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BackgroundCurrent treatment guidelines recommend adjuvant mitotane after resection of adrenocortical carcinoma with high-risk features (eg, tumor rupture, positive margins, positive lymph nodes, high grade, elevated mitotic index, and advanced stage). Limited data exist on the outcomes associated with these practice guidelines.Study designPatients who underwent resection of adrenocortical carcinoma from 1993 to 2014 at the 13 academic institutions of the US Adrenocortical Carcinoma Group were included. Factors associated with mitotane administration were determined. Primary end points were recurrence-free survival (RFS) and overall survival (OS).ResultsOf 207 patients, 88 (43%) received adjuvant mitotane. Receipt of mitotane was associated with hormonal secretion (58% vs 32%; p= 0.001), advanced TNM stage (stage IV: 42% vs 23%; p= 0.021), adjuvant chemotherapy (37% vs 5%; p < 0.001), and adjuvant radiation (17% vs 5%; p= 0.01), but was not associated with tumor rupture, margin status, or N-stage. Median follow-up was 44 months. Adjuvant mitotane was associated with decreased RFS (10.0 vs 27.9 months; p= 0.007) and OS (31.7 vs 58.9 months; p= 0.006). On multivariable analysis, mitotane was not independently associated with RFS or OS, and margin status, advanced TNM stage, and receipt of chemotherapy were associated with survival. After excluding all patients who received chemotherapy, adjuvant mitotane remained associated with decreased RFS and similar OS; multivariable analyses again showed no association with recurrence or survival. Stage-specific analyses in both cohorts revealed no association between adjuvant mitotane and improved RFS or OS.ConclusionsWhen accounting for stage and adverse tumor and treatment-related factors, adjuvant mitotane after resection of adrenocortical carcinoma is not associated with improved RFS or OS. Current guidelines should be revisited and prospective trials are needed.

ImportanceAdrenocortical carcinoma (ACC) is a rare but aggressive endocrine tumor, and the prognostic factors associated with long-term outcomes after surgical resection remain poorly defined.ObjectivesTo define clinicopathological variables associated with recurrence-free survival (RFS) and overall survival (OS) after curative surgical resection of ACC and to propose nomograms for individual risk prediction.Design, setting, and participantsNomograms to predict RFS and OS after surgical resection of ACC were proposed using a multi-institutional cohort of patients who underwent curative-intent surgery for ACC at 13 major institutions in the United States between March 17, 1994, and December 22, 2014. The dates of our study analysis were April 15, 2015, to May 12, 2015.Main outcomes and measuresThe discriminative ability and calibration of the nomograms to predict RFS and OS were tested using C statistics, calibration plots, and Kaplan-Meier curves.ResultsIn total, 148 patients who underwent surgery for ACC were included in the study. The median patient age was 53 years, and 65.5% (97 of 148) of the patients were female. One-third of the patients (35.1% [52 of 148]) had a functional tumor, and the median tumor size was 11.2 cm. Most patients (77.7% [115 of 148]) underwent R0 resection, and 8.8% (13 of 148) of the patients had N1 disease. Using backward stepwise selection of clinically important variables with the Akaike information criterion, the following variables were incorporated in the prediction of RFS: tumor size of at least 12 cm (hazard ratio [HR], 3.00; 95% CI, 1.63-5.70; P

Several groups have defined pancreatic surgery quality metrics that identify centers delivering quality care. Although these metrics are perceived to be associated with good outcomes, their relationship with actual outcomes has not been established.A national cadre of pancreatic surgeons was surveyed regarding perceived quality metrics, which were evaluated against the Central Pancreas Consortium (CPC) database to determine actual performance and relationships with long-term outcomes.The most important metrics were perceived to be participation in clinical trials, appropriate clinical staging, perioperative mortality, and documentation of receipt of adjuvant therapy. Subsequent analysis of 1399 patients in the CPC dataset demonstrated that a R0 retroperitoneal and neck margin was obtained in 79% (n = 1109) and 91.4% (n = 1278) of cases, respectively. 74% of patients (n = 1041) had10 lymph nodes harvested, and LN positivity was 65% (n = 903). 76% (n = 960) of eligible patients (surgery first approach) received adjuvant therapy within 60 days of surgery. Multivariate analysis demonstrated margin status, identification of10 lymph nodes, nodal status, tumor grade and delivery of adjuvant therapy within 60 days to be associated with improved overall survival.These analyses demonstrate that systematic monitoring of surgeons' perceived quality metrics provides critical prognostic information, which is associated with patient survival.

© 2015 Société Internationale de Chirurgie Background: The association of postoperative complications with long-term oncologic outcomes remains unclear. We sought to determine the incidence of complications among patients who underwent surgery for adrenocortical carcinoma (ACC) and define the relationship of morbidity with long-term survival. Methods: Patients who underwent surgery for ACC between 1993 and 2014 were identified from 13 academic institutions participating in the US ACC group study. The incidence and type of the postoperative complications, the factors associated with them as well their association with long-term survival were analyzed. Results: A total of 265 patients with median age of 52 years (IQR 44–63) were identified; at surgery, the majority of patients underwent an open abdominal procedure (n = 169, 66.8 %). A postoperative complication occurred in 99 patients for a morbidity of 37.4 %; five patients (1.9 %) died in hospital. Factors associated with morbidity included a thoraco-abdominal operative approach (reference: open abdominal; OR 2.85, 95 % CI 1.00–8.18), and a hormonally functional tumor (OR 3.56, 95 % CI 1.65–7.69) (all P < 0.05). Presence of any complication was associated with a worse long-term outcome (median survival: no complication, 58.9 months vs. any complication, 25.1 months; P = 0.009). In multivariate analysis, after adjusting for patient- and disease-related factors postoperative infectious complications independently predicted shorter overall survival (hazard ratio (HR) 5.56, 95 % CI 2.24–13.80; P < 0.001). Conclusion: Postoperative complications were independently associated with decreased long-term survival after resection for ACC. The prevention of complications may be important from an oncologic perspective.

Background: The influence of surgical margin status on long-term outcomes of patients undergoing adrenal resection for ACC remains not well defined. We studied the impact of surgical tumor margin status on recurrence-free survival (RFS) and overall survival (OS) of patients undergoing resection for ACC. Methods: A total of 165 patients who underwent adrenal resection for ACC and met inclusion criteria were identified form a multi-institutional database. Clinicopathological data, pathologic margin status, and long-term outcomes were assessed. Patients were stratified into two groups based on margin status: R0 (margin >1mm) versus R1. Results: R0 resection was achieved in 126 patients (76.4%), whereas 39 patients (23.6%) had an R1 resection. Median and 5-year OS for patients undergoing R0 resection were 96.3months and 64.8% versus 25.1months and 33.8% for patients undergoing an R1 resection (both p&nbsp

BACKGROUND: The role of routine lymphadenectomy for perihilar cholangiocarcinoma is still controversial and no study has defined the minimum number of lymph nodes examined (TNLE). We sought to assess the prognostic performance of American Joint Committee on Cancer/Union Internationale Contre le Cancer (7th edition) N stage, lymph node ratio, and log odds (LODDS; logarithm of the ratio between metastatic and nonmetastatic nodes) in patients with perihilar cholangiocarcinoma and identify the optimal TNLE to accurately stage patients. METHODS: A multi-institutional database was queried to identify 437 patients who underwent hepatectomy for perihilar cholangiocarcinoma between 1995 and 2014. The prognostic abilities of the lymph node staging systems were assessed using the Harrell's c-index. A Bayesian model was developed to identify the minimum TNLE. RESULTS: One hundred and fifty-eight (36.2%) patients had lymph node metastasis. Median TNLE was 3 (interquartile range, 1 to 7). The LODDS had a slightly better prognostic performance than lymph node ratio and American Joint Committee on Cancer, in particular among patients with 2, the hazard ratio for N1 patients was statistically significant and the hazard ratio for N1 patients increased from 1.51 with 4 TNLE to 2.10 with 10 TNLE. Although the 5-year overall survival of N1 patients was only slightly affected by TNLE, the 5-year overall survival of N0 patients increased significantly with TNLE. CONCLUSIONS: Perihilar cholangiocarcinoma patients undergoing radical resection should ideally have at least 4 lymph nodes harvested to be accurately staged. In addition, although LODDS performed better at determining prognosis among patients with = 4 TNLE. (C) 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

© 2015 Society of Surgical Oncology Background: Adrenocortical carcinoma (ACC) is a rare malignancy. The aim of this study was to determine the incidence and patterns of recurrence after curative-intent surgery for ACC. Methods: Patients who underwent curative-intent resection for ACC between 1993 and 2014 were identified from 13 academic institutions participating in the United States ACC study group. Patients with metastasis or an R2 margin were excluded. Patterns and rates of recurrence were determined and classified as locoregional and distant recurrence. Results: A total of 180 patients with a median age of 52 years (interquartile range 43–61) were identified. Most patients underwent open surgery (n = 111, 64.5 %) and had an R0 resection margin (n = 117, 75.0 %). At last follow-up, 116 patients (64.4 %) had experienced recurrence (locoregional only, n = 41, 36.3 %; distant only, n = 51, 45.1 %; locoregional and distant, n = 21, 18.6 %). Median time to recurrence was 18.8 months. Several factors were associated with locoregional recurrence, including left-sided ACC location (odds ratio [OR] 2.71, 95 % confidence interval [CI] 1.06–6.89) and T3/T4 disease (reference T1/T2, OR 3.04, 95 % CI 1.19–7.80) (both p < 0.05). Distant recurrence was associated with larger tumor size (OR 1.11, 95 % CI 1.01–1.24) and T3/T4 disease (reference T1/T2, OR 5.23, 95 % CI 1.70–16.10) (both p < 0.05). Patients with combined locoregional and distant recurrence had worse survival (3- and 5-year survival: 39.5, 19.7 %) versus patients with distant-only (3- and 5-year survival 55.1, 43.3 %) or locoregional-only recurrence (3- and 5-year survival 81.4, 64.1 %) (p = 0.01). Conclusions: Nearly two-thirds of patients experienced disease recurrence after resection of ACC. Although a subset of patients experienced recurrence with locoregional disease only, many patients experienced recurrence with distant disease as a component of recurrence and had a poor prognosis.

Postoperative complications (POCs) can negatively impact survival after oncologic resection. POCs may also decrease the rate of adjuvant therapy completion. We evaluated the impact of complications on gastric cancer survival and analyzed the combined effect of complications and adjuvant therapy on survival. We analyzed 824 patients from 7 institutions of the U.S. Gastric Cancer Collaborative who underwent curative resection for gastric adenocarcinoma between 2000 and 2012. POC were graded using the modified Clavien–Dindo system. Survival probabilities were estimated using the method of Kaplan and Meier and analyzed using multivariate Cox regression. Median follow-up was 35 months. The overall complication rate was 41 %. The 5-year overall survival (OS) and recurrence-free survival (RFS) of patients who experienced complications were 27 and 23 %, respectively, compared with 43 and 40 % in patients who did not have complications (p

Although the extent of resection frequently dictates the method of reconstruction following distal subtotal gastrectomy, it is unclear whether Roux-en-Y gastrojejunostomy compared with Billroth II gastrojejunostomy is associated with superior perioperative outcomes. Patients who underwent resection for gastric cancer with Roux-en-Y or Billroth II reconstruction between 2000 and 2012 in seven academic institutions (US Gastric Cancer Collaborative) were identified. Patients who underwent total gastrectomy, gastric wedge, or palliative resections (metastatic disease or R2 resections) were excluded. Of a total of 965 patients, 447 met the inclusion criteria. A comparison between the Roux-en-Y (n = 257) and Billroth II (n = 190) groups demonstrated no differences in patient and tumor characteristics, except for Billroth II patients having a higher proportion of antral tumors (71 % vs. 50 %, p

Pancreaticoduodenectomy is the treatment of choice of pancreas head lesions, and can be performed as a pylorus-sparing or standard (pylorus resecting) operation. This complex operation is fraught with a high rate of complications, and mortality increases in lower-volume hospitals and is best performed by an experienced team.

ObjectivesCriteria for the selection of patients for adjuvant chemotherapy in intrahepatic cholangiocarcinoma (IHCC) are lacking. Some authors advocate treating patients with lymph node (LN) involvement; however, nodal assessment is often inadequate or not performed. This study aimed to identify surrogate criteria based on characteristics of the primary tumour.MethodsA total of 58 patients who underwent resection for IHCC between January 2000 and January 2010 at any of three institutions were identified. Primary outcome was overall survival (OS).ResultsMedian OS was 23.0months. Median tumour size was 6.5cm and the median number of lesions was one. Overall, 16% of patients had positive margins, 38% had perineural invasion (PNI), 40% had lymphovascular invasion (LVI) and 22% had LN involvement. A median of two LNs were removed and a median of zero were positive. Lymph nodes were not sampled in 34% of patients. Lymphovascular and perineural invasion were associated with reduced OS [9.6months vs. 32.7months (P= 0.020) and 10.7months vs. 32.7months (P= 0.008), respectively]. Lymph node involvement indicated a trend towards reduced OS (10.7months vs. 30.0months; P= 0.063). The presence of either LVI or PNI in node-negative patients was associated with a reduction in OS similar to that in node-positive patients (12.1months vs. 10.7months; P= 0.541). After accounting for adverse tumour factors, only LVI and PNI remained associated with decreased OS on multivariate analysis (hazard ratio4.07, 95% confidence interval 1.60–10.40; P= 0.003).ConclusionsLymphovascular and perineural invasion are separately associated with a reduction in OS similar to that in patients with LN-positive disease. As nodal dissection is often not performed and the number of nodes retrieved is frequently inadequate, these tumour-specific factors should be considered as criteria for selection for adjuvant chemotherapy.

As compared with open distal pancreatectomy, laparoscopic distal pancreatectomy (LDP) is associated with lower morbidity and shorter hospital stays. Existing reports do not elucidate trends in patient selection, technique, and outcomes over time. We aimed to determine outcomes after LDP at a specialized center, analyze trends of patient selection and operative technique, and validate a complication risk score (CRS).Patients undergoing LDP between January 2000 and January 2011 were identified and divided into 2 equal groups to represent our early and recent experiences. Demographics, tumor characteristics, operative technique, and perioperative outcomes were examined and compared between groups. A CRS was calculated for the entire cohort and examined against observed outcomes.A total of 132 LDPs were attempted, of which 8 (6.1%) were converted to open procedures. Thirty-day overall and major complication rates were 43.2% and 12.9%, respectively, with mortality1%. Pancreatic fistulas occurred in 28 (21%) patients, of which 14 (11%) were clinically significant. Recent LDPs (n = 66) included patients with increasingly severe comorbidities (Charlson scores2, 40.9% vs 16.7%, p = 0.003), more proximal tumors (74.2% vs 26.2%, p0.001), more extended resections (10.6 vs 8.3 cm, p0.001), shorter operative times (141 vs 172 minutes, p = 0.007), and less frequent use of a hand port (25.8% vs 66.6%, p0.001). No significant differences were found in perioperative outcomes between the groups. As compared with the hand access technique, the total laparoscopic approach was associated with shorter hospital stays (5.3 vs 6.8 days, p = 0.032). Increasing CRS was associated with longer operative time, significant fistulas, wound infections, blood transfusions, major complications, ICU readmissions, and rehospitalizations.This large, single-institution series demonstrates that despite a shift in patient selection to sicker patients with more proximal tumors, similar perioperative outcomes can be achieved with laparoscopic distal pancreatectomy. The CRS appears to be a reliable preoperative assessment tool for assessing other adverse perioperative outcomes in addition to predicting overall complications and fistulas as originally published.

hpb_432 228..235 Background: The effect of diabetes on survival after resection pancreatic ductal carcinoma (PDAC) is unclear. The present study was undertaken to determine whether pre-operative diabetes has any predictive value for survival. Methods: A retrospective review from seven centres was performed. Metabolic factors, tumour char- acteristics and outcomes of patients undergoing resection for PDAC were collected. Univariate and multivariable analyses were performed to determine factors associated with disease-free (DFS) and overall survival (OS). Results: Of the 509 patients in the present study, 31.2% had diabetes. Scoring systems were devised to predict OS and DFS based on a training set (n = 245) and were subsequently tested on an independent set (n = 264). Pre-operative diabetes (P 2c m (P = 0.001), metastatic nodal ratio >0.1 (P < 0.001) and R1 margin (P < 0.001) all correlated with DFS and OS on univariate analysis. Scoring systems were devised based on multivariable analysis of the above factors. Diabetes and the metastatic nodal ratio were the most important factors in each system, earning two points for OS and four points for DFS. These scoring systems significantly correlated with both DFS (P < 0.001) and OS (P < 0.001). Conclusion: Pre-operative diabetes status provides useful information that can help to stratify patients in terms of predicted post-operative OS and DFS.

Background: CMS recently began penalizing hospitals for readmissions if they exceeded benchmark rates. While many strategies have been proposed to help minimize readmissions, none have evaluated surgical patients’ perspectives. Study design: All patients with unplanned readmissions within 30 days of discharge from a general surgery service over a three month period were interviewed. Patients admitted to a general surgery service from 2011 - 2012 as identified by the NSQIP database were used as a comparison. Results: A total of 50 patients were enrolled in the study. There were no differences between the study patients and NSQIP patients in terms of age or gender, but there was a significant difference in ASA class (p < 0.01). The majority of patients had a scheduled follow up appointment, however 66% were readmitted before they were able to attend and 6% were readmitted from their postoperative clinic visit. When asked about suggestions to improve discharge planning, 50% were satisfied with the process. Among the other half, 32% suggested improving discharge instructions, 28% advocated for better communication within the care team, 12% felt the discharge process was too long, 12% thought they were discharged too soon, and 8% suggested better communication with family. Conclusions: Understanding the perspectives of surgical patients allows providers to identify targets for quality improvement aimed at reducing readmissions. Using this concept, systems can be developed which target high-risk patients in need of early follow-up, with the ultimate goal of lowering postoperative readmission rates.

Copyright © 2016 Wolters Kluwer Health, Inc. Objective: To evaluate conditional disease-free survival (CDFS) for patients who underwent curative intent surgery for adrenocortical carcinoma (ACC). Background: ACC is a rare but aggressive tumor. Survival estimates are usually reported as survival from the time of surgery. CDFS estimates may be more clinically relevant by accounting for the changing likelihood of diseasefree survival (DFS) according to time elapsed after surgery. Methods: CDFS was assessed using a multi-institutional cohort of patients. Cox proportional hazards models were used to evaluate factors associated with DFS. Three-year CDFS (CDFS3) estimates at "x" year after surgery were calculated as follows: CDFS3=DFS(x+3)/DFS(x). Results: One hundred ninety-two patients were included in the study cohort; median patient age was 52 years. On presentation, 36% of patients had a functional tumor and median size was 11.5 cm. Most patients underwent R0 resection (75%) and 9% had N1 disease. Overall 1-, 3-, and 5-year DFS was 59%, 34%, and 22%, respectively. Using CDFS estimates, the probability of remaining disease free for an additional 3 years given that the patient had survived without disease at 1, 3, and 5 years, was 43%, 53%, and 70%, respectively. Patients with less favorable prognosis at baseline demonstrated the greatest increase in CDFS3 over time (eg, capsular invasion: 28%-88%, D60% vs no capsular invasion: 51%-87%, D36%). Conclusions: DFS estimates for patients with ACC improved dramatically over time, in particular among patients with initial worse prognoses. CDFS estimates may provide more clinically relevant information about the changing likelihood of DFS over time.

Use of adjuvant chemotherapy (CTx) and chemoradiation therapy (cXRT) for the treatment of gallbladder cancer (GBC) remains varied. We sought to define the utilization and effect of adjuvant therapy for patients with GBC.Using a multi-institutional national database, 291 patients with GBC who underwent curative-intent resection between 2000 and 2015 were included. Patients with metastasis or an R2 margin were excluded.Median patient age was 66.6 years. Most patients had a T2 (46.2 %) or T3 (38.6 %) lesion, and 37.8 % of patients had lymph node (LN) metastasis. A total of 186 (63.9 %) patients underwent surgery alone, 61 (21.0 %) received CTx, and 44 (15.1 %) patients received cXRT. On multivariable analysis, factors associated with worse overall survival (OS) included T3/T4 stage [hazard ratio (HR) 1.82], LN-metastasis (HR 1.84), lymphovascular invasion (HR 2.02), perineural invasion (HR 1.42), and R1 surgical margin status (HR 2.06); all P 0.05). In contrast, receipt of CTx/cXRT was associated with improved OS (CTx, HR 0.38; cXRT, HR 0.26; P 0.001) compared with surgery alone. Similar results were observed for disease-free survival (DFS) (CTx, HR 0.61; cXRT, HR 0.43; P 0.05). Of note, only patients with high-risk features, such as AJCC T3/T4 stage (HR 0.41), LN metastasis (HR 0.45), and R1 disease (HR 0.21) (all P 0.05) derived an OS benefit from CTx/cXRT.Adjuvant CTx/cXRT was utilized in 36 % of patients undergoing curative-intent resection for GBC. After adjusted analyses, CTx/cXRT were independently associated with improved long-term outcomes, but the benefit was isolated to only patients with high-risk characteristics.

Background Level 1 data demonstrate that adjuvant chemotherapy (ACT) improves survival after surgical resection of pancreatic ductal adenocarcinoma (PDAC), (adjuvant gemcitabine, CONKO-001 study; adjuvant 5-FU, ESPAC3 study). The role of adjuvant chemoradiation therapy (ACRT) remains controversial. What is less clear is whether adjuvant therapy influences patterns of recurrence. The purpose of this study was to perform the first multicenter study analyzing patterns of recurrence after adjuvant therapy for PDAC. Study Design Patients undergoing resection for PDAC from 8 medical centers over a 10-year period were analyzed. Demographics, tumor characteristics, operative treatment, type of adjuvant therapy, recurrence pattern, and survival were reviewed. Using Cox-proportional hazards multivariate (MV) regression, the impact of ACT and ACRT on overall survival (OS), local recurrence (LR), and distant recurrence (DR) was investigated. Results There were 1,130 patients who were divided into those having surgery alone (n = 392), ACT (n = 291), or ACRT (n = 447). Median follow-up was 18 months. Compared with patients undergoing surgery alone, ACT, but not ACRT, demonstrated a significant OS advantage on MV analysis. Patients receiving ACT had significantly fewer recurrences (LR and DR); those receiving ACRT had significantly less LR but not DR. On subset MV analysis, ACT and ACRT resulted in less LR in patients with lymph node (LN) positive and margin negative disease. No improvements in LR, DR, or OS were seen in margin positive patients with either ACT or ACRT. Conclusions This is the first analysis demonstrating differences in recurrence patterns in PDAC patients based on type of adjuvant therapy. Adjuvant chemotherapy provided an OS advantage likely related to its effect on reducing both LR and DR. Adjuvant chemoradiation therapy appears to decrease LR, but not DR, and therefore has less impact on OS. Future investigations and treatment protocols should consider additional ACT rather than ACRT in the treatment of PDAC.

To investigate the influence of type of surgery (transplant vs resection) on overall survival (OS) in patients with hilar cholangiocarcinoma (H-CCA).Outcomes after resection for H-CCA are poor, yet transplantation is currently only reserved for well-selected patients with unresectable disease.All patients with H-CCA who underwent resection from 2000 to 2015 at 10 institutions were included. Three institutions additionally had active H-CCA transplant protocols with similar selection criteria over similar time periods.Of 304 patients with suspected H-CCA, 234 underwent attempted resection and 70 were enrolled in a transplant protocol. Excluding incomplete/R2 resections (n = 43), patients who were enrolled, but did not undergo transplant (n = 24), and transplants without confirmed H-CCA diagnoses (n = 5), 191 patients underwent curative-intent resection and 41 curative-intent transplant. Compared with resection, transplant patients were younger (52 vs 65 years; P0.001), and more frequently had primary sclerosing cholangitis (PSC; 61% vs 2%; P0.001) and received chemotherapy and/or radiation (98% vs 57%; P0.001). Groups were otherwise similar in demographics and comorbidities. Patients who underwent transplant for confirmed H-CCA diagnosis had improved OS compared with resection (3-year: 72% vs 33%; 5-year: 64% vs 18%; P0.001). Among patients who underwent resection for tumors3 cm with lymph-node negative disease, and excluding PSC patients, transplant was still associated with improved OS (3-year: 54% vs 44%; 5-year: 54% vs 29%; P = 0.03). Transplant remained associated with improved survival on intention-to-treat analysis, even after accounting for tumor size, lymph node status, and PSC (P = 0.049).Resection for hilar cholangiocarcinoma that meets criteria for transplantation (3 cm, lymph-node negative disease) is associated with substantially decreased survival compared to transplant for the same criteria with unresectable disease. Prospective trials are needed and justified.

Background: Laparoscopic left pancreatectomy (LLP) is associated with favorable outcomes compared with open left pancreatectomy (OLP). However, it is unclear if the risk factors associated with operative morbidity differ between these two techniques. Guidelines for determining which patients should undergo OLP versus LLP do not exist. Methods: A multi-institutional analysis of OLP and LLP performed in 9 academic medical centers was undertaken. LLP cases were defined in an intent-to-treat manner. Perioperative variables were analyzed to identify factors associated with complications and pancreatic fistulae after OLP and LLP. In addition, complication and fistula rates for patients undergoing OLP and LLP were compared in matched cohorts to determine if one approach resulted in superior outcomes over the other. Results: Six hundred and ninety-three left pancreatectomy cases (439 OLP, 254 LLP) were analyzed. OLP and LLP cases were similar with respect to patient age and American Society of Anesthesiologists score. Body mass index (BMI) was higher in patients undergoing LLP. OLP was more often performed for adenocarcinoma and larger tumors, resulted in longer resected specimen lengths, and more commonly involved concomitant splenectomy. Estimated blood loss was higher and operative times were longer during OLP. On multivariate analysis, variables associated with major complications and clinically significant fistulae differed between OLP and LLP. Patients with body mass index ≤27, without adenocarcinoma, and with pancreatic specimen length ≤8.5 cm had significantly higher rates of significant fistulae after OLP than after LLP; in contrast, no preoperatively evaluable variables were associated with a higher likelihood of significant fistula after LLP versus OLP. Conclusions: Risk factors for complications and pancreatic fistulae after left pancreatectomy differ when open versus laparoscopic techniques are employed. Preoperative characteristics may identify cohorts of patients who will benefit more from LLP, and no patient cohorts had higher postoperative complication rates after LLP than OLP. These observations suggest that LLP may be the operative procedure of choice for most patients with left-sided pancreatic lesions; a more definitive prospective and randomized comparison may be warranted.

Background Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection. Study Design Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as 3 /μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality. Results A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p=0.031), PLI (30% versus 6%, p=0.001), and 60-day mortality (22% versus 6%, p=0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p=0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p=0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p=0.009). Conclusions LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.

Evaluation of risk factors for adverse outcomes following distal pancreatectomy (DP) has been limited to data collected from retrospective, primarily single-institution studies. Using a large, multi-institutional prospectively collected dataset, we sought to define the incidence of complications after DP, identify the preoperative and operative risk factors for the development of complications, and develop a risk score that can be utilized preoperatively. The American College of Surgeons National Surgical Quality Improvement Program participant use file was utilized to identify patients who underwent DP from 2005 to 2008 by Current Procedural Terminology codes. Multivariate logistic regression analysis was performed to identify variables associated with 30-day morbidity and mortality. A scoring system was developed to allow for preoperative risk stratification. In 2,322 patients who underwent DP, overall 30-day complication and mortality were 28.1% and 1.2%, respectively. Serious complication occurred in 22.2%, and the most common complications included sepsis (8.7%), surgical site infection (5.9%), and pneumonia (4.7%). On multivariate analysis, preoperative variables associated with morbidity included male gender, high BMI, smoking, steroid use, neurologic disease, preoperative SIRS/sepsis, hypoalbuminemia, elevated creatinine, and abnormal platelet count. Preoperative variables associated with 30-day mortality included esophageal varices, neurologic disease, dependent functional status, recent weight loss, elevated alkaline phosphatase, and elevated blood urea nitrogen. Operative variables associated with both morbidity and mortality included high intraoperative transfusion requirement (≥3 U) and prolonged operation time (>360 min). Weighted risk scores were created based on the preoperatively determined factors that predicted both morbidity (p

Colorectal carcinoma (CRC) is the third leading cause of cancer-related death in the United States. The liver is the most frequent site of metastasis and a key determinant of survival in patients with isolated colorectal liver metastasis (CRLM). Surgical resection remains the only hope for prolonged survival in patients with CRLM. However, most patients are deemed to be unresectable at presentation due to a small future liver remnant (FLR) and fear of post-hepatectomy liver failure. Procedures such as portal vein ligation or embolization (PVL/PVE) followed by hepatectomy have been established as standard methods to increase FLR volume, but have limitations dependent upon extent of disease and patient's ability to grow the liver remnant. Recently, associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) has been introduced as a technique to induce liver hypertrophy over a shorter time period. Being a complex two-stage surgical procedure, initial reports of higher ALPPS-associated complications and mortality limited its worldwide adoption by hepatobiliary surgeons. However, recent studies have showed ALPPS superiority over conventional procedures in terms of feasibility and inducing liver hypertrophy, with comparable morbidity and mortality. We herein review the role of ALPPS in management of patients with CRLM.

Background As compared with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) affords improved perioperative outcomes. The role of LDP for patients with pancreatic ductal adenocarcinoma (PDAC) is not defined. Study Design Records from patients undergoing distal pancreatectomy (DP) for PDAC from 2000 to 2008 from 9 academic medical centers were reviewed. Short-term (node harvest and margin status) and long-term (survival) cancer outcomes were assessed. A 3:1 matched analysis was performed for ODP and LDP cases using age, American Society of Anesthesiologists (ASA) class, and tumor size. Results There were 212 patients who underwent DP for PDAC; 23 (11%) of these were approached laparoscopically. For all 212 patients, 56 (26%) had positive margins. The mean number of nodes (± SD) examined was 12.6 ±8.4 and 114 patients (54%) had at least 1 positive node. Median overall survival was 16 months. In the matched analysis there were no significant differences in positive margin rates, number of nodes examined, number of patients with at least 1 positive node, or overall survival. Logistic regression for all 212 patients demonstrated that advanced age, larger tumors, positive margins, and node positive disease were independently associated with worse survival; however, method of resection (ODP vs. LDP) was not. Hospital stay was 2 days shorter in the matched comparison, which approached significance (LDP, 7.4 days vs. ODP, 9.4 days, p=0.06). Conclusions LDP provides similar short- and long-term oncologic outcomes as compared with OD, with potentially shorter hospital stay. These results suggest that LDP is an acceptable approach for resection of PDAC of the left pancreas in selected patients.

212 Background: Preoperative factors that reliably predict lymph node (LN) metastases in pancreatic neuroendocrine tumors (PanNETs) are unclear. The number of LNs needed to accurately stage PanNETs has not been defined. Methods: Patients who underwent curative-intent resection of primary non-functional PanNETs at 8 institutions from 2000-2016 were analyzed. Tumors with poor differentiation and Ki-67 > 20% were excluded. Preoperative factors associated with LN metastases were identified. A procedure specific target for LN retrieval to accurately stage patients was determined. Results: Of 2182 pts with GI NETs, 695 underwent resection of PanNETs. 33% of tumors were proximal (head/uncinate), and 67% were distal (neck/body/tail). 26% of pts (n = 158) had LN+ disease, which was associated with worse 5-yr recurrence-free survival (RFS) (60% vs 86%; p < 0.001). Increasing number of +LNs was not associated with worse RFS. Preoperative factors associated with +LNs included tumor size ≥2 cm (OR 6.6; p < 0.001), proximal location (OR 2.5; p < 0.001), moderate vs well differentiation (OR 2.1; p = 0.006), and Ki-67≥3% (OR 3.1; p < 0.001). LN metastases were also present in tumors without these risk factors: < 2cm (9%), distal location (19%), well differentiated (23%), and Ki-67 < 3% (16%). Median LN retrieval was 13 for pancreatoduodenectomy (PD), but only 9 for distal pancreatectomy (DP). Given that PD routinely includes a complete regional lymphadenectomy, a minimum number of LNs to accurately stage pts was not identified. For DP, however, removal of < 7 LNs failed to discriminate 5-yr RFS between LN (+) and (-) pts ( < 7 LNs: 72% vs 83%, p = 0.198; ≥7 LNs: 67% vs 86%, p = 0.002). Conclusions: Tumor size ≥2 cm, proximal location, moderate differentiation, and Ki-67≥3% are preoperative factors that predict LN positivity in resected non-functional PanNETs. Given the 9-23% incidence of LN metastases in patients without such risk factors, routine regional lymphadenectomy should be considered. Pancreatoduodenectomy inherently includes sufficient LN retrieval, while distal pancreatectomy should aim to remove ≥7 LNs for accurate staging.

139 Background: Gastric carcinoids are rare neuroendocrine tumors of the GI tract. They are typically managed according to their etiology. However, there is little known about the impact of surgical strategy on the long-term outcomes of these patients. Methods: All patients who underwent resection of gastric carcinoids at 8 institutions from 2000-2016 were analyzed retrospectively. Tumors were stratified according to subtype (I, II, III, IV) and resection type (local resection LR or formal gastrectomy FG). Clinicopathological parameters, recurrence-free (RFS), and overall survival (OS) were compared between groups. Results: Of 79 patients identified with gastric carcinoids, 34 had type I lesions associated with atrophic gastritis, 4 had type II lesions associated with a gastrinoma, 37 had type III sporadic lesions, and 4 had type IV poorly-differentiated lesions. The mean age of presentation was 56 years in predominantly Caucasian (77%) and female (63%) patients. Mean tumor size was 2.4 cm and multifocal tumors were found in 24 (30%) of patients with the majority occurring in those with type I tumors. Lymph node positive tumors were seen in 15 (19%) patients and 7 (8%) had M1 disease; both most often in type IV followed by type III tumors. R0 resection was achieved in 56 (71%) patients while 15 (19%) had R1 resections and 6 (8%) had R2 resections. Patients with type I and III tumors were equally likely to have a LR (50% and 43% respectively) compared to FG while those with type II and IV all had FG with one exception. Type IV tumors had the poorest RFS and OS while Type II tumors had the most favorable RFS and OS (p < 0.04 and p < 0.0004, respectively). While there was no difference in RFS in those patients undergoing FG versus LR, OS was worse in the FG group (p < 0.017). This trend persisted when type II and type IV groups were excluded (p < 0.045). Conclusions: Gastric carcinoid treatment should be tailored to tumor type, as biologic behavior rather than resection technique is the more important factor contributing to long-term outcomes.

TPS874 Background: Colorectal cancer (CRC) is one of the few cancers in which aggressive local approaches to treat systemic metastases have resulted in clinical benefit. Despite these approaches 70-80% of patients (pts) with resectable metastatic disease will recur. The one-year recurrence rate for this population is ~40-50%. Immunotherapeutics have yet to be studied in this setting. To sensitize microsatellite stable (MSS) CRCs to immune therapies adjunctive therapies are required. Gross tumor microenvironments suppress systemic anti-cancer immune responses. Stereotactic body radiation therapy (SBRT) is commonly utilized to treat liver metastatic CRC, using very high doses of focused radiation to ablate tumors. This causes localized inflammation, a potential increase in immunogenic intra-tumoral and intra-lymphatic antigen release, and a rapid influx of responding immune cells. We hypothesize that radiotherapy-induced tumor necrosis, and surgical removal of the remaining immunosuppressive gross disease will enhance the immunogenicity of CRC and potentiate the effectiveness of PD-1 blockade. Methods: This is a single arm phase 1b investigator-initiated study (NCT02837263) to evaluate the use of pem in combination with ablative radiotherapy for the treatment of oligometastatic CRC. This study examines the sequential use of SBRT, then pem followed by resection of all known sites of disease and 6 months of adjuvant pem. Pts with MSS CRC with resectable liver metastatic disease who have received prior FOLFOX are eligible. The primary endpoints are safety/tolerability and the rate of cancer recurrence at 1 year. Secondary endpoints include time to disease recurrence, disease free survival and overall survival. This study is currently enrolling with a planned total accrual of 15 patients. Correlative studies examine PD-L1 status, tumor infiltrating lymphocytes, evidence of an abscopal effect, versican proteolysis as a novel immune biomarker, and the ability of multiparametric fluorodeoxyglucose (FDG) PET MR and fluorothymidine (FLT) PET CT to detect immune infiltration. Clinical trial information: NCT02837263.

Improved outcomes have been associated with the use of adjuvant therapy after resection of pancreas adenocarcinoma. However, the frequency with which patients receive adjuvant therapy and the factors impacting its use remain largely undefined. We hypothesized that nonutilization of adjuvant therapy was primarily associated with patient comorbidity and onset of postoperative complications.A prospectively maintained database was reviewed to identify patients who underwent potentially curative resection of histologically confirmed pancreas adenocarcinoma at our institution from January 1996 to May 2007. Clinicopathological data and postoperative treatment history were collected to identify variables associated with receipt of adjuvant therapy.Of 119 patients, 33% did not receive adjuvant therapy. The frequency with which patients underwent adjuvant therapy did not change over time. On multivariate analysis, patient age 70 years or greater, major postoperative complications, distal pancreatectomy, absence of nodal metastases, and absence of perineural invasion were associated with decreased utilization of adjuvant therapy.One-third of patients in this contemporary dataset of patients did not go on to receive adjuvant therapy. The likelihood of receiving adjuvant treatment is negatively impacted by the course of postoperative recovery. Moreover, the fact that adjuvant therapy was undertaken less often for older patients and patients with favorable pathological features highlights the selection bias impacting the decision to pursue postoperative therapy for this disease. This selective utilization of postoperative therapy for patients with adverse oncological characteristics is likely to bias any retrospective analysis attempting to measure the efficacy of adjuvant treatment for pancreas adenocarcinoma.

Technological advancements, along with economic and political issues, have resulted in major changes in surgical education. The development of high fidelity simulators and the widespread availability of the Internet have allowed learning to be shifted away from the operating room. Furthermore, the Internet provides an opportunity for surgical educators to standardize general surgery training and assessment and to develop collaborations nationally and globally. This paper highlights presentations about the challenges as well as the rewards of surgical education in the age of the Internet from the 2009 Academic Surgical Congress.

Background The use of staging laparoscopy has been highly institutional dependent. We sought to assess the incidence of occult intra-abdominal metastases identified at the time of staging laparoscopy for patients with either potentially resectable or locally advanced pancreatic adenocarcinoma (LAPC). We also compared the rate of occult metastases in patients who underwent staging laparoscopy versus laparotomy. Methods Patients were confirmed to have potentially resectable or LAPC at a multidisciplinary hepatopancreaticobiliary conference. Patients with potentially resectable lesions were initially explored via staging laparoscopy or laparotomy, based on surgeon preference. Results Over a 4-year period, 25 patients with potentially resectable tumors and 33 patients with LAPC were staged with laparoscopy, with an equivalent prevalence of occult metastases found at laparoscopy (28% potentially resectable vs. 33% LAPC, P = 0.8). Fifty-two patients with potentially resectable lesions were explored initially via laparotomy. Occult peritoneal metastases were more likely to be detected in patients with potentially resectable tumors that were explored via laparoscopy than via laparotomy (32% vs. 10%, P = 0.018). Conclusions Staging laparoscopy is more likely than open exploration to detect occult metastases. Current preoperative imaging inadequately identifies unresectable pancreatic adenocarcinoma; therefore, all patients with potentially resectable disease should undergo staging laparoscopy. J. Surg. Oncol. 2009;100:663–669. © 2009 Wiley-Liss, Inc.

Few studies have analyzed the impact of mentoring on general surgical graduates' future career choices. We attempted to characterize the impact mentoring had on choices made by graduates from our residency program regarding surgical subspecialty training.A 32 item web survey was sent to 99 graduates of a university general surgery program, who matriculated between 1985 and 2007. The intent of the questionnaire was to evaluate influences on future subspecialty choice. Focusing on the influence of mentoring, we compared graduates who indicated that an influential mentor was an important factor in their decision (MENTOR) to those respondents who ranked this factor as unimportant (OTHER). Results were analyzed using Fisher's exact test with significance determined at por = 0.05.A total of 83 respondents (84%) answered the questionnaire (61 men, 18 women, 4 not indicated). Of these respondents, 61 (75%) indicated that an influential mentor was important or very important in choosing their specialty field (MENTOR). The most common fields of the mentors were general surgery (22%), surgical oncology (15%), and plastic surgery (13%). Protégés indicated that their decision to pursue a subspecialty was most influenced by the following mentor characteristics: demonstrating expertise (77%), being a role model (72%), and practicing professional integrity (70%). In the MENTOR group, the vast majority of respondents [72% (43/60)] were in the same field as their mentor (P =0.0001). Protégés also tended to practice in the same setting as their mentor: All (8/8) of those who identified a mentor in a non-academic practice were also currently in a non-academic practice (P = 0.002). Respondents in a non-academic practice were more likely than those in academic practice to have identified their mentor before or during medical school [59% (20/34) versus 8% (2/26)]. Alternatively, 62% (16/26) of academic practitioners identified their mentor during their PGY 2 or 3 y compared to only 21% (7/34) of those in a non-academic practice (P = 0.003).Mentored surgical residency graduates were likely to enter the same specialty and practice type as their mentor. Also, the timing of identifying a mentor was strongly correlated with future practice type. With increasing concerns about "the impending disappearance of the general surgeon" along with increasing growth in surgical sub-specialization, it is essential that all types of surgeons provide early and sustained mentorship to medical students and residents to help shape the future of surgery.

Colorectal cancer liver metastases and hepatocellular carcinoma remain significant health problems in the United States and worldwide. Although surgical resection is often the treatment of choice, patient comorbidities or disease extent may preclude this option. Alternative approaches to primary and secondary hepatic malignancies have been developed, and their impact on disease control has been the subject of much recent study. These therapies can be administered alone but can also be effective when used in combination, or with other chemotherapeutic regimens. This article reviews the different techniques of liver-directed therapy and the available literature on short- and long-term outcomes.

Aggressive management of hepatic neuroendocrine (NE) metastases improves symptoms and prolongs survival. Because of the rarity of these tumors, however, the best method for hepatic artery embolization has not been established. We hypothesized that in patients with hepatic NE metastases, hepatic artery chemoembolization (HACE) would result in better symptom improvement and survival compared to bland embolization (HAE).Retrospective review identified all patients with NE hepatic metastases managed by HACE or HAE at three institutions from January 1996 through December 2007.We identified 100 patients managed by HACE (n = 49) or HAE (n = 51) that were similar with respect to age, gender, and primary tumor type. The percentage of patients experiencing morbidity, 30-day mortality, and symptom improvement were similar between the two groups (HACE vs. HAE: 2.4% vs. 6.6%; 0.8% vs. 1.8%; and 88% vs. 83%, respectively.) No differences in the median overall survival were observed between HACE and HAE from the time of the first embolization procedure (25.5 vs. 25.7 months, p = 0.79). Multivariate analysis revealed that resection of the primary tumor predicted survival (73.8 vs. 19.4 months, p0.04).These data suggest that morbidity, mortality, symptom improvement, and overall survival are similar in patients with hepatic neuroendocrine metastases managed by chemo- or bland hepatic artery embolization.

Background: Hilar cholangiocarcinoma is an uncommon tumor with a poor prognosis. We sought to evaluate recurrence patterns and prognostic factors for disease-specific and disease-free survival in patients with surgically resected hilar cholangiocarcinoma in a single institution over the last 21 years. Methods: From 1985 to 2006, all patients with hilar cholangiocarcinoma referred to a tertiary surgical clinic were evaluated. Demographic data, tumor characteristics, and outcome were analyzed retrospectively. Outcome was compared in patients treated in a recent era (1995-2006) compared with an earlier era (1985-1994). Results: Of 91 patients evaluated, 22 patients (24%) had unresectable disease at presentation. Of the 69 patients submitted to laparotomy, resection was possible in 55% and the curative (R0) resection rate was 63%. In patients submitted to exploration, the operative (60 day) morbidity and mortality rates were 26% and 3%. Median disease-specific (DSS) and disease-free survival (DFS) were 29 and 20 months, respectively (median FU, 29 months.). In patients undergoing R0 resection, the median survival was prolonged (65 months). In the more recent era, resectability rates improved (69% vs. 17%; P = 0.0002), and this was associated with an improvement in median survival (30 vs. 4 months; P < 0.001). Factors predictive of improved disease-specific and disease-free survival included negative histologic margins, concomitant hepatic lobectomy, lack of nodal disease, well-differentiated histology, and an earlier tumor stage (P < 0.05). Concomitant liver resection was associated with a higher R0 resection rate (P = 0.006) and improved DSS and DFS (P = 0.005). In addition, concomitant liver resection was associated with a decreased incidence of initial recurrence in liver (P = 0.031). Conclusions: In patients with hilar cholangiocarcinoma, concomitant hepatic resection is associated with improved DFS, DSS, and decreased hepatic recurrence. Therefore, hepatectomy combined with bile duct resection should be considered standard treatment.

Background For nearly two decades, interest in general surgery has been declining among U.S. medical school graduates. Many factors appear to be important in a medical student's choice of a surgical residency and career. We hypothesized that previous exposure to family members who are surgeons would significantly influence a student's decision to pursue a career in surgery. Methods Since 2001, nearly 600 third-year medical students completing the general surgery clerkship were issued a pre- and post-clerkship survey. Responses were collected, retrospectively analyzed, and correlated to the 2001–2007 National Residency Matching Program match results. Results The response rate of students completing both surveys was 87% (n = 510). Based on a numeric scale, surgical progeny (SP) indicated a significantly higher likelihood than nonsurgical progeny (NSP) of pursing a surgical career/residency in the pre-clerkship period (SP mean, 5.1 ± 0.42; NSP mean, 3.7 ± 0.11; P = 0.0005). Post-clerkship, SPs noted no more enjoyment from the surgical clerkship than NSPs (SP mean, 7.2 ± 0.25; NSP mean, 6.9 ± 0.96; P = 0.91); furthermore, there was no difference in the percentage of students pursuing a surgical residency (categorical or surgical subspecialty) in the National Residency Matching Program match (SP, 12.5%; NSP, 12.7%; P = 1.00). Conclusion These data suggest that previous exposure to a surgeon within the family positively influences a medical student's pre-clerkship interest in pursuing a surgical career. However, this interest is not sustained; SPs and NSPs match into surgical residencies at equivalent rates. Clearly, further studies are needed to identify the factors responsible for this phenomenon.

Background Few studies have examined whether women and men identify the same factors as important in choosing their specialty. We sought to evaluate whether the factors influencing residents' choice of surgical specialty differed by gender. Study Design A 32-item Web survey, designed to elucidate which factors motivated residents to seek fellowship training, was sent to 99 graduates of a university general surgery program, all of whom matriculated between 1985 and 2006. Results A total of 74 (75%) respondents replied (16 women, 58 men). There was a higher proportion of men who pursued fellowship training than women (69% versus 38%, p=0.04), but there was no significant difference in those who were currently in academic practice (men, 46% versus women, 27%, p=0.2). Both genders were equally likely to respond that interest in and intellectual appeal of their field, clinical opportunities in that field, and having an influential mentor during residency were important in choosing their future specialty. But significantly more women listed lifestyle as an important factor in choosing their future careers (69% versus 43%, p=0.03). When respondents' data from the most recent decade were analyzed, there was no difference between genders in completion of fellowship training or in those in academic practice. But lifestyle continued to be more important to women. Conclusions Both genders were influenced by many similar factors when deciding to pursue subspecialty training, but women were more likely than men to be influenced by their perception of the lifestyle associated with their career choice. These findings suggest that general surgical residency programs might improve efforts to recruit women by addressing the perception of the lifestyle associated with choosing a surgical career.

WEB This is a Web exclusive article. epatic cavernous hemangioma is a common benign neoplasm of the liver present in as many as 20% of bodies at autopsy [1]. Hemangioma generally has a benign course and rarely necessitates intervention of any kind. Some hemangiomas, however, are symptomatic and can cause hepatic hemorrhage, thrombocytopenia, and jaundice [2]. Current medical therapy for symptomatic hemangioma is largely ineffective, and surgical removal, although effective, is associated with high morbidity [3–5]. We describe the use of radiofrequency ablation in the minimally invasive management of a large symptomatic hepatic hemangioma. When this article was first submitted to and accepted for publication, it was the first to describe use of a multipleelectrode radiofrequency ablation system based on a switching algorithm in treatment of a tumor in a human [6].

Utilization of computed tomography (CT) scans in patients with presumed appendicitis was evaluated at a single institution to determine the sensitivity of this diagnostic test and its effect on clinical outcome. Adult patients (age > 17 years) with appendicitis were identified from hospital records. Findings at surgery, including the incidence of perforation, were correlated with imaging results. During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients who had preoperative imaging (8.2 ± 0.3 h) compared to those who did not (5.1 ± 0.2 h, p

The aim of this article is to report our experience with incidental detection of extracolonic tumors of the gastrointestinal tract identified prospectively at screening CT colonography. A total of 2014 patients (1097 females, 917 males; mean age, 56.9 years) underwent primary CT colonography evaluation at our institution over an 18-month period. Following cathartic preparation and colonic distention, supine and prone multidetector CT scans were obtained with thin-collimation low-dose technique without intravenous contrast. We reviewed our database for lesions of the extracolonic gastrointestinal tract that were detected during the prospective reading. Focal extracolonic gastrointestinal tract lesions were prospectively detected in 10 (0.5 percent) of 2014 patients (8 females; 2 males; mean age, 58.5 years). All patients were asymptomatic. Tumor locations included ileum (n = 3), stomach (n = 3), jejunum (n = 2), and appendix (n = 2). Mean tumor size was 2.2 (range, 0.8–3.4) cm. Lesions in eight patients were subsequently confirmed by conventional or capsule endoscopy and/or by intravenous contrast-enhanced CT. Seven lesions were surgically excised and one was removed at endoscopy; two patients with lipomas did not undergo further evaluation or treatment. Final diagnoses were benign in all cases and included lipoma (n = 3), small-bowel hamartoma (n = 2), appendiceal mucinous cystadenoma (n = 2), gastric leiomyoma (n = 1), small-bowel lymphangioma (n = 1), and gastric fundic gland polyp (n = 1). Incidental extracolonic tumors of the gastrointestinal tract detected at screening CT colonography were all asymptomatic and benign but often prompted more invasive workup. Although the incidence of these tumors was relatively low, widespread population screening with CT colonography would result in new surgical referrals for these findings.