Advances in the Pharmacologic Treatment of Hepatocellular Carcinoma.

Medical therapy for hepatocellular carcinoma (HCC) is an area of active investigation because fewer than 25% of patients are candidates for curative resection or transplantation. Single agent doxorubicin, the former standard of care, generated a 10% tumor response but resulted in substantial toxicity. The resulting recommendation of the NCCN has been to administer cytotoxic chemotherapy only under clinical protocol.

Is a diverting ostomy needed in mid-high rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? An NSQIP analysis.

Introduction: A diverting stoma is often performed at the time of low anterior resection (LAR) for rectal cancer after neoadjuvant chemoradiation (nCRT) to protect the anastomosis. The aim of this study was to compare surgical outcomes in large cohorts of mid-high rectal cancer patients undergoing LAR after nCRT with and without a diverting stoma.

Methods: Patients undergoing LAR for rectal cancer (ICD-9 diagnosis code 154.

End of the road for a dysfunctional end organ: laparoscopic gastrectomy for refractory gastroparesis.

Introduction: Gastroparesis is a functional disorder resulting in debilitating nausea, esophageal reflux, and abdominal pain and is frequently refractory to medical treatment. Therapies such as pyloroplasty and neurostimulators can improve symptoms. When medical and surgical treatments fail, palliative gastrectomy is an option.

Overall survival by pattern of recurrence following curative intent surgery for colorectal liver metastasis.

Background: Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), patterns of recurrence and subsequent survival outcomes are not widely reported.

Methods: An institutional database (January 2002-December 2012) was reviewed to evaluate patterns of recurrence following CIS for CRLM.

Results: 163 patients with CRLM underwent successful CIS.

Gastro-bronchial fistula closed by endoscopic fistula plug (with video).

Background: Fistulae between the tracheobronchial tree and the gastric conduit post-esophagectomy are a rare but sometimes fatal complication. Clinical presentation can range from asymptomatic to acute pulmonary decompensation. Traditional management options, such as esophageal exclusion alone or combined with transthoracic fistula division, and closure (with tissue interposition), are highly invasive, technically difficult, and associated with variable success rates.

Determinants of repeat curative intent surgery in colorectal liver metastasis.

Introduction: Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), repeat CIS for recurrence improves survival. The factors associated with repeat CIS are not widely reported.

Methods: An institutional database (January 2002-December 2012) was reviewed to evaluate factors influencing repeat CIS.

Technique of per-oral endoscopic myotomy (POEM) of the esophagus (with video).

Background: Per-Oral Endoscopic Myotomy (POEM) is becoming an acceptable alternative to laparoscopic cardiomyotomy for esophageal motility disorders. The aim of this video is to provide key technical steps to completing this procedure.

Method: Each patient underwent diagnostic investigations including high resolution manometry (HRM), esophageogastroduodenoscopy (EGD), and timed-barium swallow for primary esophageal motility disorders preoperatively.

A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia.

Objective: To compare symptomatic and objective outcomes between HM and POEM.

Background: The surgical gold standard for achalasia is laparoscopic Heller myotomy (HM) and partial fundoplication. Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative.

Perioperative outcomes of pancreaticoduodenectomy compared to total pancreatectomy for neoplasia.

Purpose: Total pancreatectomy (TP) eliminates the risk and morbidity of pancreatic leak after pancreaticoduodenectomy (PD). However, TP is a more extensive procedure with guaranteed endocrine and exocrine insufficiency. Previous studies conflict on the net benefit of TP.

Morbidity of total pancreatectomy with islet cell auto-transplantation compared to total pancreatectomy alone.

Background: In 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.

Endoscopic therapies for leaks and fistulas after bariatric surgery.

Bariatric surgery is the most effective treatment for the medical comorbidities associated with morbid obesity. Though uncommon, staple line or anastomotic leaks after bariatric surgery are highly morbid events and challenging to treat. In selected patients without severe sepsis or distant pollution, endoscopic transluminal peritoneal drainage may provide source control.

Subxyphoid thyroidectomy: a feasibility study.

Objective: The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance.

Do patients' outcomes suffer when surgical fellows are involved in hepatic resection?

Introduction: Hepatectomy is an advanced technique learned during surgical fellowship. Outcomes have not been described for hepatectomies involving fellows.

Methods: We analyzed hepatectomies from the 2005-2011 National Surgical Quality Improvement Program database.

Defining "the elderly" undergoing major gastrointestinal resections: receiver operating characteristic analysis of a large ACS-NSQIP cohort.

Objective: "The elderly" is an often used but poorly defined descriptor of surgical patients. Investigators have used varying subjectively determined age cutoffs to report outcomes in the elderly. We set out to use objective outcomes data to determine the "at-risk" elderly population.

Esophagectomies with thoracic incisions carry increased pulmonary morbidity.

Importance: Thoracic incisions are not required for all esophagectomies and may increase pulmonary morbidity.

Objective: To compare the pulmonary and overall morbidity of esophagectomies with and without thoracic incisions.

Design: Observational study.

Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia.

Background: Per-oral endoscopic myotomy (POEM) requires advanced flexible endoscopic skills, especially in the management of complications.

Methods: We present a full-thickness esophagotomy while performing POEM and repair using an endoscopic suturing device.

Standard Operative Technique: An anterior esophageal 2 cm mucosectomy is created 7-10 cm proximal to the gastroesophageal junction after a submucosal wheal is raised.

Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention.

Objective: We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions.

Patients: This study involves 40 consecutive patients undergoing POEM.

Intervention: POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm.

Titles versus titles and abstracts for initial screening of articles for systematic reviews.

Background: There is no consensus on whether screening titles alone or titles and abstracts together is the preferable strategy for inclusion of articles in a systematic review.

Methods: TWO METHODS OF SCREENING ARTICLES FOR INCLUSION IN A SYSTEMATIC REVIEW WERE COMPARED: titles first versus titles and abstracts simultaneously. Each citation found in MEDLINE or Embase was reviewed by two physician reviewers for prespecified criteria: the citation included (1) primary data; (2) the exposure of interest; and (3) the outcome of interest.

Simultaneous colorectal and hepatic procedures for colorectal cancer result in increased morbidity but equivalent mortality compared with colorectal or hepatic procedures alone: outcomes from the National Surgical Quality Improvement Program.

Background: Simultaneous colorectal and hepatic surgery for colorectal cancer (CRC) is increasing as surgery becomes safer and less invasive. There is controversy regarding the morbidity associated with simultaneous, compared with separate or staged, resections.

Methods: Data for 2005-2008 from the National Surgical Quality Improvement Program (NSQIP) were used to compare morbidity after 19,925 colorectal procedures for CRC (CR group), 2295 hepatic resections for metastatic CRC (HEP group), and 314 simultaneous colorectal and hepatic resections (SIM group).

Does morbid obesity worsen outcomes after esophagectomy?

Background: With worldwide increases in esophageal cancer and obesity, esophagectomies in the morbidly obese (MO) will only increase. Risk stratification and patient counseling require more information on the morbidity associated with esophagectomy in the obese.

Methods: We studied nonemergent subtotal or total esophagectomies with reconstruction in the National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2010.

Night-shift work and risk of breast cancer: a systematic review and meta-analysis.

A 2007 report by the International Agency for Research on Cancer classified night-shift work as possibly carcinogenic to humans, emphasizing, in particular, its association with breast cancer. Since this report and the publication of the last systematic review on this topic, several new studies have examined this association. Hence, to provide a comprehensive update on this topic, we performed a systematic review and meta-analysis.

Peroral endoscopic esophageal myotomy: defining the learning curve.

Background: Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management.

Objective: Determine the learning curve for POEM.

Partial anterior vs partial posterior fundoplication following transabdominal esophagocardiomyotomy for achalasia of the esophagus: meta-regression of objective postoperative gastroesophageal reflux and dysphagia.

Objectives: To review transabdominal esophagocardiomyotomy (surgical treatment of achalasia) of the esophagus and to compare outcomes of partial anterior vs partial posterior fundoplication.

Data Sources: An electronic search was conducted among studies published between January 1976 and September 2011 using the keywords achalasia, myotomy, antireflux surgery, and fundoplication.

Study Selection: Prospective studies of transabdominal esophagocardiomyotomy were selected.