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Introduction: Camera handling and navigation are essential skills in laparoscopic surgery. Surgeons rely on camera operators, usually the least experienced members of the team, for visualization of the operative field. Essential skills for camera operators include maintaining orientation, an effective horizon, appropriate zoom control, and a clean lens. Virtual reality (VR) simulation may be a useful adjunct to developing camera skills in a novice population. No standardized VR-based camera navigation curriculum is currently available. We developed and implemented a novel curriculum on the LapSim VR simulator platform for our residents and students. We hypothesize that our curriculum will demonstrate construct and face validity in our trainee population, distinguishing levels of laparoscopic experience as part of a realistic training curriculum., Methods: Overall, 41 participants with various levels of laparoscopic training completed the curriculum. Participants included medical students, surgical residents (Postgraduate Years 1-5), fellows, and attendings. We stratified subjects into three groups (novice, intermediate, and advanced) based on previous laparoscopic experience. We assessed face validity with a questionnaire. The proficiency-based curriculum consists of three modules: camera navigation, coordination, and target visualization using 0° and 30° laparoscopes. Metrics include time, target misses, drift, path length, and tissue contact. We analyzed data using analysis of variance and Student's t-test., Results: We noted significant differences in repetitions required to complete the curriculum: 41.8 for novices, 21.2 for intermediates, and 11.7 for the advanced group (P < 0.05). In the individual modules, coordination required 13.3 attempts for novices, 4.2 for intermediates, and 1.7 for the advanced group (P < 0.05). Target visualization required 19.3 attempts for novices, 13.2 for intermediates, and 8.2 for the advanced group (P < 0.05). Participants believe that training improves camera handling skills (95%), is relevant to surgery (95%), and is a valid training tool (93%). Graphics (98%) and realism (93%) were highly regarded., Conclusions: The VR-based camera navigation curriculum demonstrates construct and face validity for our training population. Camera navigation simulation may be a valuable tool that can be integrated into training protocols for residents and medical students during their surgery rotations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Cervical spine injury (CSI) in octogenarians continues to carry a high morbidity and mortality rate. The incidence of CSI among individuals who are below the age of 80 is declining, whereas the incidence of CSI for those 80 years and above is rising.The aim of the study was to evaluate outcomes of cervical spine injuries in octogenarians caused by different mechanisms: motor vehicle accidents, compared to a fall.Material and methods. The National Trauma Data Bank (NTDB) was queried for patients ages 80 and above, who sustained a cervical spine injury via motor vehicle collision and falls. Patient demographics, mechanism of injury, Glasgow Coma Score (GCS), injury severity score (ISS), days in Intensive Care Unit, Temperature on arrival, blood pressure on arrival, CT Scan of head results, complications, sex, and mortality.Results. Three-thousand three hundred seventy-five patients, 80 years of age and older with CSI were included in the study; fifteen percent of these octogenarians with cervical spine injuries died. It was observed that patients in the motor vehicle accident (MVA) group have 1.737 (95% CI 1.407, 2.144 p-value < 0.0001) times the odds of dying, compared to those in the fall group. Patients over the age of 80 who were in a MVA have 1.209 (95% CI 0.941, 1.554 p-value = 0.1372) times the odds of having a positive head CT, compared with people over the age of 80 who experienced a fall. Patients involved in a motor vehicle accident with associated CSI were more likely to be a younger age, have a lower GCS on arrival, have a longer length of stay in the Intensive Care Unit, and a higher ISS (p<0.05).Conclusions. Cervical spine injury in octogenarians carries a high mortality regardless of mechanism. Elderly patients who suffer cervical spine injuries in motor vehicle accidents have a lower SBP, a higher ISS and are nearly twice as likely to die as those who were injured in a fall.

A wound-healing agent developed in the European Union is based on the combination of organic hyaluronan with inorganic iodine. The aim of this pilot study was to assess the efficacy and safety of hyaluronate-iodine in the treatment of sternal wounds. Eight patients with sternal wound dehiscence were entered into the study. After debridement, wounds were dressed with gauze soaked in hyaluronate-iodine. In one patient with an epipleural abscess, hyaluronate-iodine was instilled directly into the abscess cavity daily. Complete healing was achieved in 7 patients, and 1 patient underwent a reconstructive operation for wound closure. The mean (SD) length of treatment was 136 (114.2) days. No adverse effects or complications were apparent in this group. Hyaluronate-iodine is safe and effective in healing sternal wound dehiscence. Randomized controlled trials are needed for further validation.

Background: Manual skill proficiency is not currently employed in selecting residents for general surgery training programs. The study objective was to assess whether the technical skill levels of applicants to a general surgery residency program are higher than those of internal medicine residents., Material and Methods: Forty-two applicants to a community general surgery program underwent manual skill testing on interview day. Four laparoscopic tasks on a virtual reality (VR) simulator (LapSim, Goteborg, Sweden) were tested. Performance scores were computer-generated. Participants' previous experience with other manual dexterity activities was assessed via a questionnaire. Applicants' self-perception of their surgical skills was correlated with their skill dexterity scores on the simulator. Candidates' simulator scores were also compared with those of a group of internal medicine interns (n = 9) and a group of mid-level surgical residents, PGY 2-3 (n = 7)., Results: Simulator scores of the applicants were significantly lower than those of mid-level surgical residents in all VR tasks (P < 0.05). The internal medicine interns scored higher that the surgery candidates in three of four simulator tasks. Participation in other manual dexterity activities was not associated with increased dexterity scores., Conclusion: This study suggests that surgical dexterity levels do not correlate with the self-assessed skill levels or with previous experience with other manual dexterity activities. Moreover, there appears to be no self-selection of applicants for surgery residency based on actual surgical skills. Selection criteria for surgical training, which incorporate technical proficiency skills, may potentially better discriminate those applicants with an aptitude for a surgical specialty., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The early development of total parenteral nutrition and its evolution as an adjunct to the nutritional, metabolic, and antineoplastic therapy of cancer patients is described. Examples related to the sine wave of responses to new data and discovery are placed in context to understand better past, present, and how and where to proceed in the future to achieve optimal results from multimodal comprehensive management of patients with malignancies. Practical and philosophic thoughts are proffered to justify continued, intensified, logical, controlled clinical studies directed toward establishing the most rational, safe, and effective use of total parenteral nutrition in treating patients with cancer., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The most significant events and discoveries regarding the development of enteral nutrition (EN) dating back to 1500 BC are chronicled. A more detailed description and discussion of subsequent more recent progress during the past two decades is focused primarily on 3 of the most dynamic areas of endeavor: tight glycemic control; timing and combining of EN and total parenteral nutrition to meet early target nutrition goals in intensive care unit patients; and the role, advances, and future of immunonutrition. An abridged classification of solutions for enteral feeding, and a brief outline of key prudent oral dietary guidelines are also presented., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Surgery in geriatric patients is accompanied by increases in morbidity and mortality, increases in functional abnormalities and poor outcomes, and increases in severe malnutrition, compared with surgery of similar magnitude in nongeriatric patients. Hospitalized elderly patients are at significant risk of presenting with, or developing, protein-energy and other nutrient deficiencies. However, nutritional assessment of older geriatric patients, 65 to 100 years of age, is a challenging task because of lack of adequate age-specific reference data in this diverse and heterogeneous population. Dietary counseling and conscientious, aggressive nutritional support are required for optimal metabolic and surgical care of this age group., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The importance of the preoperative nutritional status of cardiothoracic surgical patients in determining outcomes is demonstrated and discussed. Demographic, anthropometric, and biochemical changes in patients undergoing cardiothoracic surgery increase the importance of identifying those at risk for postoperative complications resulting from malnutrition. The interrelationships of chronic heart failure, cardiac cachexia, nutritional status, and nutritional support are identified and emphasized. The complexities of myocardial energetics and metabolism are outlined together with the nutrient needs for patients undergoing cardiac, pulmonary, or other intrathoracic operative procedures., (Copyright © 2011 Elsevier Inc. All rights reserved.)

This article presents an overview of the current knowledge, status, and use of supplements by patients before surgical operations, together with the benefits expected of the supplements by the patients. The indications, potential advantages and disadvantages, and the relationships with various aspects of the preoperative preparation and postoperative management of surgical patients are discussed, with emphasis on the significant percentage of this population that is deficient in fundamental nutrients. Recent revisions and recommendations for some of the macronutrients are presented, together with a summary of federal regulations and an oversight of supplements., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Benefits of laparoscopic techniques over traditional open techniques in colon surgery are well recognized. Although both hand-assisted laparoscopic colectomy (HALC) and laparoscopic-assisted colectomy (LAC) can beeffective in the treatment of colon cancer, the superiority of either technique has yet to be determined for oncologic procedures., Materials and Methods: A five-year retrospective study comparing outcomes of hand-assisted laparoscopic and laparoscopic-assisted colectomies for cancer was conducted at our community-based teaching hospital. Demographic data, tumor location and stage of the disease were analyzed. Outcomes compared between the two procedures included number of lymph nodes retrieved, presence of positive margins, operative time, length of stay, and number of early postoperative complications., Results: Fifty patients underwent HALC, while 23 underwent LAC during the study period. Demographic data were similar between the two groups. Operative time was longer for LAC, compared with HALC (178 vs. 125 min., p < 0.05), however, the average number of lymph nodes retrieved was significantly higher in LAC compared with HALC (14 vs. 10, p < 0.05). No significant differences were recorded for positive margins, postoperative complications, or the length of hospital stay., Conclusions: While HALC was more prevalent at our institution and proved to be associated with decreased operative times, the number of lymph nodes retrieved was sub-optimal and compared less favorably with LAC. Above all, oncologic principles should be respected and achieved regardless of the operative technique used.

The events and discoveries thought to be the most significant prerequisites to the development of total parenteral nutrition (TPN) dating back to the early 17th century are chronicled. A more detailed description and discussion of the subsequent early modern highlights of the basic and clinical research beginning in the mid-20th century and the advances culminating in the first demonstration of the feasibility and practicality of TPN, and its successful, safe and efficacious applications clinically, are presented. Some of the reasoning, insights, and philosophy of a pioneer clinician-scientist in the field are shared with readers., (2011 Elsevier Inc. All rights reserved.)

Cachexia has plagued clinicians for centuries. Although all cachexia is related to malnutrition, cachexia associated with malignant diseases differs from starvation cachexia in that it is more recalcitrant to nutritional therapy. All cachexia responds to judicious nutritional support; however, cancer cachexia worsens autonomously as the disease advances and cannot be arrested or reversed by any known form of nutrition, hormonal, or pharmacologic therapy. Cachexia must be treated cautiously to avoid overfeeding syndrome, which may result in serious or dangerous complications or death., (2011 Elsevier Inc. All rights reserved.)

Methods and Materials: The historical highlights of the management of fistulas of the gastrointestinal tract during the past century are presented briefly, together with the significant lessons learned from the studies published in the literature., Discussion: The evolution from predominantly operative or technical approaches to comprehensive multidisciplinary management of metabolic and nutritional support, which are essential to optimal fistula closure, and morbidity and mortality outcomes are discussed. The importance of achieving hemodynamic stability, fluid and electrolyte homeostasis, fistula effluent control, protection of the skin, control of infection and sepsis, and cardiopulmonary and major organ support, preferably by specially trained and motivated teams in critical care units of institutions with the interest, resources, and skills in managing the metabolic consequences of gastrointestinal fistula patients, is emphasized. The current status of the nutritional and metabolic support of patients with gastrointestinal tract fistulas is outlined and discussed briefly., Conclusions: The optimal metabolic and nutritional management of patients with gastrointestinal tract fistulas is an extraordinary and daunting challenge which has yet to be perfected, demonstrated, and applied universally. Much education, research, motivation, proficiency, and concerted conscientious effort will be required in order to achieve this elusive but noble goal. Some suggestions for achieving success in this endeavor are proffered, consistent with the senior author's philosophy, which has evolved during a half-century of experience and endeavor in this vital area.

An abridged background of the history, cause, and nature of early controversies related to the development and clinical application of total parenteral nutrition (TPN) is presented, followed by discussions of highlights of some of the more prominent controversies that continue to prevail, including nutritional support of geriatric patients with and without cancer, the importance of maintenance of normal glycemia, the primacy of nutrition support teams, and TPN versus total enteral nutrition. Reflections related to nutritional support and TPN are interspersed throughout the discussions, together with a compilation of legacies of TPN to the modern practice of medicine., (2011 Elsevier Inc. All rights reserved.)

Hyaluronate-iodine complex is a wound healing adjuvant approved for use in the European Union. The objective of this study is to validate hyaluronate-iodine as a potential wound healing agent. Patients were recruited from the hospital, the outpatient clinic, and the wound healing center. Hyaluronate-iodine soaked gauze was applied to wounds either daily or every other day depending on the amount of wound exudate. Wounds were measured weekly, and progression was documented with digital photography. All wounds were debrided as needed using standard surgical techniques. Fourteen patients (19 wounds) were entered into this prospective study, and 10 patients completed treatment. Fourteen wounds progressed to complete healing with a mean healing time of 18.1 ± 15.1 weeks. Treatment was interrupted in four patients. One patient discontinued treatment due to pain related to application of hyaluronate-iodine, another patient for transportation issues, and the other two patients were lost to follow-up due to relocation out of state and noncompliance with scheduled appointments. Hyaluronate-iodine was helpful in the healing of all types of wounds treated in this pilot study. The antiadhesive and antimicrobial properties of hyaluronate-iodine create a desirable environment conducive to wound healing without apparent detrimental effects.

An abridged overview of the development of surgery and early surgical education, training and practice is presented, beginning in colonial America in the 18th century, extending throughout the 19th century, evolving rapidly during the 20th century, and progressing into the first decade of the 21st century. The metamorphosis and transformation of surgery training programs in the United States are described and discussed, together with some of the most relevant rationale and justifications for the many changes introduced, established, mandated and in progress. The current accreditation requirements, oversight, and governance of general surgery training programs; the incorporation of multiple technical and technological advances into general surgical practice; the addition of required training modules and systems to the programs; and their secondary implications, consequences, and impact upon the programs, are presented. These include financial and other resource impediments, the 80-h work week implications and constraints, the technological explosion, the demands of the required expanded general surgical curriculum and operative case experience, the continued erosion of general surgery by surgical and medical specialists, the increasing workload coupled with decreasing reimbursement for surgeons and their services; and the challenges and difficulties of amalgamating all of these confounding or conflicting factors into an effective and viable general surgery program. Finally, some of the personal insights, opinions, experiences, and philosophy of the author are incorporated into the narrative.

Hypothesis: Use of a modified clinical grading score improves accuracy in diagnosing acute appendicitis in the pediatric population while decreasing the use of computed tomography (CT)., Design: Retrospective medical records review after approval by the institutional review board. We determined the Alvarado score for each patient and correlated it with the pathological findings and imaging studies to evaluate the efficacy of CT and its attendant radiation exposure., Setting: Community teaching hospital., Patients: Sixty-one patients, aged 3 to 16 years, admitted with suspected acute appendicitis., Main Outcome Measures: Sensitivity, specificity, and accuracy of the modified Alvarado scoring system., Results: The standard Alvarado score for acute appendicitis had a sensitivity of 92% and a specificity of 82%, with an accuracy of 92%. In the modified Alvarado scoring system, CT findings were substituted for Alvarado scores in the ranges of 5 or 6, 5 to 7, 5 to 8, and 5 to 9. The modification resulted in the greatest accuracy (98%) in diagnosing appendicitis in patients with scores in the range of 5 to 7. This modification theoretically would have decreased the use of CT by about 27% in this group of retrospectively studied patients. Furthermore, in patients with Alvarado scores of 1 to 4, another diagnosis should be considered; in patients with scores of 5 to 7, CT should be performed; and, in patients with scores of 8 to 10, an appendectomy should be performed promptly without further studies., Conclusions: The modified Alvarado score is useful as an aid in diagnosing acute appendicitis in the pediatric population. This scoring system eliminates unnecessary use of CT and the attendant potential cancer-inducing radiation in the pediatric population.

Background: The incidence of colorectal cancer (CRC) in young adults is rising, and young age is a predictor of poor survival. The purpose of this study was to examine factors leading to increased mortality in patients ≤ 50 years of age, and to examine this population for characteristics that could lead to benefit from CRC screening., Methods: Charts of patients 50 years of age and under, diagnosed with CRC from 1998 through 2007, at our community teaching hospital, were reviewed retrospectively. Demographics, social and family history, staging, treatment and death were evaluated. Mann Whitney, Fisher Exact, and χ(2) tests were used with P <0.05 considered statistically significant., Results: Forty-five young patients with CRC were identified. Twenty-five patients were female and 20 male; the mean age was 43.6 y. Most patients presented with rectal bleeding. Right-sided cancers had a higher presenting stage (P < 0.05). Men had both a higher presenting stage (P = 0.35) and a higher incidence of smoking compared with women (P = 0.001). Female patients were more likely to have left-sided CRC (65%) compared with men (35%). Ninety-six percent of patients underwent surgical resection; 14 patients died., Conclusions: CRC in young adults is not common, but is often advanced when discovered. Diagnostic efforts should be aggressive in young patients who have rectal bleeding, especially young male smokers. Sigmoidoscopy is not adequate for comprehensive diagnosis of CRC in young patients, as the majority have right-sided colon cancers, which often result in subsequent presentation of the disease at a higher stage, risk, and mortality rate., (Copyright © 2011. Published by Elsevier Inc.)

In 2003, the revised American Cancer Society guidelines recommended that breast self-examination (BSE) be optional. Of 822 women diagnosed with breast cancer in our hospital from 1994 to 2004, sixty four (7.7%) were 40 years of age or younger. Forty four (68.7%) of these young women discovered their breast cancers on BSE, 17 (18%) by mammography, and 3 (4.7%) by clinical breast examination by medical professionals. Of 758 women over 40 years of age diagnosed with breast cancer, 382 (49%) discovered their cancer by mammography, 278 (39%) by BSE, and 98 (14%) by a clinical breast examination. Lymph node metastases in the older women was one-half that in the younger women (21% versus 42%), and a higher percentage of younger women presented with more advanced disease. In response to increasing breast cancer in young women under 41 years of age, encouragement of proper breast self-examination is warranted and should be advocated.

A 53-year-old Caucasian female presented with an erythematous, tender, fluctuant mass in the periumbilical region. A computerized tomography scan of the abdomen and pelvis suggested a large tumor extending from the umbilicus to the dome of the bladder with elements of tissue within the bladder consistent with a malignancy of either bladder or urachal origin. The patient subsequently underwent a cystoscopic biopsy which was positive for papillary adenocarcinoma arising in a villous adenoma. Metastatic workup revealed multiple hepatic and bilateral pulmonarynodules. Palliative laparotomywithlysis of adhesions, smallbowel resection, partial cystectomy, omentectomy, abdominal wall and umbilical resection were performed.

Objective: To determine the outcomes of patients undergoing total extraperitoneal inguinal hernia repair without fixation of the mesh., Design: Prospective cohort., Setting: Community teaching hospital., Patients: A total of 274 consecutive patients were included in the study group., Interventions: All operations were performed by the same surgeon with the patients under general anesthesia in an outpatient setting. A preformed polyester mesh (Parietex; Covidien, Mansfield, Massachusetts) was used in all cases without any fixation., Main Outcome Measures: All patients were prospectively followed up at 2 weeks, 1 month, and 1 year after surgery. Operative morbidity, chronic pain, and hernia recurrence were recorded., Results: Two hundred seventy-four consecutive patients underwent 311 total extraperitoneal inguinal hernia repairs. No conversions were made to open hernia repairs. No recurrences were found at the 12-month follow-up visit. There were 19 inguinal seromas (6.1%) identified at 2 weeks, but only 7 (1.9%) remained at 1 month, and none at 1 year. No wound infections, scrotal hematomas, or other perioperative complications were reported. Two hundred thirty-six patients used fewer than the 30 prescribed tablets for pain control, while 23 patients requested a refill, 12 of whom had seromas (P < .01). At 12 months, no patient was taking pain relief medication; however, 8 patients reported occasional discomfort in the groin, and 1 patient reported occasional umbilical discomfort., Conclusion: This single general surgeon experience supports total extraperitoneal inguinal hernia repair without mesh fixation as a safe, effective procedure with low morbidity and no evidence of recurrence at the 1-year follow-up visit.

Despite significant improvements in the practice of metabolic support of critically ill patients in recent years, malnutrition continues to be common among surgical patients, adding significantly to complications, infections, length of stay, costs, and increased mortality. Furthermore, hypercatabolism is the major metabolic response after major trauma and emergency surgery, making this patient population a unique subgroup of critically ill patients vulnerable to further decline in nutritional status. Many questions have already been answered, such as whether critically ill patients should be fed, when they should be fed, and how nutrients should be delivered. What is not entirely clear is what we should feed critically ill patients at different phases of specific diseases and disorders, as well as whether or not we should enhance and/or modulate patients' immunity.

Acidovorax avenae is a gram-negative rod in the family Comamonadaceae and a phytopathogen found in the environment. Human infections caused by members of the Comamonadaceae are extremely rare. We report a case of implanted-port-catheter-related sepsis caused by Acidovorax avenae and methicillin (meticillin)-sensitive Staphylococcus aureus (MSSA).

Introduction: Mucinous cystadenomas of the ovary are known for their potential to grow to massive proportions and are often incidentally diagnosed. They are typically benign tumors accounting for 15% of ovarian neoplasms and up to 80% of all mucinous tumors., Case Report: We report a 50-year-old, morbidly obese female admitted with left lower extremity edema who was incidentally found to have a massive, benign, mucinous cystadenoma of the ovary. The tumor was managed by laparotomy, cystectomy, and right salpingo-oophorectomy. Pathology revealed a benign cyst., Conclusion: The clinically silent course of these large, benign tumors can have unique presentations.

Introduction: Laparoscopic virtual reality simulators are becoming a ubiquitous tool in resident training and assessment. These devices provide the operator with various levels of realism, including haptic (or force) feedback. However, this feature adds significantly to the cost of the devices, and limited data exist assessing the value of haptics in skill acquisition and development. Utilizing the Laparoscopy VR (Immersion Medical, Gaithersburg, MD), we hypothesized that the incorporation of force feedback in the simulated operative environment would allow superior trainee performance compared with performance of the same basic skills tasks in a non-haptic model., Methods: Ten medical students with minimal laparoscopic experience and similar baseline skill levels as proven by performance of two fundamentals of laparoscopic surgery (FLS) tasks (peg transfer and cutting drills) voluntarily participated in the study. Each performed two tasks, analogous to the FLS drills, on the Laparoscopy VR at 3 levels of difficulty, based on the established settings of the manufacturer. After achieving familiarity with the device and tasks, the students completed the drills both with and without force feedback. Data on completion time, instrument path length, right and left hand errors, and grasping tension were analyzed. The scores in the haptic-enhanced simulation environment were compared with the scores in the non-haptic model and analyzed utilizing Student's t-test., Results: The peg transfer drill showed no difference in performance between the haptic and non-haptic simulations for all metrics at all three levels of difficulty. For the more complex cutting exercise, the time to complete the tasks was significantly shorter when force feedback was provided, at all levels of difficulty (158+/-56 versus 187+/-51 s, 176+/-49 versus 222+/-68 s, and 275+/-76 versus 422+/-220 s, at levels 1, 2, and 3, respectively, P<0.05). Data on instrument path length, grasping tension, and errors showed a trend toward a benefit from haptics at all difficulty levels, but this difference did not achieve statistical significance., Conclusions: In the more advanced tasks, haptics allowed superior precision, resulting in faster completion of tasks and a trend toward fewer technical errors. In the more basic tasks, haptic-enhanced simulation did not demonstrate an appreciable performance improvement among our trainees. These data suggest that the additional expense of haptic-enhanced laparoscopic simulators may be justified for advanced skill development in surgical trainees as simulator technology continues to improve.

The concept of feeding patients entirely parenterally by injecting nutrient substances or fluids intravenously was advocated and attempted long before the successful practical development of total parenteral nutrition (TPN) four decades ago. Realization of this 400 year old seemingly fanciful dream initially required centuries of fundamental investigation coupled with basic technological advances and judicious clinical applications. Most clinicians in the 1950's were aware of the negative impact of starvation on morbidity, mortality, and outcomes, but only few understood the necessity for providing adequate nutritional support to malnourished patients if optimal clinical results were to be achieved. The prevailing dogma in the 1960's was that, "Feeding entirely by vein is impossible; even if it were possible, it would be impractical; and even if it were practical, it would be unaffordable." Major challenges to the development of TPN included: (1) formulate complete parenteral nutrient solutions (did not exist), (2) concentrate substrate components to 5-6 times isotonicity without precipitation (not easily done), (3) demonstrate utility and safety of long-term central venous catheterization (not looked upon with favor by the medical hierarchy), (4) demonstrate efficacy and safety of long-term infusion of hypertonic nutrient solutions (contrary to clinical practices at the time), (5) maintain asepsis and antisepsis throughout solution preparation and delivery (required a major culture change), and (6) anticipate, avoid, and correct metabolic imbalances or derangements (a monumental challenge and undertaking). This presentation recounts approaches to, and solution of, some of the daunting problems as really occurred in a comprehensive, concise and candid history of parenteral nutrition.

Introduction: Over a 10-y period at our community hospital, more than 50% of women 40 y of age and younger underwent a mastectomy as first line breast cancer treatment. These results catapulted a study to identify personal and physical implications of a mastectomy and to determine if, in women of all ages, breast conservation therapy with close follow-up is a better alternative to mastectomy., Methods: Six hundred eight women underwent a mastectomy for breast cancer from 1989 to 2005 at our teaching institution; 77% (n = 120) of 156 successfully contacted women agreed to participate in the study, and 70% (n = 84) of them completed a questionnaire., Results: Most women discovered their breast cancer through mammography or self breast examination, 31% and 28%, respectively. Five patients were diagnosed at Stage 0, 35 at Stage 1, 26 at Stage 2, 8 at Stage 3, 1 at Stage 4, and 9 patients had an unknown stage of disease. Sixty-three patients primarily discussed their treatment plan with a surgeon; 80 were satisfied with the time spent discussing their treatment. Twenty-four patients underwent various reconstruction procedures; most (75%) were satisfied with their treatment and reconstruction choices., Conclusions: Mastectomy as a treatment choice for breast cancer did not have the negative personal and physical outcome that we had predicted. Personal choice and a surgeon's advice were the primary influencing factors on the women's treatment choice of mastectomy. Adequate preoperative discussion time and a multimodality cancer team can be most helpful in providing comprehensive treatment options for all women with breast cancer.

Verrucous carcinoma, a variant of well-differentiated squamous cell carcinoma, is usually described in the literature as arising in the oral cavity, skin, and larynx. The reports on verrucous carcinoma arising in the genital tract, usually originating in the vagina, vulva, or uterine cervix, are few. Verrucous carcinoma arising in the ovary has not been previously reported. In this article, a unique hybrid carcinoma, a large aggressive verrucous carcinoma in combination with squamous carcinoma of the left ovary and synchronously occurring with a squamous cell carcinoma in the endometrium, is presented. This unique case of a hybrid carcinoma includes the first-known case of this type of carcinoma involving the ovary. The negative cervical evaluation findings, together with the histologic patterns of the tumors in the uterus and the ovary, support the conclusion that these 2 carcinomas are synchronous, one arising in the left ovary and the other arising in the uterus.

Background: Cancer of unknown primary (CUP) origin is a very aggressive disease with a poor prognosis. Most of the literature reports of CUP are generated from tertiary cancer centers., Methods: A retrospective chart review of all patients with a diagnosis of CUP was performed between January 1995 and January 2005. Age, gender, diagnostic evaluation, histologic diagnosis, location of metastases, treatment, and survival were recorded., Results: Ninety-one patients met the inclusion criteria. The pathologic diagnoses included adenocarcinoma (42.8%), undifferentiated carcinoma (34.5%), squamous cell carcinoma (9.8%), neuroendocrine cancer (6.5%), sarcoma (3.2%), and nonspecific malignant neoplasm (3.2%). The overall mean survival was 9.2 months (95% confidence interval, 6.1-12.4 mo), and for squamous cell carcinoma was 26.9 months (standard error, 5.7; P = .007)., Conclusions: CUP encompasses a variety of different pathologic entities with an overall dismal 5-year survival. Nonetheless, squamous cell and neuroendocrine CUP are associated with a significantly better early prognosis than the other malignancies.

Introduction: Perceptions of poor outcome may detract caregivers from offering standard therapies to patients over 80 years who have been diagnosed with rectal cancer. We evaluate the effect of operative intervention on their survival., Methods: Demographics, tumor characteristics, treatment, and survival for patients over 80 years with rectal and rectosigmoid cancer from 1993 to 2002 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute were examined. Survival was determined by using the Kaplan-Meier method. Patients who underwent operation (Group A) were compared with those who did not undergo surgery (Group B). Fisher's exact, chi-squared, analysis of variance, and log-rank tests were used as appropriate, and P < 0.05 was considered statistically significant., Results: A total of 9,501 patients (19 percent) were aged older than 80 years. Mean age was 85 years, and median survival was 24 months. Stage of disease was unknown for 2,915 patients. Median survival was 58, 53, 39, 27, and 5 months for Stages 0 (n=163), I (n=1,878), II (n=1,796), III (n=1,536), and IV (n=1,213), respectively. A total of 6,900 patients (81 percent) underwent surgery. Median survival for operated patients was significantly longer for all stages (36 vs. 5 months, P < 0.00001), Stage 0 (60 vs. 7 months, P < 0.01), Stage I (55 vs. 11 months, P < 0.0001), Stage II (41 vs. 13 months, P < 0.0001), Stage III (28 vs. 14 months, P < 0.05), and Stage IV (8 vs. 3 months, P < 0.0001). For patients with rectal cancer, local therapy also significantly improved median survival compared with nonoperated patients (P < 0.0001)., Conclusions: Operative intervention provides sustained benefit in terms of survival to patients aged >80 years with rectal cancer at all stages who are assessed to be a good operative risk. Age older than 80 years should not detract surgeons from offering optimal therapy to good-risk patients.

Objective: To examine the epidemiology and clinical characteristics of small-bowel cancer., Design: Patients with small-bowel tumors reported between 1980 and 2000, studied retrospectively., Setting: Data from the Connecticut Tumor Registry., Patients: One thousand sixty small-bowel cancer cases: 628 men (49.84%) and 632 women (50.16%). Mean age at presentation was 65.2 years., Results: The most common location of small-bowel tumors was the ileum (374 cases; 29.7%), followed by the duodenum (320 cases; 25.4%) and the jejunum (193 cases; 15.3%). In 367 patient cases (29.1%: 192 men [30.6%] and 175 women [27.7%]), a prior or subsequent tumor of the gastrointestinal tract was reported. The most prevalent histologic type was carcinoid (417 cases; 33%), followed by adenocarcinoma (341 cases; 27%) and lymphoma (205 cases; 16.3%). The patient population was predominantly white (1159 patients; 92%), followed by African American patients (91 patients; 7.2%). Stratification by consecutive 7-year intervals showed the following: from 1980 to 1986, there were 10.5 cases per 100 000 individuals; from 1987 to 1993, there were 13.05 cases per 100 000 individuals; and from 1994 to 2000, there were 14.86 cases per 100 000 individuals. Men comprised 44.8% of cases from 1980 to 1986, 50.2% of cases from 1987 to 1993, and 53.3% of cases from 1994 to 2000. African American patients accounted for 7.5% of all cases from 1980 to 1986, 5.8% from 1986 to 1993, and 8.2% of cases from 1994 to 2000. In 1106 patients (87.7%), the primary therapy was surgical, including intestinal bypass, radical excision, excisional biopsy, and subtotal or total excision., Conclusions: The incidence of small-bowel tumors in Connecticut has increased during the past 2 decades, with the highest rate of increase in men. Carcinoid tumors are the most common small intestinal cancers identified histologically, followed by adenocarcinomas. The former seems to be more frequently seen in the ileum, the latter in the duodenum. Surgery is the treatment of choice for the cure or palliation of small-bowel cancers.

Background: Little is known about the trends in the incidence, survival, and treatment patterns of gallbladder cancer over the last decade., Methods: Data of patients in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute (SEER 13) with a diagnosis of primary gallbladder cancer from 1973-2002 were examined. The effect of surgery and radiotherapy on survival was examined. Incidence of disease, survival, use of surgery, and radiotherapy for patients diagnosed between 1993 and 2002 (Group B) were compared to the others (Group A)., Results: Median age of the 10301 included patients was 73. 72.4% were female and median survival was 4 months. SEER histologic stage was classified as localized (23.7%), regional (37.4%), and distant (38.9%) patients. Median survival for these stages was 20 months, 5 months, and 2 months, respectively. 81.5% patients underwent surgery and 13.3% radiotherapy. Median survival of patients undergoing surgery was significantly longer (8 versus 2 months, P < 0.0001). Radiotherapy in addition to surgery was associated with prolonged survival for patients with regional and distant stages but not localized stage. Over the 3 decades, the incidence of gallbladder cancer gradually decreased in patients older than 50 years, but increased in younger patients. Significantly fewer Group B patients underwent surgery compared with Group A (74.6% versus 89.9%, P < .001). However, the use of radiotherapy was higher in Group B (14.5% versus 12.4%, P < 0.01)., Conclusions: Over the last decade, the incidence of gallbladder cancer has reduced in patients older than 50 years with an increased incidence in younger patients. Survival of patients has also improved over the last decade. The number of patients undergoing surgery has reduced with an increase in the use of radiotherapy.

Background: The objective of the study was to assess if performance of basic laparoscopic skills on a virtual reality (VR) simulator is impaired in microgravity relative to normal gravitational influences., Materials and Methods: Fourteen subjects with various educational backgrounds underwent basic laparoscopy skill training for five consecutive days on the ground before flying aboard NASA's KC-135 zero-gravity laboratory. The participants performed basic laparoscopic exercises (clip applying, grasping, cutting, and suturing) on a VR laparoscopy simulator, both on the ground and during 25-s microgravity windows in parabolic flight. Skill levels after ground training were compared with skill levels in performing the same tasks in microgravity. Blinded reviewers measured the number of tasks successfully completed, tissue damage number, left and right hand path lengths during task execution, and percentage of task attempts that resulted in successful completion., Results: A significant increase in tissue injury (t test, P < 0.05) and task erosion were seen in clip applying, cutting, and grasping in microgravity (45%, 20% and 57% decrease in task attempts that resulted in a successful completion, respectively). However, there was no significant difference in the left and right hand path lengths, and the total number of tasks successfully completed on the ground versus in microgravity, for any of the four laparoscopic exercises (t test, P > 0.05)., Conclusion: This study demonstrates decreased efficiency and increased injury to the simulated tissues in performing laparoscopic skills during microgravity as compared to performing these skills in standard gravitational influence. Additional experiments are indicated to further develop and validate VR microgravity surgical simulation.

Adenosquamous carcinoma of the colon is rare. A paraneoplastic syndrome presenting as hypercalcemia may occasionally occur in association with these tumors. Survival for more advanced stages of disease is lower than for patients with adenocarcinoma at a corresponding stage. We report a patient who presented with a primary adenosquamous carcinoma of the rectosigmoid junction and we review the literature regarding the clinical presentation, management, and prognosis of this tumor.

Premalignant and malignant conditions of the skin may sometimes require excision of extensive areas of the skin and subcutaneous tissues. Coverage of the ensuing raw area may be afforded by allowing healing by secondary intention, skin grafts, or flaps. Wide excision of the perianal skin poses special problems. We describe the use of bilateral V-Y advancement flaps for the management of an extensive defect resulting from the wide excision of squamous cell carcinoma arising in scarred perianal skin.

Milestones in the history of the development of vascular access and the subsequent advances in practical clinical applications of the knowledge, techniques, technology, and experience to the beneficial management of a variety of patients are described. The original achievements are presented and briefly discussed primarily, but not exclusively, in relationship to the successful development of parenteral nutrition (PN). Beginning with the discovery of the circulation of blood, landmark events, resulting from astute observations, experimentation, and ingenious technological advances, are summarized or outlined chronologically over the past 4 centuries, with emphasis on the many recent accomplishments of basic and clinical scientists during the past 6 decades. Brief descriptions of several seminal contributions to safe and effective IV access, management, and therapy acknowledge and recognize the historical highlights that have allowed a complex and potentially hazardous therapeutic modality to evolve into a commonly applied useful adjunct to our current inpatient and outpatient armamentarium. A comprehensive list of references documents the highlights of the development of vascular access for the student of history.

Purpose: To evaluate thrombolysis and/or thrombectomy and selective endovascular stent placement in treating acute deep vein thrombosis (DVT)., Methods: During a 5-year period, 28 patients were treated with catheter-directed thrombolytics and/or thrombectomy with endovascular stent placement. Seventy-two percent (n = 20) of patients had symptoms for less < or = 14 days; 14% (n = 4) had symptoms for > 14 days. Fourteen percent (n = 4) had recurrent symptoms; 43% (n = 12) had ileofemoral DVT, and 57% (n = 16) had common femoral, superficial femoral, and/or popliteal DVT; and 11% (n = 3) had thrombus extending into the inferior vena cava., Results: Eighteen percent (n = 5) of patients had complete thrombolysis of the thrombus; 72% (n = 20) had partial thrombolysis. Twenty-two stents were also placed in 12 patients. Average follow-up was 15.5 months; 80% had long-term patency., Conclusions: Catheter-directed thrombolysis and/or thrombectomy and selective stent placement are effective alternatives to systemic anticoagulation in the treatment of DVT. More studies are needed to determine specific indications and to validate long-term efficacy.

Background: Elderly patients are a rapidly expanding segment of the population. Recent studies suggest that octogenarians have mortality and morbidity after carotid endarterectomy (CEA) similar to that in their younger cohort. Outcomes of CEA performed in nonagenarians have not been commonly reported; this study seeks to determine the safety of CEA in nonagenarians in general practice., Study Design: All patients in nonfederal Connecticut hospitals undergoing CEA between 1990 and 2002 were identified using the state discharge database (Chime Inc; )., Results: A total of 14,679 procedures were performed during the 12 study years. Sixty-four patients were nonagenarians (0.4%). Perioperative mortality was higher among nonagenarians (3.1%) compared with younger patients, including the 2,379 octogenarians (0.6%; p = 0.008, chi-square; odds ratio = 9.1, p = 0.006). No statistically significant difference was noted in perioperative stroke rates between nonagenarians (3.1%) and octogenarians (1.2%; p = 0.35, chi-square; odds ratio 2.3, p = 0.28). Nonagenarians had longer hospital lengths of stay (7.3 days, p < 0.0001), intensive care unit lengths of stay (1.2 days, p = 0.0013), and greater hospital charges ($17,967 +/- $1,907, p < 0.0001) than younger patients. Nonagenarians underwent operative procedures more frequently in an emergent setting (22%) compared with octogenarians (11%, p < 0.001) and had a greater percentage of symptomatic presentations (stroke: 14% versus 11%, p = 0.04; transient ischemic attack: 8% versus 5%, p = 0.04, respectively). All perioperative deaths and strokes occurred in symptomatic nonagenarians (15% versus 0%, p = 0.038; 15% versus 0%, p = 0.038; respectively)., Conclusions: Carotid endarterectomy is performed in nonagenarians, as a group, with greater rates of perioperative mortality and morbidity than in younger patients, including octogenarians. But nonagenarians have a greater rate of symptomatic and emergent presentations than younger patients, which may account for their increased mortality, morbidity, length of stay, and incurred charges. Asymptomatic nonagenarians have similar outcomes after carotid endarterectomy compared with younger patients, including octogenarians, with low rates of mortality and morbidity.