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Background Optimal management of patients with intrahepatic cholangiocarcinoma (ICCA) and elevated CA19-9 remains undefined. We hypothesized CA19-9 elevation above normal indicates aggressive biology and that inclusion of CA19-9 would improve staging discrimination. Methods The National Cancer Data Base (NCDB-2010-2012) was reviewed for patients with ICCA and reported CA19-9. Patients were stratified by CA19-9 above/below normal reference range. Unadjusted Kaplan–Meier and adjusted Cox-proportional-hazards analysis of overall survival (OS) were performed. Results A total of 2,816 patients were included: 938 (33.3%) normal; 1,878 (66.7%) elevated CA19-9 levels. Demographic/pathologic and chemotherapy/radiation were similar between groups, but patients with elevated CA19-9 had more nodal metastases and less likely to undergo resection. Among elevated-CA19-9 patients, stage-specific survival was decreased in all stages. Resected patients with CA19-9 elevation had similar peri-operative outcomes but decreased long-term survival. In adjusted analysis, CA19-9 elevation independently predicted increased mortality with impact similar to node-positivity, positive-margin resection, and non-receipt of chemotherapy. Proposed staging system including CA19-9 improved survival discrimination over AJCC 7th edition. Conclusion Elevated CA19-9 is an independent risk factor for mortality in ICCA similar in impact to nodal metastases and positive resection margins. Inclusion of CA19-9 in a proposed staging system increases discrimination. Multi-disciplinary therapy should be considered in patients with ICCA and CA19-9 elevation. J. Surg. Oncol. 2016;114:475–482. © 2016 Wiley Periodicals, Inc.

Summary Objective Islet autotransplantation (IAT) may decrease the morbidity and mortality of postpancreatectomy diabetes mellitus. The current systematic review and meta-analysis examined the rate of insulin independence (II) and mortality after IAT post-total (TP) or partial pancreatectomy (PP). Methods Ovid MEDLINE, EMBASE, Web of Science, SCOPUS and reference lists were searched until 31 January 2011. Eligible studies enrolled adult patients with IAT post-TP or PP, regardless of study design, sample size and language. Two investigators identified eligible studies and extracted data independently. From each study, 95% confidence intervals (CIs) were estimated and pooled using random effects meta-analysis. Results Fifteen observational studies were eligible (11 IAT post-TP, two post-PP and two including both). The II rates for IAT post-TP at last follow-up and transiently during the study were 4·62 per 100 person-years (95% CI: 1·53–7·72) and 8·34 per 100 person-years (95% CI: 3·32–13·37), respectively. In the later group, patients achieved transient II lasting 15·57 months (95% CI: 10·35–20·79). The II rate at last follow-up for IAT post-PP was 24·28 per 100 person-years (95% CI: 0·00–48·96). Whereas the 30-day mortality for IAT post-TP and post-PP was 5% (95% CI: 2–10%) and 0, respectively, the long-term mortality was 1·38 per 100 person-years (95% CI: 0·66–2·11) and 0·70 per 100 person-years (95% CI: 0·00–1·80) respectively. Conclusions IAT postpancreatectomy offers some patients a chance for insulin independence. Better data reporting are essential to establish the risks and benefits of IAT after pancreatic surgery.

Summary Introduction Total pancreatectomy (TP) has been associated with substantial metabolic abnormalities and poor glycaemic con- trol limiting its use. Because data reported to date are limited, we evaluated outcomes related to the diabetes mellitus obligated by TP. Methods A case series study of all patients who underwent TP from 01/01/1985 to 12/31/2006 at Mayo Clinic was conducted. TP cases were summarized according to perioperative procedures, mortality and morbidity after TP. To complement this retrospec- tive examination, a survey was developed to measure DM treat- ment modality, target organ failure and complications in patients alive in 2007. We performed a meta-analysis to compare our results with similar previous studies and provide overall estimates of out- comes. Results A total of 141 cases were studied (97 malignant diseases, 44 benign diseases). The median survival was much less for malig- nant pathology (2AE2 vs 8AE7 years, Log rank P =0 AE0009). In 2007, there were 59 patients that were presumed alive and 47 (80%) responded to the survey. Mean HbA1c at last follow-up was 7AE5% with 89% of respondents on a complex insulin programme (mean daily insulin requirement 35 ± 13 units). Episodic hypoglycaemia was experienced by 37 (79%); 15 (41%) experienced severe hypo- glycaemia. In contrast, diabetic ketoacidosis developed in only 2 (4%). Target organ complications and chronic diarrhoea devel- oped in 13 patients (28%) each. Conclusion The primary factor determining survival after TP is the aetiology necessitating TP, i.e. pancreatic malignancy. Most respondents used complex insulin programmes, but hypoglyca- emia continues to be a problem.

Background and Objectives Postoperative wound seromas are a frequent and troublesome occurrence after mastectomy. Recent reports have suggested the efficacy of topical sclerosants at reducing their formation. Methods A prospective, randomized, double-blinded trial was performed to examine the effect of intraoperatively administered topical tetracycline on the occurrence of postoperative mastectomy seromas. Thirty-two women were randomized to the control arm (normal saline) and 30 women to the tetracycline arm. In the treatment group, 100 ml (2 g) of tetracycline solution was administered topically to the chest wall and skin flaps prior to skin closure. The control group received an equal volume of normal saline. Patients were monitored for the development of postoperative wound seroma. Results There were no significant differences between groups regarding total volume of closed suction drainage, numbers of patients leaving hospital with drains in place, or duration of catheter drainage. Seroma formation 2 weeks postoperatively was greater in the tetracycline group than the control group (53% vs. 22%, P = 0.01). There were no differences between groups regarding the degree of postoperative pain, wound infection, or seroma formation 1 month postoperatively. Conclusions Topical tetracycline is not effective at preventing post-mastectomy wound seromas. J. Surg. Oncol. 2000;73:224–227. © 2000 Wiley-Liss, Inc.

Subtotal gastric resection usually provides the best palliation in advanced gastric cancer; however, if total gastrectomy (TG) is required there is doubt about its benefit. The authors reviewed 53 consecutive patients undergoing TG for advanced gastric adenocarcinoma between 1980 and 1989. Indications for TG were tumor location in 30% and extent of tumor in 70%, including nine patients (17%) with linitis plastica. Four patients (8%) died postoperatively, and six patients required reoperation for postoperative complications. The median postoperative hospital stay was 13 days. The median survival was 19 months, and 13 patients (24%) lived for more than 2 years. The quality of life was graded in survivors as good in 59%, satisfactory in 28%, and poor in 13% of patients. It was concluded that TG is a worthwhile procedure for selected patients, even in the presence of advanced disease, providing prolongation of good quality of life with low morbidity and mortality.