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Objective: In digital nerve defects that require grafting, autografts remain the efficacious option. The sensory posterior interosseous nerve (PIN) is an ideal choice as it is of similar caliber to digital nerves and leaves no donor morbidity upon resection. However, a finite length of harvestable PIN exists, and considerable variations of this length have been reported in the literature. There exists no predictive model to estimate this length. We sought to determine a method to accurately predict the available length of PIN based on individual patient anthropometry.Methods: A cadaveric dissection study was performed in a fresh tissue laboratory. The length of the sensory branch of the PIN and various anthropometric measurements were made in respect to surface anatomy of the ulna to develop a predictable ratio for available PIN donor graft.Results: A total of 16 specimens were obtained. On average the length of the PIN was 5.7 cm (range: 3.3-9. cm) and the length of the ulna was 25.7 cm (range: 23.5-30.6 cm). The ratio of PIN to ulnar length was 0.222 (r= 0.4651). Using one-fifth the length of the ulna, the mean predicted length of the PIN was 5.14 cm (range: 4.7-6.1 cm). On univariate analysis, there was no significant difference between the measured and predicted PIN length (P= .249).Conclusion: An anthropometric ratio predicated on reproducible surface anatomy of the ulna is a useful tool in predicting the sensory PIN length. Such a prediction may be a useful in guiding patient discussions concerning surgical options for digital nerve reconstruction.

Surgical skills training is a recognized vital component of medical education, yet a standardized curriculum does not exist. Early opportunities for skills development and mentorship may increase student interest in pursuing surgery. We evaluated the effects of a student-led, faculty-supervised suture clinic on student comfort level with basic surgical skills and interest in surgery.

Merkel cell carcinoma is a cutaneous neuroendocrine neoplasm that has been poorly studied in contemporary cohorts. Patients with Merkel cell carcinoma from 1986 to 2011 were identified in the Surveillance Epidemiology and End Results registry. A total of 5211 patients met the inclusion criteria. The mean age was 74.9 years; majority were male (61.4%) and white (94.9%). Patients were divided into two cohorts: Group 1 (1986 and 1999) and Group 2 (1999–2010). Group 2 was more likely to have Stage III disease (14.6 vs23.3%, P <0.001) and less likely to have Stage I/II disease (71.8 vs65.1%, P <0.0001). The increase in Stage III was likely secondary to increased use of sentinel lymph node biopsy. Disease-specific five-year survival for Stages I/II was 78.1 per cent and Stage III was 54 per cent. Disease-specific five-year survival was unchanged between Groups 1 and 2, 69.9 versus66.6 per cent, respectively (P= 0.44). Both incidence and mortality significantly increased over the study period with Pvalue for both trends <0.0001. In 1986, incidence and mortality rates per 100,000 were 0.22 and 0.03, respectively, and increased to 0.79 and 0.43 in 2011, respectively. There has been a greater than 333 per cent increase in mortality from Merkel cell carcinoma.

Duodenal neuroendocrine tumors are rare but increasing in incidence and optimal management is hindered by lack of duodenum-specific staging. Duodenal carcinoids were identified in the Surveillance, Epidemiology and End Results tumor registry. Depth of invasion was defined as limited to lamina propria (LP), invading muscularis propria (MP), through muscularis propria (TMP), and through serosa (S). Nine hundred forty-nine patients were identified with majorities being male (57%), white (70%), and node-negative (87%). Tumor size (cm) was less than 1, 47 per cent; 1 to 2, 35 per cent; and greater than 2, 8 per cent with 76 per cent LP. Lymph node (LN) involvement was associated with age, depth of invasion (LP 4%, MP 28%, TMP 54%, and S 57%) and size (less than 1 cm, 3%; 1 to 2 cm, 13%; and greater than 2 cm, 40%). Using the current T staging, LN involvement was: T1 (LP) 2 per cent, T2 (MP or greater than 1 cm) 13 per cent, T3 (TMP) 54 per cent, and T4 (S) 57 per cent. We reclassified current T1 to T1a and current T2 stage to T1b (1 to 2 cm and LP) and T2 (MP or greater than 2 cm). LN metastasis for T1b tumors was 4.7 per cent compared with 20.8 per cent for T2. The resulting TNM classification better defines 5-year disease-specific survival. Our modified staging schema identifies a low-risk group (T1a and T1b) that may be considered for local therapy.

Mortality from breast cancer in eastern North Carolina (ENC) surpasses the rest of North Carolina (RNC). We sought to identify modifiable factors associated with the increased mortality of women diagnosed with breast cancer in ENC. A retrospective cohort study of women diagnosed with breast cancer in North Carolina between January 1, 2004, and December 31, 2007 (n = 27,631) was studied. There was no difference in the pathologic T (P= 0.62), N (P= 0.26), or stage grouping (P= 0.25) at diagnosis. Women in ENC were less likely to be white (P< 0.001), estrogen receptor (ER)-positive (P< 0.001), progesterone receptor (PR)-positive (P< 0.001), or to receive adjuvant chemotherapy (P= 0.02). The median survival of ENC patients was worse than RNC patients (39 vs. 43 months, P= 0.003). Improved median survival was associated with ER status (P< 0.001), PR status (P< 0.001), race/ethnicity (P< 0.001), and delivery of timely chemotherapy (P< 0.0001). ER-negative status (P= 0.01), black race (P= 0.03), and adjuvant chemotherapy within 90 days of surgery (P< 0.001) remained significant predictors of survival. The poor outcomes observed in ENC can be attributed to recognized prognostic primary patient and tumor characteristics. However, a failure in process of care remains significantly associated with poorer outcomes. Improved timing of delivery of chemotherapy could affect breast cancer mortality.

Patients undergoing pancreatic resection are at risk for developing postoperative exocrine dysfunction. We sought to determine the incidence of and clinical factors associated with exocrine dysfunction after pancreatectomy. A retrospective review of a prospective database composed of patients undergoing pancreatic resection between 2004 and 2013 was performed. Logistic regression was used to identify preoperative factors that influenced postoperative exocrine insufficiency. One hundred sixty-one patients with complete follow-up were identified. The mean age was 64.1 ± 12.65 years. The majority were: female (51%), white (66%), tobacco users (61%), nondrinkers (68%), nondiabetic (71%), and without preoperative exocrine dysfunction (96%). Average body mass index was 27.8 ± 6.32 kg/m2. Most underwent a pancreaticoduodenectomy (67.3%) for pancreatic cancer (59.6%). Pancreatic fistula occurred in 6.8 per cent. Seven patients were on enzyme replacement therapy preoperatively. Forty-four patients (27%) had postoperative exocrine dysfunction (five of whom were on enzyme replacement therapy preoperatively). Two of seven (29%) of patients with preoperative exocrine dysfunction had complete resolution of their exocrine dysfunction. On univariate analysis, only the type of operation (Whipple) was significantly associated with exocrine dysfunction (P= 0.04). On multivariate analysis, both female gender and type of operation were independently associated with postoperative exocrine dysfunction (P= 0.05). Pancreatic exocrine dysfunction occurred less frequently in this population than what is commonly reported in the literature. Female patients undergoing resection of the pancreatic head have significantly increased risk of exocrine dysfunction.

Outcomes are superior for pancreatic resection at high-volume centers. To assess the impact of focused high-volume multidisciplinary care, a quality index (QI) was used to review our experience. Data from 1996 to July 2012 were analyzed in three groups: 1) early (1996 to 2007); 2) transition (2008 to 2009); and 3) mature (2010 to July 2012). A total of 239 patients were included with a mean age of 63.4 years and the majority were white (65.7%). The number of patients with Charlson comorbidity index greater than 2 and age older than 80 years increased comparing Group 1 with latter groups. Volume increased over time: Group 1 (n = 93) 7.75/year, Group 2 (n = 51) 25.5/year, and Group 3 (n = 95) 39/year. Overall mortality was 5.9 per cent: Group 1, 4.3 per cent; Group 2, 11.5 per cent; and Group 3, 3.9 per cent (P= 0.0454). The QI score incorporates documentation, chemotherapy, resection for Stage I/II, time to treatment, margins, lymph nodes, mortality, and surgical volume with a maximum possible score 10. The QI increased over time: 3 in Group 1; 4 in Group 2; and 6 in Group 3. An improvement was noted for the quality indicators: surgical resection (P= 0.0125) and use of palliative and adjuvant therapy (P= 0.0144 and < 0.0001). Implementation of a focused multidisciplinary pancreatic surgery program increases quality.

Understanding basic surgical skills is important for medical students prior to entering residency regardless of future specialty. In these videos we provide instruction for suturing as it relates to skin closure.