in the matched comparison, which approached significance (LDP, 7.4 days vs. ODP, 9.4 days, p = 0.06). Conclusions LDP provides similar short- and long-term oncologic outcomes as compared with OD, with potentially shorter hospital stay. These results suggest that LDP is an acceptable approach for resection of PDAC of the left pancreas in selected patients.
Background Indices for prediction of surgical site infection (SSI) are well documented in the adult population; however, these factors have not been validated in children. Study Design A ...retrospective case-control study was performed by examining the medical records of children (0 to 18 years) who developed an SSI within 30 days of selected class I and class II procedures at our institution from 1996 to 2008. Two controls were selected from among patients undergoing identical procedures within 12 months of each case. Statistical analysis was performed using Wilcoxon test for continuous and chi-square test for categorical variable. Factors thought a priori to be associated with risk of SSI and statistically significant variables from a univariate analysis were used to create a logistic regression model. Results Of 16,031 patients, 159 children (0.99%) developed an SSI. Univariate analysis showed race, postoperative location, skin preparation, urinary catheter, procedure duration, and implantable device as risk factors for development of an SSI. Independent predictors of SSI in multiple conditional logistic regression were age (adjusted odds ratio aOR 4.97 neonate vs adolescent; 95% CI 1.38 to 17.90), race (aOR 2.36 for African American vs white; 95% CI 1.32 to 4.18), postoperative location (aOR 6.55 ICU vs home; 95% CI 1.58 to 27.21), urinary catheter placement (aOR 3.56; 95% CI 1.50 to 8.48), and implantable device (aOR 3.05; 95% CI 1.14 to 8.21). Wound classification and antibiotic administration were not independent predictors of SSI. Conclusions Postoperative location, urinary catheter insertion, and use of an implantable device are potentially modifiable risk factors for an SSI in children. The higher risk of SSI in younger patients and non-white race suggest a possible developmental, socioeconomic, or genetic marker for impaired host defense.
Background Pancreatic neuroendocrine neoplasms are rare malignancies for which the ideal staging method remains controversial. Ki-67 is a cell proliferation marker that has been shown to have some ...utility in predicting prognosis in neuroendocrine neoplasms. We sought to test the predictive ability of Ki-67 staining for disease recurrence and overall survival (OS) in pancreatic neuroendocrine neoplasms. Methods The medical records of patients who underwent pancreatic resection for pancreatic neuroendocrine neoplasms at a tertiary referral hospital from 1994 to 2009 were reviewed. The pathologic specimens of all were stained for Ki-67 and recorded as percentage of cells staining positive per high-powered field. The 10-year disease-free and OSs were analyzed. Results We identified 140 patients. Gender and age were not associated with increased risk of disease recurrence. Patients with tumors >4 cm or with Ki-67 staining >9% were more likely to have disease recurrence ( P = .0454 and .047) and have decreased OS ( P < .0001 and .0007). Conclusion Increasing tumor size and increasing Ki-67 staining both correlate with increased risk of disease recurrence and decreased OS. Designing a staging system that incorporates both of these clinical variables will enable better identification of patients at risk for recurrent pancreatic neuroendocrine neoplasms.
Abstract Background For appendicitis, single-incision laparoscopic appendectomy (SIA) has been proposed as an alternative to 3-port appendectomy (3PA). However, there remains controversy regarding ...outcomes and cost of SIA. We sought to review our experience with these two techniques to identify differences in these factors. Materials and Methods The charts of children (0-17 years old) who underwent appendectomy at a tertiary pediatric hospital from 2011- 2014 were retrospectively reviewed. Appendectomy was either performed through traditional 3PA or SIA (laparoscopically-assisted via externalization through an umbilical incision). Demographic data including age, BMI, comorbidities and gender was examined. Information on perforation, operative time and cost, length of stay, and infectious complications for both SIA and 3PA was identified. Data was analyzed using student-t tests and Chi square analysis. Results Three hundred thirty-seven patients underwent appendectomy (141 SIA and 197 3PA), 35.6% of whom (40 SIA, 80 3PA) had perforated appendicitis. For non-perforated appendicitis, SIA had significantly shorter operative times, decreased operative costs, and length of stay. However, these differences were not found for perforated appendicitis. Regardless of appendicitis severity, there was no difference in rates of wound infection, abscess, or readmission between the two techniques. Conclusions Our study suggests that SIA is a faster, more cost effective alternative than 3PA for acute appendicitis. SIA did not result in increased infection rates for acute or perforated appendicitis and can be considered an equivalent alternative to 3PA in the surgical management of appendicitis.
Abstract Background Tracheal reconstruction relies on the use of a split skin graft to re-epithelialise the mucosal layer. Since split skin grafts are made up of a keratinising stratified epithelial ...layer, sloughing occurs within the airway with mucus retention and subsequent airway obstruction. The delivery of a graft with the same mucociliary function as the native airway would overcome these limitations and greatly improve the safety and effectiveness of this type of surgery. We aimed to generate a transplantable tissue-engineered respiratory epithelial graft with mucociliary function. Methods Cadaveric human skin was decellularised and the epidermal layer removed. Human bronchial epithelial cells were seeded with human respiratory fibroblasts onto the dermis at densities of 1 × 106 per cm2 and 1 × 104 per cm2 , respectively, and cultured at air–liquid interface in a transwell system. At 3 weeks, the constructs were transplanted onto a decellularised trachea that had been prevascularised within a muscle wrap in an immunosuppressed New Zealand White rabbit. Findings After 3 weeks of air–liquid interface culture, high-speed video microscopy showed beating cilia on the surface of the dermis, and the epithelial layer stained positively for the ciliated cell marker acetylated α-tubulin, the secretory cell marker MUC5AC, and the epithelial cell marker pan-cytokeratin on top-down whole-mount confocal microscopy. Staining with haematoxylin and eosin (H&E) demonstrated a pseudostratified mucociliary layer along the length of the dermis. 24 h after transplantation, a pseudostratified, ciliated layer could be observed on H&E staining of sections of trachea. At 5 days, the respiratory epithelial layer consisted of a single layer of cytokeratin 5-positive epithelial cells. Interpretation This study is the first, to our knowledge, to report the delivery of a transplantable tissue-engineered respiratory epithelial graft with mucociliary function. 24 h after transplantation the mucociliary layer was preserved although only a basal layer was demonstrated by 5 days, possibly due to the loss of the air–liquid interface within the muscle wrap. Funding Medical Research Council.
Mild traumatic brain injury in children Hamilton, Nicholas A., MD; Keller, Martin S., MD
Seminars in pediatric surgery,
11/2010, Letnik:
19, Številka:
4
Journal Article
Recenzirano
Head injury occurs frequently in childhood and results in approximately 500,000 emergency department visits and over $1 billion in costs annually. Nearly 75% of these children are ultimately ...diagnosed with mild traumatic brain injury (MTBI), a misnomer because many will have radiographically identified intracranial injuries and long-term consequences. Identification of the brain at risk and prevention of secondary injury is associated with the largest reduction in head trauma morbidity and mortality. This article reviews the current literature to discuss the initial evaluation, management, and long-term outcomes in children sustaining MTBI.
Background:. The subjective degenerative spondylolisthesis instability classification (S-DSIC) system attempts to define preoperative instability associated with degenerative lumbar spondylolisthesis ...(DLS). The system guides surgical decision-making based on numerous indicators of instability that surgeons subjectively assess and incorporate. A more objective classification is warranted in order to decrease variation among surgeons. In this study, our objectives included (1) proposing an objective version of the DSIC system (O-DSIC) based on the best available clinical and biomechanical data and (2) comparing subjective surgeon perceptions (S-DSIC) with an objective measure (O-DSIC) of instability related to DLS. Methods:. In this multicenter cohort study, we prospectively enrolled 408 consecutive adult patients who received surgery for symptomatic DLS. Surgeons prospectively categorized preoperative instability using the existing S-DSIC system. Subsequently, an O-DSIC system was created. Variables selected for inclusion were assigned point values based on previously determined evidence quality. DSIC types were derived by point summation: 0 to 2 points was considered stable, Type I); 3 points, potentially unstable, Type II; and 4 to 5 points, unstable, Type III. Surgeons’ subjective perceptions of instability (S-DSIC) were retrospectively compared with O-DSIC types. Results:. The O-DSIC system includes 5 variables: presence of facet effusion, disc height preservation (≥6.5 mm), translation (≥4 mm), a kyphotic or neutral disc angle in flexion, and low back pain (≥5 of 10 intensity). Type I (n = 176, 57.0%) and Type II (n = 164, 53.0%) were the most common DSIC types according to the O-DSIC and S-DSIC systems, respectively. Surgeons categorized higher degrees of instability with the S-DSIC than the O-DSIC system in 130 patients (42%) (p < 0.001). The assignment of DSIC types was not influenced by demographic variables with either system. Conclusions:. The O-DSIC system facilitates objective assessment of preoperative instability related to DLS. Surgeons assigned higher degrees of instability with the S-DSIC than the O-DSIC system in 42% of cases. Level of Evidence:. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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