Search

Background: The effect of obliquity of tendon laceration on repair strength is not well studied. The overwhelming majority of biomechanical studies assess repair strength following a laceration that is perpendicular to the long axis of the tendon. The aim of this study was to investigate whether the angle of tendon laceration affects the core suture strength. Methods: In all, 110 fresh human cadaveric flexor tendons were cut at varying angles of 15°, 30°, 45°, and 60° and the control group at 90°. All tendons were repaired with 6-strand modified Tang technique. The repair strength was tested using a custom-made tensioning machine, and the initial static gap force and the ultimate breaking force were measured. Results: The mean gap force and 95% confidence interval (CI) for the 15°, 30°, 45°, 60°, and 90° groups were 15.2 N (11.4-19.0 N), 15.8 N (13.6-18.1 N), 15.6 N (13.1-18.4 N), 16.6 N (13.7-19.5 N), and 22.3 N (16.6-27.9 N), respectively. In the same respective order, the break force and 95% CI were 25.9 N (21.9-29.8 N), 26.5 N (23.2-29.7 N), 31.1 N (26.1-36.1 N), 35.6 N (28.2-43.1 N), and 51.8 N (62.5-41.0), respectively. The Fisher least significant difference demonstrated significant differences between the control group and all experimental groups for both gap force and break force. Conclusions: Obliquity of tendon laceration affects the core suture strength when compared with a transverse cut. Flexor tendons cut at 90° demonstrated a higher overall gap force and breaking strength that were statistically significant when compared with all obliquely cut groups. These findings should be considered when repairing and starting postoperative therapy for obliquely cut tendons. [ABSTRACT FROM AUTHOR]

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 Tla and current T2 stage to Tib (1 to 2 cm and LP) and T2 (MP or greater than 2 cm). LN metastasis for Tib 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 (Tla and Tib) that may be considered for local therapy. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Elephantiasis nostras verrucosa (ENV) is a rare dermatologic condition caused by chronic nonfilarial lymphedema. The treatment for ENV is challenging and based solely on case reports. We report novel therapy for ENV with maggot debridement therapy (MDT), an effective wound therapy that has gained popularity with the rise of antimicrobial resistance. MDT, in combination with tangential surgical debridement, was effective in the treatment of ENV. In nature, sheep infested with more than 16 000 blow fly larvae exhibit ammonia toxicity. Although hyperammonemia as a side effect of maggot therapy has been theorized, its existence has not been described in human studies until this case. This patient exhibited hyperammonemia during maggot therapy; with alterations in serum ammonia reflecting changes in larval population. Maggot therapy should be considered for the treatment of ENV. Hyperammonemia with maggot therapy exists, and clinicians who employ this treatment should be aware of this potential adverse effect. [ABSTRACT FROM AUTHOR]

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 vs 23.3%, P < 0.001) and less likely to have Stage I/II disease (71.8 vs 65.1%, 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 versus 66.6 per cent, respectively (P = 0.44). Both incidence and mortality significantly increased over the study period with P value 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. [ABSTRACT FROM AUTHOR]

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 I 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. [ABSTRACT FROM AUTHOR]