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Purpose: Indeterminate thyroid lesions on fine needle aspiration (FNA) harbor malignancy in about 25% of cases. Hemi- or total thyroidectomy has, therefore, been routinely advocated for definitive diagnosis. In this study, we analyzed miRNA expression in indeterminate FNA samples and determined its prognostic effects on final pathologic diagnosis.Experimental Design: A predictive model was derived using 29 ex vivo indeterminate thyroid lesions on FNA to differentiate malignant from benign tumors at a tertiary referral center and validated on an independent set of 72 prospectively collected in vivo FNA samples. Expression levels of miR-222, miR-328, miR-197, miR-21, miR-181a, and miR-146b were determined using reverse transcriptase PCR. A statistical model was developed using the support vector machine (SVM) approach.Results: A SVM model with four miRNAs (miR-222, miR-328, miR-197, and miR-21) was initially estimated to have 86% predictive accuracy using cross-validation. When applied to the 72 independent in vivo validation samples, performance was actually better than predicted with a sensitivity of 100% and specificity of 86%, for a predictive accuracy of 90% in differentiating malignant from benign indeterminate lesions. When Hurthle cell lesions were excluded, overall accuracy improved to 97% with 100% sensitivity and 95% specificity.Conclusions: This study shows that that the expression of miR-222, miR-328, miR-197, and miR-21 combined in a predictive model is accurate at differentiating malignant from benign indeterminate thyroid lesions on FNA. These findings suggest that FNA miRNA analysis could be a useful adjunct in the management algorithm of patients with thyroid nodules. Clin Cancer Res; 18(7); 2032–8. ©2012 AACR.

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Gender bias has been identified consistently in written performance evaluations. Qualitative tools may provide a standardized way to evaluate surgical skill and minimize gender bias. We hypothesized that there is no difference in operative time or GEARS scores in robotic hysterectomy for men vs women surgeons.Patients undergoing robotic hysterectomies performed between June 2019 and March 2020 at 8 hospitals within the same hospital system were captured into a prospective database. GEARS scores were assigned by crowd-sourced evaluators by a third party blinded to any surgeon- or patient-identifying information. One-way ANOVA was used to compare the mean operative time and GEARS scores for each group, and significant variables were included in a one-way ANCOVA to control for confounders. Two-tailed p-value 0.05 was considered significant.Seventeen women and 13 men performed a total of 188 hysterectomies; women performed 34 (18%) and men performed 153 (81%). Women surgeons had a higher mean operative time (133 ± 58 vs 86.3 ± 46 min, p = 0.024); after adjustment, there were no significant differences in operative time (p = 0.607). There was no significant difference between the genders in total GEARS score (20.0 ± 0.77 vs 20.2 ± 0.70, p = 0.415) or GEARS subcomponent scores: bimanual dexterity (3.98 ± 0.03 vs 4.00 ± 0.03, p = 0.705); depth perception (4.04 ± 0.04 vs 4.05 ± 0.02, p = 0.799); efficiency (3.79 ± 0.02 vs 3.82 ± 0.02, p = 0.437); force sensitivity (4.01 ± 0.04 vs 4.05 ± 0.05, p = 0.533); or robotic control (4.16 ± 0.03 vs 4.26 ± 0.01, p = 0.079).There was no difference in GEARS score between men vs women surgeons performing robotic hysterectomies. Video-based blinded assessment of skills may minimize gender biases when evaluating surgical skill for competency evaluation and credentialing.

Background Recording intraoperative videos has become commonplace during surgery, with applications in video-based assessment, education and research. These videos can be both manually and automatically analyzed for performance analysis. A number of commercial entities providing video acquisition and processing has flourished over the recent years. As these companies expand, a number of medico-legal, licensing, intellectual property and data sharing related questions have been raised. Methods We performed a qualitative survey of surgeons, hospital administrators, lawyers and commercial entities offering video recording capabilities for serious issues that the average surgeon who records their videos should consider. To address these concerns, we reviewed relevant legal precedent and currently available contracts. Results We identified several key medico-legal constraints, including data ownership and storage, FDA compliance, privacy and potential for use in litigation, present the legal background and potential solutions. Conclusion Given the availability of surgical recording and the future of video-based performance analysis, surgeons need to become comfortable with the medico-legal issues and the potential solutions available with national physician-led lobbying.

Operative time has been traditionally used as a proxy for surgical skill and is commonly utilized to measure the learning curve, assuming that faster operations indicate a more skilled surgeon. The Global Evaluative Assessment of Robotic Skills (GEARS) rubric is a validated Likert scale for evaluating technical skill. We hypothesize that operative time will not correlate with the GEARS score. Patients undergoing elective robotic sleeve gastrectomy at a single bariatric center of excellence hospital from January 2019 to March 2020 were captured in a prospectively maintained database. For step-specific scoring, videos were broken down into three steps: ligation of short gastric vessels, gastric transection, and oversewing the staple line. Overall and step-specific GEARS scores were assigned by crowd-sourced evaluators. Correlation between operative time and GEARS score was assessed with linear regression and calculation of the R2 statistic. Sixty-eight patients were included in the study, with a mean operative time of 112 ± 27.4 min. The mean GEARS score was 20.1 ± 0.81. Mean scores for the GEARS subcomponents were: bimanual dexterity 4.06 ± 0.17; depth perception 3.96 ± 0.24; efficiency 3.82 ± 0.19; force sensitivity 4.06 ± 0.20; robotic control 4.16 ± 0.21. Operative time and overall score showed no correlation (R2 = 0.0146, p = 0.326). Step-specific times and scores showed weak correlation for gastric transection (R2 = 0.0737, p = 0.028) and no correlation for ligation of short gastric vessels (R2 = 0.0262, p = 0.209) or oversewing the staple line (R2 = 0.0142, p = 0.344). Operative time and crowd-sourced GEARS score were not correlated. Operative time and GEARS scores measure different performance characteristics, and future studies should consider using both a validated skills assessment tool and operative time for a more complete evaluation of skill.

The relationship between intraoperative surgical performance scores and patient outcomes has not been demonstrated at a single-case level. The GEARS score is a Likert-based scale that quantifies robotic surgical proficiency in 5 domains. Given that even highly skilled surgeons can have variability in their skill among their cases, we hypothesized that at a patient level, higher surgical skill as determined by the GEARS score will predict individual patient outcomes.Patients undergoing robotic sleeve gastrectomy between July 2018 and January 2021 at a single-health care system were captured in a prospective database. Bivariate Pearson's correlation was used to compare continuous variables, one-way ANOVA for categorical variables compared with a continuous variable, and chi-square for two categorical variables. Significant variables in the univariable screen were included in a multivariable linear regression model. Two-tailed p-value 0.05 was considered significant.Of 162 patients included, 9 patients (5.5%) experienced a serious morbidity within 30 days. The average excess weight loss (EWL) was 72 ± 12% at 6 months and 74 ± 15% at 12 months. GEARS score was not significantly correlated with EWL at 6 months (p = 0.349), 12 months (p = 0.468), or serious morbidity (p = 0.848) on unadjusted analysis. After adjusting, total GEARS score was not correlated with serious morbidity (p = 0.914); however, GEARS score did predict EWL at 6 (p 0.001) and 12 months (p 0.001). All GEARS subcomponent scores, bimanual dexterity, depth perception, efficiency, force sensitivity, and robotic control were predictive of EWL at 6 months (p 0.001) and 12 months (p 0.001) on multivariable analysis.For patients undergoing sleeve gastrectomy, surgical skill as assessed by the GEARS score was correlated with EWL, suggesting that better performance of a sleeve gastrectomy can result in improved postoperative weight loss.

Background The Global Evaluative Assessment of Robotic Skills (GEARS) rubric provides a measure of skill in robotic surgery. We hypothesize surgery performed by more experienced operators will be associated with higher GEARS scores. Method Patients undergoing sleeve gastrectomy from 2016 to 2020 were analyzed. Three groups were defined by time in practice: less than 5, between 5 and 15, and more than 15 years. Continuous variables were compared with ANOVA and multivariable regression was performed. Results Fourteen operators performing 154 cases were included. More experienced surgeons had higher GEARS scores and shorter operative times. On multivariable regression, operative time (P = 0.027), efficiency (P = .022), depth perception (P = 0.033), and bimanual dexterity (P = 0.047) were associated with experience. Conclusions In our video-based assessment (VBA) model, operative time and several GEARS subcomponent scores were associated with surgical experience. Further studies should determine the association between these metrics and surgical outcomes.

Laparoscopic paraesophageal hernia (PEH) is associated with a low morbidity and mortality but an objective hernia recurrence rate in excess of 50% at 5 years. Biologic mesh has not been shown to reduce hernia recurrence rates. Recently, a new bioresorbable mesh made with poly-4-hydroxybutyrate with a Sepra-Technology coating on one side (Phasix-ST mesh) has become available. The aim of this study was to evaluate the feasibility, safety, and short-term efficacy of Phasix-ST mesh for reinforcement of the primary crural closure in patients undergoing elective, laparoscopic PEH repair. A prospective database was initiated and maintained for all patients undergoing PEH repair with the use of Phasix-ST mesh. We retrospectively reviewed the records of consecutive patients who had an elective, first-time laparoscopic PEH repair with Phasix-ST mesh and who completed their 1-year objective follow-up study. Patients having a reoperation, non-laparoscopic repair, or who failed to comply with the objective follow-up were excluded. To achieve the desired 50 patients with 1-year objective follow-up, we reviewed the records of 90 consecutive PEH patients. In the final cohort of 50 patients, there were 32 females (64%) and 18 males. The median age of the patients at surgery was 67 years (range 44–84). The operation was PEH repair with fundoplication alone in 29 patients (58%) and PEH repair with Collis gastroplasty and fundoplication in 21 patients (42%). Phasix-ST mesh was used for crural reinforcement in all patients, and there were no intraoperative issues with the mesh or any difficulty placing or fixating the mesh at the hiatus. A diaphragm relaxing incision was performed in 2 patients (4%). The mean length of hospital stay was 2.8 days, and there was no major morbidity or mortality. On the 1-year objective follow-up study (median 12 months) a recurrent hernia was found in 4 patients (8%). No patient that had a Collis gastroplasty or a relaxing incision had a recurrent hernia. No patient had a reoperation. No patient had a mesh infection or mesh erosion. Phasix-ST mesh reinforcement of the crural closure during laparoscopic primary, elective PEH repair was associated with no adverse mesh-related events such as infection or erosion. Phasix-ST crural reinforcement in combination with tension-reduction techniques when necessary resulted in a very low (8%) objective hernia recurrence rate at a median follow-up of 1 year. These results demonstrate the safety of Phasix-ST mesh for use at the hiatus for crural reinforcement. This safety, along with the encouraging short-term efficacy for reducing hernia recurrence, should encourage further studies using the combination of resorbable biosynthetic mesh crural reinforcement and tension-reducing techniques during repair of paraesophageal hernias.

Evaluation of robotic surgical skill has become increasingly important as robotic approaches to common surgeries become more widely utilized. However, evaluation of these currently lacks standardization. In this paper, we aimed to review the literature on robotic surgical skill evaluation.A review of literature on robotic surgical skill evaluation was performed and representative literature presented over the past ten years.The study of reliability and validity in robotic surgical evaluation shows two main assessment categories: manual and automatic. Manual assessments have been shown to be valid but typically are time consuming and costly. Automatic evaluation and simulation are similarly valid and simpler to implement. Initial reports on evaluation of skill using artificial intelligence platforms show validity. Few data on evaluation methods of surgical skill connect directly to patient outcomes.As evaluation in surgery begins to incorporate robotic skills, a simultaneous shift from manual to automatic evaluation may occur given the ease of implementation of these technologies. Robotic platforms offer the unique benefit of providing more objective data streams including kinematic data which allows for precise instrument tracking in the operative field. Such data streams will likely incrementally be implemented in performance evaluations. Similarly, with advances in artificial intelligence, machine evaluation of human technical skill will likely form the next wave of surgical evaluation.

Operative time has been traditionally used as a proxy for surgical skill and is commonly utilized to measure the learning curve, assuming that faster operations indicate a more skilled surgeon. The Global Evaluative Assessment of Robotic Skills (GEARS) rubric is a validated Likert scale for evaluating technical skill. We hypothesize that operative time will not correlate with the GEARS score.Patients undergoing elective robotic sleeve gastrectomy at a single bariatric center of excellence hospital from January 2019 to March 2020 were captured in a prospectively maintained database. For step-specific scoring, videos were broken down into three steps: ligation of short gastric vessels, gastric transection, and oversewing the staple line. Overall and step-specific GEARS scores were assigned by crowd-sourced evaluators. Correlation between operative time and GEARS score was assessed with linear regression and calculation of the RSixty-eight patients were included in the study, with a mean operative time of 112 ± 27.4 min. The mean GEARS score was 20.1 ± 0.81. Mean scores for the GEARS subcomponents were: bimanual dexterity 4.06 ± 0.17; depth perception 3.96 ± 0.24; efficiency 3.82 ± 0.19; force sensitivity 4.06 ± 0.20; robotic control 4.16 ± 0.21. Operative time and overall score showed no correlation (ROperative time and crowd-sourced GEARS score were not correlated. Operative time and GEARS scores measure different performance characteristics, and future studies should consider using both a validated skills assessment tool and operative time for a more complete evaluation of skill.

Bariatric surgery allows for rapid, often sustained weight loss and effective treatment of the comorbidities associated with morbid obesity. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most common bariatric surgical procedures performed in the United States. Leaks, fistulas, and strictures are complications that can occur in a non-negligible minority of these patients. Staple line leaks and strictures are potentially highly morbid events, which historically required operative therapy. While leaks tend to occur in the early postoperative period, and their management is dependent upon the timing and patient condition, strictures tend to manifest more as a chronic and progressively worsening entity. Endoscopy is an integral part of the multimodal approach required to diagnose and treat these occurrences, and today’s therapeutic endoscopic armamentarium offers several devices that can assist in the management of these challenging situations.

Optimal treatment for symptomatic patients with non-achalasia motility disorders (NAD) such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder is not well established. POEM has been offered to these patients since it is a less invasive and less morbid procedure but long-term outcomes remain undetermined. The aim of this study was to assess long-term outcomes of POEM for patients with NAD.Records of 40 consecutive patients undergoing POEM for NAD from May 2011 to January 2016 at a single center were retrospectively reviewed. Preoperative and 6-month postoperative symptom scores, high-resolution manometry, pH testing, and timed barium swallow (TBS) data were collected. Patients were contacted by phone to obtain long-term symptom assessment. Symptoms were assessed using a standardized symptom questionnaire with scores for symptoms graded according to frequency and the Eckardt score.Ten percent had minor complications with no postoperative sequelae. 90% of patients had significant improvement in their mean Eckardt scores (5.02 vs. 1.12, p 0.001) at early follow-up. Improvements in chest pain (1.02-0.36, p = 0.001) and dysphagia (2.20 vs. 0.40, p = 0.001) were seen. Significant improvements in manometric pressures and esophageal emptying on TBS were observed across groups. 38% (10/26) of patients had a postoperative pH score 14.72. Long-term (median 48 months) symptom scores were obtained from 29 (72.5%) patients. 82% of patients (24/29) had sustained symptom improvement. A small increase in the dysphagia scores was reported in the long-term follow-up compared to the immediate postoperative period (0.36-0.89, p = 0.046).Chest pain and dysphagia are effectively palliated with POEM in patients with non-achalasia disorders of the esophagus. Significant improvements are durable in long-term follow-up. Despite earlier reports by our group suggesting possible inferior outcomes from POEM for this difficult group of patients, this study is far more encouraging. POEM should be considered in the treatment of patients with non-achalasia disorders of the esophagus.

The safety of single-incision laparoscopic cholecystectomy (SILC) has been proven in well-selected patients. The objective of this study was to determine whether SILC can be offered to all patients with any indication for cholecystectomy.A total of 173 consecutive SILCs were performed between January 2010 and November 2012 with no exclusion criteria. Demographic data, operative, and postoperative outcomes were prospectively collected and analyzed.Patients with acute cholecystitis and gallstone pancreatitis had longer operative times and a higher conversion to 4-port cholecystectomy than patients with biliary colic. Similar relationships were seen when comparing patients with obesity to nonobese patients. There were no differences in complication rates between the groups.SILC can be safely offered to patients with a wide spectrum of biliary disease with the understanding that this may result in increased operative times and a higher likelihood of conversion to multiport laparoscopy.

Background Little is known about the initial development and natural history of a hiatal hernia. Methods A database containing 12,050 upper gastrointestinal (UGI) studies dating from 1991 to 2013 was queried to identify patients that had more than one study a minimum of 5 years apart showing a hernia. The x-ray films or digital images were reviewed and the type and size of any hernia determined. Results There were 56 patients with 133 UGI studies. On initial UGI; 13 patients had no hernia, 35 patients had a sliding hernia (SH), and 8 patients had a paraesophageal hernia (PEH). Follow-up UGI results are shown in the Figure. A third or fourth UGI study was available for 17 patients. Over a median of 41 months, the most recent UGI showed that the majority (78%) of SH increased in size, with 1 changing to PEH. Among patients with PEH, 2 were already completely intrathoracic stomachs and on most recent UGI 4 of the remaining 6 increased in size with 1 turning into complete intrathoracic stomach. Conclusion Most PEHs (77%) started out as a SH. Over time the majority of both SH and PEH increase in size, with many PEH becoming completely intrathoracic stomachs. Given the risks associated with a PEH, patients with SH should be re-evaluated for progression of their hernia. Disclosure All authors have declared no conflicts of interest.

The aim of this study was to determine the predictive value of the preoperative three-dimensional reconstructed volume (3D volumetry) for outcomes of laparoscopic splenectomy. The impact of splenomegaly on the feasibility of laparoscopic splenectomy is still debated. We hypothesized that splenic volumetry may accurately estimate splenic volume preoperatively and be used by surgeons to select patients for laparoscopic splenectomy.We performed a retrospective review of 88 patients seen at a tertiary referral center undergoing laparoscopic or open splenectomy between 2001 and 2010. Patients included in the study underwent elective splenectomy without associated procedures and had preoperative imaging available at our institution. We evaluated clinical, demographic characteristics and perioperative imaging as predictors of outcome. Study endpoints included conversion to open splenectomy, operating time, estimated blood loss (EBL), length of stay (LOS), postoperative complications, and mortality.In all, 53 procedures were started laparoscopically. Among them, 7 (13.2 %) were converted to open splenectomy and 7 (13.2 %) to hand-assisted laparoscopic splenectomy. The conversion group was matched with 35 patients who underwent open splenectomy to determine differences in outcomes between these groups. There were no conversions in spleens measuring1100 cc, whereas spleens of 1100 to 2700 cc had a conversion rate of 41 %. Spleen volume2700 cc was associated with an 87.5 % conversion rate. Spleen 3D volumetry2700 cc was the only independent predictor of surgical conversion on multivariate analysis (odds ratio 38.0, confidence interval 4.02-358.75, p = 0.001). Patients who underwent open splenectomy had shorter operating times (160.3 vs. 253.0 min, p = 0.001) than those converted from laparoscopic to open splenectomy.A 3D reconstructed splenic volume of2700 cc is a predictor of conversion from laparoscopic to open splenectomy. For spleens measuring2700 cc, laparoscopic splenectomy may be performed by experienced surgeons with low to moderate rates of conversion. For spleens with a 3D reconstructed volume2700 cc, laparoscopic splenectomy is associated with high rates of conversion to open surgery.

This study aims to determine the efficacy of calcimimetics in improving bone mineral density (BMD) in patients with primary hyperparathyroidism (pHPT) and compare those results to patients undergoing parathyroidectomy.Parathyroidectomy has been shown to improve BMD in pHPT, but calcimimetics have recently been advocated as a medical alternative to parathyroidectomy for pHPT.We identified 17 patients that were treated with calcimimetics for pHPT. Seventeen patients with pHPT who underwent parathyroidectomy served as surgical controls. Serum calcium level, parathyroid hormone (PTH) level, and femur and spine BMD T scores were compared before and 1 year after therapy.Both groups were demographically matched. Calcium levels normalized in 70.6% of medically versus 100% of surgically treated patients (P = 0.026). PTH levels normalized in 35% of patients treated with calcimimetics versus 76% of surgical patients (P = 0.036). Femur BMD improved in 18.8% of medically treated patients versus 58.8% of surgical patients (P = 0.032). Spine BMD improved in 70.6% of medically treated patients versus 82.4% of surgical patients (P = 0.69). Further analysis demonstrated that regardless of treatment, normalization of PTH was associated with significant improvement in femur (P = 0.03) and spine BMD (P0.001). Normalization of calcium without normalization of PTH did not impact BMD.Parathyroidectomy results in greater normalization of serum calcium and PTH levels and significantly improves cortical BMD compared to calcimimetics. Regardless of treatment, normalization of PTH is associated with significant improvement in spine and femur BMD, suggesting that the superior effects of surgery may be mediated by better control of PTH.

Pneumoperitoneum following trauma usually indicates the presence of a perforated intra-abdominal viscus and the need for laparotomy.1 Other causes of a pneumoperitoneum demonstrate the alternative routes that air can take into the peritoneal cavity: through the abdominal wall, through the diaphragm, through the female genital tract, and through the retroperitoneum.2–5 By recognising that air may have taken one of the alternative routes into the peritoneal cavity, an unnecessary laparotomy may be avoided. Pneumoperitoneum has also been reported to be a complication of mechanical ventilation,6 likely related to air from the pleural cavity tracking into the peritoneum.7 8 We present two cases of blunt thoraco-abdominal trauma, with CT findings of massive pneumothorax with large amounts of abdominal free air. These cases show two different possibilities of localisation of intra-abdominal free air associated with traumatic pneumothorax. ### Case 1 A 21-year-old man was referred to our trauma centre from the casualty department of a local hospital, after falling and being repeatedly kicked by a horse. The patient was haemodynamically unstable at the scene (blood pressure 80/50 mm Hg), tachycardic (114 beats/min (bpm)), and breath sounds were absent on the right side and notably decreased on the left. At the casualty department he underwent immediate needle decompression of the right tension pneumothorax followed by left intercostal drain insertion. The abdomen was slightly distended and tender at palpation, and subcutaneous emphysema was palpable on the upper chest. Focused assessment with sonography for trauma (FAST) was limited by a large amount of intra-abdominal free air. The patient remained unstable after intercostal chest drain (ICD) insertion; he was intubated and referred to us …

Dear Editor: Hereditary nonpolyposis colon cancer (HNPCC or Lynch syndrome) is a multisystemic disorder, affecting the colon and rectum in up to 70% of cases. It is characterized by autosomal dominant inheritance and the development of multiple neoplasms including colorectal, endometrial, ovarian, pancreatic, small bowel, and urinary tract tumors. HNPCC is the leading cause of hereditary colorectal cancers (CRC) with an incidence of 2–5%. The genetic defects associated with this disorder arise from errors in the mismatch repair genes (MMR). Currently, five different genetic mutations have been identified (hMLH1, hMSH2, hMSH3, hMSH6, hPMS1) that lead to accelerated carcinogenic transformation, some of which show distinct phenotypic features like inflammatory component or expansive growth. Herein, we describe the first case report of an HNPCC patient with simultaneous loss of expression of MSH-2 and MSH-6 genes in the setting of a T4N0 colon cancer invading the duodenum and the head of the pancreas. A 38-year-old man presented to the emergency department of a tertiary referral center complaining of right-sided abdominal pain, nausea, vomiting, skinny stools, and weight loss (20 lbs) for the past 6 weeks prior to admission. He had no significant past medical history. However, he reported that his father died at the age of 50 of colon cancer. Physical exam was significant for mild discomfort in the right upper quadrant. His stool guaiac test was positive for occult blood, but no frank blood was seen and no mass was palpated on rectal digital exam. Laboratory tests were significant for mild transaminitis and a CT scan of the abdomen and pelvis revealed a 7.6-cm mass arising from the hepatic flexure of the right colon and extending into the second and third portion of the duodenum and pancreatic head. An upper and lower GI endoscopy with biopsy of the mass showed moderately differentiated adenocarcinoma of the colon. A subsequent PET scan showed no metastatic focus of fludeoxyglucose uptake. The patient underwent an exploratory laparotomy with an extended right hemicolectomy and pancreaticoduodenectomy. No contraindication to resection was encountered in the exploratory phase. The patient had an uneventful postoperative course and was discharged home on POD#14. Upon follow-up in the clinic 2 weeks later, he was eating a regular diet, having normal bowel movements, and was back to regular activities. The surgical specimen consisted of the resected colon, duodenum, and the head of the pancreas. Microscopic examination revealed a high grade (G3), poorly differentiated adenocarcinoma of the hepatic flexure, with mild to moderate lymphocytic invasion, infiltrating the full thickness of the colonic wall into the duodenum. The authors declare no conflict of interest and/or relationships with people or businesses that could influence or bias the outcome of this paper.

Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma.The evaluation of their influence on mortality during the last 15 years can lead to further improvements.In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value.Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p 0.01). Mean GCS (10.2) increased during the period (test trend p 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p 0.05). Significant predictors of mortality in the whole group were year of admission (p 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p = 0.06).Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.

BACKGROUND: Postoperative hepatic failure is a dreadful complication after major hepatectomy and carries high morbidity and mortality rates. In this study, we assessed the accuracy of the 50/50 criteria (bilirubin ＞2.9 mg/dL and international normalized ratio ＞1.7 on postoperative day 5) and the Mullen criteria (bilirubin peak ＞7 mg/dL on postoperative days 1-7) in predicting death from hepatic failure in patients undergoing right hepatectomy only. In addition, we identified prognostic factors linked to intra-hospital morbidity and mortality in these patients. METHODS: One hundred seventy consecutive patients underwent major right hepatectomy at a tertiary medical center from 2000 to 2008. Nineteen (11.2%) patients suffered from liver cirrhosis. Univariate and multivariate analyses were performed to identify predictors of intra-hospital mortality, morbidity and death from hepatic failure. RESULTS: The intra-hospital mortality was 6.5% (11/170). Of the six patients who died from hepatic failure, one was positive for the 50/50 criteria, but all six patients were positive for the Mullen criteria. Multivariate analysis showed that male gender, hepatitis C (HCV), hepatocellular carcinoma, postoperative bilirubin ＞7 mg/dL and ALT＜188 U/L on postoperative day 1 were predictive of death from hepatic failure in the postoperative period. Age ＞65 years, HCV, reoperation, and renal failure were significant predictors of overall intrahospital mortality on multivariate analysis. CONCLUSIONS: The Mullen criteria were more accurate than the 50/50 criteria in predicting death from hepatic failure in patients undergoing right hepatectomy. A bilirubin peak ＞7 mg/dL in the postoperative period, HCV positivity, hepatocellular carcinoma, and an ALT level ＜188 U/L on postoperative day 1 were associated with death from hepatic failure in our patient population.

Purpose: Indeterminate thyroid lesions on fine needle aspiration (FNA) harbor malignancy in about 25% of cases. Hemi- or total thyroidectomy has, therefore, been routinely advocated for definitive diagnosis. In this study, we analyzed miRNA expression in indeterminate FNA samples and determined its prognostic effects on final pathologic diagnosis. Experimental Design: A predictive model was derived using 29 ex vivo indeterminate thyroid lesions on FNA to differentiate malignant from benign tumors at a tertiary referral center and validated on an independent set of 72 prospectively collected in vivo FNA samples. Expression levels of miR-222, miR-328, miR-197, miR-21, miR-181a, and miR-146b were determined using reverse transcriptase PCR. A statistical model was developed using the support vector machine (SVM) approach. Results: A SVM model with four miRNAs (miR-222, miR-328, miR-197, and miR-21) was initially estimated to have 86% predictive accuracy using cross-validation. When applied to the 72 independent in vivo validation samples, performance was actually better than predicted with a sensitivity of 100% and specificity of 86%, for a predictive accuracy of 90% in differentiating malignant from benign indeterminate lesions. When Hurthle cell lesions were excluded, overall accuracy improved to 97% with 100% sensitivity and 95% specificity. Conclusions: This study shows that that the expression of miR-222, miR-328, miR-197, and miR-21 combined in a predictive model is accurate at differentiating malignant from benign indeterminate thyroid lesions on FNA. These findings suggest that FNA miRNA analysis could be a useful adjunct in the management algorithm of patients with thyroid nodules. Clin Cancer Res; 18(7); 2032–8. ©2012 AACR.

Purpose Major liver trauma in polytraumatic patients accounts for significant morbidity and mortality. We aimed to assess prognostic factors for morbidity and mortality in patients with severe liver trauma undergoing perihepatic packing. Methods Prospectively collected records of 293 consecutive polytrauma patients with liver injury admitted at a level I trauma centre between 1996 and 2008 were reviewed. 39 patients with grade IV–V AAST liver injury and treated with peri-hepatic packing were identified and included for analysis. Univariate and multivariate analyses were performed to assess prognostic factors for morbidity and mortality. Results Mean age of patients was 41 years. 34 patients were haemodynamically unstable at initial presentation. Ten of 39 patients were treated with angiographic embolization in addition to perihepatic packing. The overall mortality rate was 51.3%. Liver-related death occurred in 23.1%. Overall and liver-related morbidity rates were 90% and 28%, respectively. Glasgow Coma Scale (GCS), respiratory rate, packed red blood cells (PRBC) transfusion, pH and Base Excess (BE), Revised Trauma Score (RTS) and Trauma Injury Severity Score (TRISS), need for angiographic embolization as well as early OR and ICU admission were associated with significant decrease of early mortality. Conclusions Revised Trauma Score, haemodynamic instability, blood pH and BE are important prognostic factors influencing morbidity and mortality in polytrauma patients with grade IV/V liver injury. Furthermore, fast and effective surgical damage control procedure with perihepatic packing, followed by early ICU admission is associated with lower complication rate and shorter ICU stays in this patient population.

Background Case control studies that randomly assign patients with diagnosis of acute appendicitis to either surgical or non-surgical treatment yield a relapse rate of approximately 14% at one year. It would be useful to know the relapse rate of patients who have, instead, been selected for a given treatment based on a thorough clinical evaluation, including physical examination and laboratory results (Alvarado Score) as well as radiological exams if needed or deemed helpful. If this clinical evaluation is useful, the investigators would expect patient selection to be better than chance, and relapse rate to be lower than 14%. Once the investigators have established the utility of this evaluation, the investigators can begin to identify those components that have predictive value (such as blood analysis, or US/CT findings). This is the first step toward developing an accurate diagnostic-therapeutic algorithm which will avoid risks and costs of needless surgery. Methods/design This will be a single-cohort prospective observational study. It will not interfere with the usual pathway, consisting of clinical examination in the Emergency Department (ED) and execution of the following exams at the physician's discretion: full blood count with differential, C reactive protein, abdominal ultrasound, abdominal CT. Patients admitted to an ED with lower abdominal pain and suspicion of acute appendicitis and not needing immediate surgery, are requested by informed consent to undergo observation and non operative treatment with antibiotic therapy (Amoxicillin and Clavulanic Acid). The patients by protocol should not have received any previous antibiotic treatment during the same clinical episode. Patients not undergoing surgery will be physically examined 5 days later. Further follow-up will be conducted at 7, 15 days, 6 months and 12 months. The study will conform to clinical practice guidelines and will follow the recommendations of the Declaration of Helsinki. The protocol was approved on November 2009 by Maggiore Hospital Ethical Review Board (ID CE09079). Trial Registration ClinicalTrials.gov identifier: NCT01096927., Article summary Article focus Acute appendicitis can have severe complications including perforation and generalised peritonitis. The appendix is found to be free of disease in 15–30% of appendectomies. As surgery carries various risks, conservative non-surgical treatment with antibiotics for suspected appendix inflammation may avoid needless surgery, in particular as the relapse rate is low and the rate of complications is similar. Key messages Case control studies that randomly assign patients with acute appendicitis to either surgical or non-surgical treatment show a relapse rate of approximately 14% at 1 year. The relapse rate of patients who are treated based on a thorough clinical evaluation should be below 14%. Once factors predictive of outcome and/or the need of surgery are identified, an accurate diagnostic-therapeutic algorithm which will help avoid the risks and costs of needless surgery can be developed. Strengths and limitations of this study This non-randomised controlled study will evaluate the effectiveness and short and long term outcomes of non-operative antibiotic treatment of acute appendicitis. Amoxicillin and clavulanic acid are common and easily managed low cost drugs, available both for intravenous and oral use. Better analysis of clinical data might lead to better decision-making in patients with right iliac fossa pain and suspected acute appendicitis. The study also aims to evaluate the Alvarado score, which is used to diagnose acute appendicitis and discriminate patients needing immediate surgery from patients who may safely undergo observation and antibiotic treatment. A large sample of patients undergoing non-operative antibiotic treatment will allow a statistically powerful evaluation of safety, efficacy and cost. An additional objective is to identify clinical, laboratory and imaging findings that are predictive of failure of conservative treatment and/or relapse of appendicitis and need for appendectomy within 1 year. As efficacy can not be reliably determined in the absence of a control group, a case series observation determining ‘efficacy’ has limited value. The Alvarado score is used to separate those with acute appendicitis from those with similar symptoms but no appendicitis and there is no evidence that this score can identify those who would benefit from antibiotic treatment.

Management of Liver Trauma may vary widely from NOM +/- angioembolization to Damage Control Surgery. Multidisciplinary management is essential for achieving better outcomes.During 2000-2009 period 308 patients with liver injury were admitted to level 1 trauma center and recorded in Trauma Registry. Collected data are demographics, AAST grade, initial treatment (operative or non-operative treatment) and outcome (failure of NOM), death. All patients were initially assessed according to ATLS guidelines. In case of haemodynamic instability and FAST evidence of intra-abdominal free fluid, the patients underwent immediate laparotomy. Hemodynamically stable patients, underwent CT scan and were admitted in ICU for NOM.Two hundred fourteen patients (69.5%) were initially managed with NOM. In 185 patients this was successful. Within the other 29 patients, failure of NOM was due to liver-related causes in 12 patients and non-liver-related causes in 17 Greater the grade of liver injury, fewer patients could be enrolled for NOM (85.8% in I-II and 83.3% in III against 39.8% in IV-V). Of those initially treated non-operatively, the likelihood of failure was greater in more severely injured patients (24.4% liver-related failure rate in IV-V against the 1.3% and 1.0% in I-II and III respectively). One hundred twenty-three patients (40% of the whole population study--308 patients) underwent laparotomy: 94 immediately after admission, because no eligible for NOM; 29 after NOM failure . In the 81 patients in which liver bleeding was still going on at laparotomy, hemostasis was attempted in two different ways: in the patients affected by hypothermia, coagulopathy and acidosis, perihepatic packing was the treatment of choice. In the other cases a "direct repair" technique was preferred. "Early mortality" which was expected to be worse in patients with such metabolic derangements, was surprisingly the same of the other group. This proves efficacy of the packing technique in interrupting the "vicious cicle" of hypothermia, coagulopathy and acidosis, therefore avoiding death ("early death" in particular) from uncontrollable bleeding.NOM +/- angioembolization is safe and effective in any grade of liver injury provided hemodynamic stability. DCS is Gold Standard for hemodynamically unstable patients.

Background Mutation analysis is potentially a powerful tool to enhance the diagnostic accuracy of thyroid fine-needle aspiration (FNA) biopsy specimens. However, some clinicians may rely on a negative mutation panel to exclude malignancy. We aimed to determine the malignancy rate in indeterminate lesions with negative mutation analysis. Methods A literature review established a mutation analysis model using the prevalence of BRAF, RET, RAS, and PAX8/peroxisome proliferator-activated receptor-γ mutations in indeterminate lesions. This model was applied retrospectively to a study cohort of 466 consecutive indeterminate lesions that underwent hemi- or total thyroidectomy for definitive diagnosis, to evaluate its accuracy for identifying malignancy. Results Of 466 indeterminate lesions in the study, 30% (139) were malignant. These included 66 cases of papillary thyroid cancer, 45 cases of follicular variant of papillary thyroid cancer, 18 cases of follicular thyroid cancer, and 10 others. The risk of malignancy was 42% when cytologic atypia was present vs 17% without. The mutation analysis model would correctly identify only 48 of 139 (34%) of malignant indeterminate lesions. Therefore, when mutation analysis is negative, the overall risk of malignancy would be 23%. When atypia is present, the risk of malignancy would be 31% vs 13% in lesions without. Conclusion Indeterminate lesions with a negative mutation analysis still carry a significant risk of malignancy, especially in the presence of atypia, requiring surgery for definitive diagnosis.

The Damage Control Surgery (DCS) approach to massive intraperitoneal hemorrhage has been shown to significantly reduce the morbidity and mortality in severely injured trauma patients. We applied the same principles to patients who developed a massive hemorrhage and the “lethal triad” (acidosis, hypothermia, coagulopathy) during a surgical procedure in order to assess feasibility and efficacy of DCS on nontraumatic grounds. A retrospective analysis of eight consecutive cases was performed aimed at collecting information on laboratory parameters, fluids requirements, operative times, APACHE II score, damage control surgery procedure, angioembolization, morbidity, mortality, and need for repacking. Average APACHE II score was 25.5 (predicted mortality rate = 54%); overall and early mortality in the nontraumatic group was nil, while the intra-abdominal septic (packing-related) complication rate was 12.5%. Intra-abdominal packing was shown to be feasible, safe, and effective for patients with intra-abdominal nontraumatic massive hemorrhage, and the application of the principles of DCS may improve survival in cases of surgical hemorrhage with development of the lethal triad.

An 82-year-old woman, with previous history of hiatal hernia, cholecystectomy and depression, has been admitted for worsening diffuse abdominal pain with constipation and vomiting for 4 days. She lived alone, without signs of dementia or cognitive impairment. The abdomen was distended and tender in middle quadrants. Abdominal x-ray revealed concentric distension of bowel loops. CT scan confirmed mechanical small bowel obstruction with a transition point in the right iliac fossa. At laparotomy, the obstruction was caused by an intraluminal mass. After enterotomy, a 5.5 cm large phytobezoar was extracted; immediately after, a small live insect jumped out from the vegetable mass crawling onto the surgical area. The specimen was sent for parasitology and identified as a crustacean isopod, terrestrial arthropod, classified in the phylum Arthropoda, subphylum Crustacea and order Isopoda. They usually live in humid, moist conditions, obtaining their nourishment from decomposing vegetable matter. They often colonise in greenhouse pot plants. No cases of parasitisation in vertebrate species have been reported to date.

argeting BRAFV600E using nanoliposomal-small nterfering RNA restores the expression of sodium iodide ymporter and increases the uptake of iodide in thyroid ancer cells aniel Buitrago MD, Hasan Aldailami BSC, Alexander Veach BSC, ilippo Filicori MD, Xavier M Keutgen MD, Mike Crowley BSC, oonsoo Jin SCD, Thomas J Fahey III MD, FACS, asa Zarnegar MD, FACS eill Cornell Medical College, New York, NY, Cornell University, thaca, NY and Memorial Sloan Kettering Cancer Center, New ork, NY