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Background Patients' satisfaction is a common parameter tracked by health care systems and Emergency Departments (EDs). Objectives To determine whether telephone calls by health care providers to patients after discharge from the ED was associated with improved patient satisfaction. Methods Retrospective analysis of Press Ganey (PG; Press Ganey Associates, South Bend, IN) surveys from two EDs operated by the University of California San Diego Health System. Responses to the YES/NO question, "After discharge, did you receive a phone call from an ED staff member?" was compared to the responses to the question "likelihood of recommending this ED to others" (LR). This variable could be ranked with a score of 1 (very poor) to 5 (very good). Responses were dichotomized into two groups, 1–4 and 5. Chi-squared was performed to assess LR between those answering YES vs. NO to the call back question. Differences in proportion, 95% confidence interval (CI), and p -value are reported. Rankings for percentage of 5s across all EDs in the PG database were compared based upon YES/NO responses. Results In the 12-month study period, about 30,000 surveys were mailed and 2250 (7.5%) were returned. Three hundred forty-seven (15.4%) checked off YES for the call back question. Percentage of 5s for LR for NO call back was 51.1% and for YES call back was 70.6% (difference = 19.5; 95% CI 14.0–24.6; p th and 85 th percentile, respectively. Conclusion This retrospective study demonstrated a strong association between post-visit patient call back and LR. Further prospective study with control for co-variables is warranted.

The neural cell adhesion molecule L1 has recently been shown to be expressed in pancreatic adenocarcinoma (PDAC) cells. In this report, we demonstrate that L1 is expressed by moderately- to poorly-differentiated PDAC cells in situ, and that L1 expression is a predictor of poor patient survival. In vitro, reduced reactivity of an anti-L1 carboxy-terminus-specific antibody was observed in the more poorly differentiated fast-growing (FG) variant of the COLO357 population, versus its well-differentiated slow-growing (SG) counterpart, even though they express equivalent total L1. The carboxy-terminus of L1 mediates binding to the MAP kinase-regulating protein RanBPM and mutation of T1247/S1248 within this region attenuates the expression of malignancy associated proteins and L1-induced tumorigenicity in mice. Therefore, we reasoned that the differential epitope exposure observed might be indicative of modifications responsible for regulating these events. However, epitope mapping demonstrated that the major determinant of binding was actually N1251; mutation of T1247 and S1248, alone or together, had little effect on C20 binding. Moreover, cluster assays using CD25 ectodomain/L1 cytoplasmic domain chimeras demonstrated the N1251-dependent, RanBPM-independent stimulation of erk phosphorylation in these cells. Reactivity of this antibody also reflects the differential exposure of extracellular epitopes in these COLO357 sublines, consistent with the previous demonstration of L1 ectodomain conformation modulation by intracellular modifications. These data further support a central role for L1 in PDAC, and define a specific role for carboxy-terminal residues including N1251 in the regulation of L1 activity in PDAC cells.

The ectodomain structure and function of the neural cell adhesion molecule L1 is shown to be regulated by the intracellular phosphorylation of a novel threonine, T1172. In pancreatic cancer cells, T1172 exhibits steady-state saturated phosphorylation, an event regulated by CKII and PKC, and which further regulates cell migration., Previous reports on the expression of the cell adhesion molecule L1 in pancreatic ductal adenocarcinoma (PDAC) cells range from absent to high. Our data demonstrate that L1 is expressed in poorly differentiated PDAC cells in situ and that threonine-1172 (T1172) in the L1 cytoplasmic domain exhibits steady-state saturated phosphorylation in PDAC cells in vitro and in situ. In vitro studies support roles for casein kinase II and PKC in this modification, consistent with our prior studies using recombinant proteins. Importantly, T1172 phosphorylation drives, or is associated with, a change in the extracellular structure of L1, consistent with a potential role in regulating the shift between the closed conformation and the open, multimerized conformation of L1. We further demonstrate that these distinct conformations exhibit differential binding to integrins αvβ3 and αvβ5 and that T1172 regulates cell migration in a matrix-specific manner and is required for a disintegrin and metalloproteinase-mediated shedding of the L1 ectodomain that has been shown to regulate cell migration. These data define a specific role for T1172 of L1 in regulating aspects of pancreatic adenocarcinoma cell phenotype and suggest the need for further studies to elucidate the specific ramifications of L1 expression and T1172 phosphorylation in the pathobiology of pancreatic cancer.

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

Background: Transanal endoscopic surgical (TES) resection using rigid transanal platforms (TEM, TEO) is associated with improved outcomes compared to traditional transanal excision (TAE) of rectal lesions. An alternative technique using a disposable single incision surgery platform was developed in 2009, transanal minimally invasive surgery (TAMIS), resulting in a surge in interest and access to transanal access platforms to perform TES. However, compared to rigid transanal access platforms, the disposable platforms do not facilitate internal rectal retraction and have limited proximal reach. A new long channel disposable transanal access platform has been developed (15 cm in length, 4cm in width) thereby facilitating endoluminal surgical access to the upper rectum and rectosigmoid colon.Methods: This is a retrospective case series report. Patient demographics and peri-operative outcome variables were recorded. The Gelpoint Path Long Channel was utilized in three patients with proximal rectal lesions that were not accessible using a standard disposable transanal access platform.Results: Three patients underwent TES excision of rectal adenomas using a long channel, disposable, transanal access platform. All patients were female, aged 51-53, BMI 23-32kg/m^2. The tumor size ranged from 2.4-8.5cm, 15-100% circumference, and proximal location from the dentate line ranged from 9-11cm. Final pathology revealed adenoma with negative margins in all three cases. The hospital length of stay ranged from 1-3 days and there were no perioperative complications. None of the patients have developed a local recurrence during the follow up period ranging from 5-11 months.Conclusions: The new long channel, disposable, transanal access platform facilitates transanal endoluminal surgical removal of lesions in the mid to upper rectum that may be difficult to reach using the standard disposable transanal access devices. We have successfully achieved 100% margin negative rate using this new device in this small series of patients with proximal rectal adenomas.

We report a case of a cystic lymphangioma arising from the lesser curvature of the stomach in a 16-year-old female who initially presented with abdominal pain, nausea, and emesis. Contrast enhanced computed tomography and magnetic resonance imaging revealed a large, thin-walled multicystic mass located anteromedial to the stomach, which was predominately supplied by the left gastric artery. Given the imaging appearance and location, a mesenteric cyst, specifically a cystic lymphangioma, was considered. Lymphangioma was the final pathological diagnosis after laparotomy with complete resection of the cystic abdominal mass.

Previously we identified threonine-1172 (T1172) in the cytoplasmic domain of the cell adhesion molecule L1 as phosphorylated in pancreatic cancer cells. Although both CKII- and PKC-blockade suppressed this modification, only CKII was capable of phosphorylating T1172 of a recombinant L1 cytoplasmic domain, suggesting the requirement for additional events to facilitate availability of T1172 to PKC. In this study, we demonstrate that the region around T1172 exists in distinct conformations based on both T1172 phosphorylation and the integrity of surrounding residues. We further demonstrate the role of membrane-proximal and membrane-distal residues in regulating cytoplasmic domain conformation, and that modification of 3 of the 4 tyrosines in the L1 cytoplasmic domain promote conformational changes that facilitate other events. In particular, phenylalanine-substitution of tyrosine-1151 or tyrosine-1229 promote opening up of the cytoplasmic domain in a manner that facilitates phosphorylation of the other 3 tyrosines, as well as phosphorylation of T1172 by PKCalpha. Importantly, we show that phosphorylation of serine-1181 is required for T1172 phosphorylation by CKII. These data define a specific role for secondary structure in regulating the availability of T1172 that facilitates phosphorylation by PKC.

Purpose : Our experience in robotic-assisted rectopexy with sigmoid colon resection (RAR+SR) or without sigmoid colon resection (RAR) was reviewed to determine if there was a significant difference in intra-operative or postoperative outcomes. Methods : We retrospectively reviewed 26 patients that underwent robotic-assisted rectopexy for rectal prolapse from 2006 to 2012. Rectopexy is performed with primary suture pexy and without mesh. Continuous variables were analyzed by t-test, while Fisher's exact test was applied for categorical data. Results : Twenty-two patients underwent RAR and 4 patients underwent RAR+SR. The average age for study participants was 56 years (range 21-78 years) and consisted of 4 men and 22 women. Recurrent rectal prolapse occurred in 2 patients at 3 and 30 months after surgery in the RAR group and no recurrence occurred in the RAR+SR group (p=1.00). The duration of surgery for RAR was 211 minutes versus 309 minutes for RAR+SR (p,0.001, CI 60.8 135.4). Intra-operative blood loss for RAR was 97.8mL compared to 87.5mL for RAR+SR (p=0.924, CI -77.4 89.7). Conversion to open procedure occurred twice with RAR and once with RAR+SR (p=0.407). Length of hospitalization averaged 3 days for RAR and 4 days for RAR+SR (p=0.196, CI -0.2 2.2). The mean follow up was 127 days (range 1-72 months). Eight of 10 patients with preoperative constipation subjectively noted improvement with RAR versus 1 of 2 patients with RAR+SR (p=0.455). Six of 10 patients with preoperative fecal incontinence had subjectively improved symptoms with RAR versus 1 of 2 patients with RAR+SR (p=1.00). Six patients in the RAR group experienced a postoperative complication (over-sedation, corneal abrasion, atrial flutter, pulmonary edema, pelvic hematoma, ileus) versus 1 complication (urinary retention) after RAR+SR (p=0.924). There were no mortalities and no complications requiring operative intervention. Conclusions : The majority of patients underwent RAR and outcomes for RAR versus RAR+SR were not significantly different in this series with the exception of increased operative time for RAR+SR. The recurrence rate was 8% and the complication rate was 27% with the majority of complications being minor complications.