Edward L. Jones

Long-term Follow-up and Survival of Patients Following a Recurrence of Melanoma After a Negative Sentinel Lymph Node Biopsy Result

OBJECTIVEnTo analyze the predictors and patterns of recurrence of melanoma in patients with a negative sentinel lymph node biopsy result.nnnDESIGNnRetrospective chart review of a prospectively created database of patients with cutaneous melanoma. SETTING Tertiary university hospital.nnnPATIENTSnA total of 515 patients with melanoma underwent a sentinel lymph node biopsy without evidence of metastatic disease between 1996 and 2008.nnnMAIN OUTCOME MEASURESnTime to recurrence and overall survival.nnnRESULTSnOf 515 patients, 83 (16%) had a recurrence of melanoma at a median of 23 months during a median follow-up of 61 months (range, 1-154 months). Of these 83 patients, 21 had melanoma that metastasized in the studied nodal basin for an in-basin false-negative rate of 4.0%. Patients with recurrence had deeper primary lesions (mean thickness, 2.7 vs 1.8 mm; P < .01) that were more likely to be ulcerated (32.5% vs 13.5%; P < .001) than those without recurrence. The primary melanoma of patients with recurrence was more likely to be located in the head and neck region compared with all other locations combined (31.8% vs 11.7%; P < .001). Median survival following a recurrence was 21 months (range, 1-106 months). Favorable characteristics associated with lower risk of recurrence included younger age at diagnosis (mean, 49 vs 57 years) and female sex (9% vs 21% for males; P < .001).nnnCONCLUSIONnOverall, recurrence of melanoma (16%) after a negative sentinel lymph node biopsy result was similar to that in previously reported studies with an in-basin false-negative rate of 4.0%. Lesions of the head and neck, the presence of ulceration, increasing Breslow thickness, older age, and male sex are associated with increased risk of recurrence, despite a negative sentinel lymph node biopsy result.

Laparoscopic sleeve gastrectomy: long-term weight loss outcomes

BACKGROUNDnLaparoscopic sleeve gastrectomy (LSG) has become an increasingly popular stand-alone weight loss surgery, but there is a paucity of long-term efficacy data.nnnOBJECTIVEnTo determine long-term outcomes for patients undergoing LSG.nnnSETTINGnTertiary care university hospital in the United States.nnnMETHODSnThis study presents a case series of the first 16 patients undergoing LSG at our institution. Inclusion criteria were accepted indications for bariatric surgery, and exclusion criteria were any prior bariatric surgery, gastrectomy, substance abuse, uncontrolled psychiatric illness, end-stage organ disease, or advanced-stage cancer. Patients were followed for 7 years. Outcomes included percent excess weight loss (%EWL), percent weight loss (%WL), resolution of co-morbidities, and major and minor complications.nnnRESULTSnPatients enrolled in this study had a mean body mass index (BMI) of 43.5 kg/m(2) and a mean age of 49, and 14 of 16 patients were women. Fourteen of 16 patients had 7-year follow-ups with a mean %WL of 29.6%±8.95 and a mean %EWL of 59.6%±89.9%. At 7 years, 11 of 14 patients achieved>50% EWL. One-year follow-up data revealed a mean EWL of 72%±20%, which was significantly greater than the %EWL at 7 years (P = .005). Complications included 1 partial obstruction at the gastric incisura angularis and 1 subacute leak; both were managed endoscopically. There were no reoperations and no deaths. Five of 14 patients experienced new-onset gastroesophageal reflux disease.nnnCONCLUSIONSnAt 7 years postoperative, the LSG remained a durable and successful operation.

Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours

BACKGROUND The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. LEVEL OF EVIDENCE Therapeutic study, level IV. Epidemiologic study, level III.

Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study

Background and study aimsu2002The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. Patients and methodsu2002All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥u200a14.72 (cases) and 2) DeMeester score of <u200a14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥u200a14.72 who was not consuming proton pump inhibitor (PPI). Resultsu2002A total of 282 patients (female 48.2u200a%, Caucasian 84.8u200a%; mean body mass index 24.1u200akg/m2) were included. Clinical success was achieved in 94.3u200a% of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10u200a-u200a24 months). A DeMeester score ofu200a≥u200a14.72 was seen in 57.8u200a% of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95u200a% confidence interval 1.04u200a-u200a2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2u200a%) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1u200a%. Conclusionu2002Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique.

Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy

IntroductionPeroral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Postoperative reflux has been found in a significant number of patients, but it is unknown whether subjective reports of reflux correlate with objective pH testing. The purpose of this study was to compare the objective rate of reflux with standardized reflux symptom scales after POEM. Our hypothesis was that subjective symptoms would not correlate with objective measurement of reflux.Methods and proceduresData on all patients undergoing POEM were collected prospectively between August 2012 and June 2014 and included demographics, objective testing (48-h pH probe, manometry, endoscopy), as well as gastroesophageal reflux disease health-related quality of life (GERD-HRQL), GERD symptom scale (GERSS), and antacid use.ResultsForty-three patients underwent POEM during the study period. The mean age was 53.5xa0±xa017.4xa0years with a BMI of 29.6xa0±xa08.4xa0kg/m2, and 27 (63%) were male. Forty-two patients (98%) completed at least 6xa0months of follow-up, and 26 (60%) underwent repeat pH measurement. Dysphagia scores improved from 4 (0–5) at baseline to 0 (0–3) (pxa0<xa00.001). On follow-up pH testing, 11 (42%) were normal and 15 (58%) had elevated DeMeester scores. Postoperative GERSS or GERD-HRQL scores did not correlate with DeMeester scores on Spearman’s rank-order tests (rxa0=xa00.02, pxa0=xa00.93 and rxa0=xa00.04, pxa0=xa00.50, respectively). Postoperative PPI use was not significantly associated with normal or abnormal pH testing: 5 of 7 (71%) patients who were taking PPIs postoperatively had abnormal DeMeester scores compared to 9 of 18 (50%) of patients who were not taking PPIs (pxa0=xa00.332).ConclusionsPeroral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a high rate of reflux on pH testing postoperatively. Subjective symptoms are not a reliable indicator of postoperative reflux. Routine pH testing should be considered in all patients following POEM.

Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia

AbstractIntroductionPer-oral endoscopic myotomy (POEM) is an emerging treatment for achalasia. Pneumatic dilation, botulinum toxin injection, and previous myotomy increase the difficulty of subsequent Heller myotomy, but their impact on POEM remains unknown. The purpose of this study was to compare patients who had undergone prior treatment for their achalasia to those undergoing POEM as an initial therapy.nMethods and ProceduresAll patients undergoing POEM were entered into a prospective database from August 2012 to October 2014. Data collected included demographics, dysphagia and symptom survey scores, operative time, clips required for mucosotomy closure, perioperative complications and length of hospital stay.ResultsForty-five patients underwent POEM during the study period. Fifteen (30xa0%) had undergone previous treatment (seven Botox injection, five pneumatic dilation and three Heller myotomy). Primary POEM patients were younger than those who had had prior treatment (mean age 46xa0±xa017 vs. 64xa0±xa012xa0years, pxa0<xa00.001), but gender, body mass index and ASA class were not significantly different. There were no conversions to Heller myotomy or perioperative complications in either group. Operative time for primary POEM was 103xa0±xa027 versus 102xa0±xa029xa0min following prior treatment (pxa0=xa00.84). Mucosotomy closure required a median 7 (4–16) and 8 (5–16) clips, respectively (pxa0=xa00.08). Length of stay was 1xa0day in each group. Median dysphagia scores decreased from 4 (0–5) to 1 (0–4) following primary POEM and 4 (0–5) to 0 (0–4) in the prior treatment group (pxa0=xa00.45) during a median follow-up of 10xa0months (5–17xa0months). All patients in each group expressed satisfaction with their procedure and would undergo the procedure again given the benefit of hindsight.ConclusionPer-oral endoscopic myotomy is a safe and effective treatment for achalasia which improves dysphagia and disease-specific quality of life. Previous endoscopic or laparoscopic treatment of achalasia does not affect the performance or early outcome of POEM.

Radiofrequency energy antenna coupling to common laparoscopic instruments: practical implications

BackgroundElectromagnetic coupling can occur between the monopolar “Bovie” instrument and other laparoscopic instruments without direct contact by a phenomenon termed antenna coupling. The purpose of this study was to determine if, and to what extent, radiofrequency energy couples to other common laparoscopic instruments and to describe practical steps that can minimize the magnitude of antenna coupling.MethodsIn a laparoscopic simulator, monopolar radiofrequency energy was delivered to an L-hook. The tips of standard, nonelectrical laparoscopic instruments (either an unlit 10xa0mm telescope or a 5xa0mm grasper) were placed adjacent to bovine liver tissue and were never in contact with the active electrode. Thermal imaging quantified the change in tissue temperature nearest the tip of the telescope or grasper at the end of a 5xa0s activation of the active electrode.ResultsA 5xa0s activation (30 watts, coagulation mode, 4xa0cm separation between instruments) increased tissue temperature compared with baseline adjacent to the grasper tip (2.2xa0±xa02.2xa0°C; pxa0=xa00.013) and telescope tip (38.2xa0±xa08.0xa0°C; pxa0<xa00.001). The laparoscopic telescope tip increased tissue temperature more than the laparoscopic grasper tip (pxa0<xa00.001). Lowering the generator power from 30 to 15 Watts decreased the heat generated at the telescope tip (38.2xa0±xa08.0 vs. 13.5xa0±xa07.5xa0°C; pxa0<xa00.001). Complete separation of the camera/light cords and the active electrode cord decreased the heat generated near the telescope tip compared with parallel bundling of the cords (38.2xa0±xa08.0 vs. 15.7xa0±xa011.6xa0°C; pxa0<xa00.001).ConclusionsCommonly used laparoscopic instruments couple monopolar radiofrequency energy without direct contact with the active electrode, a phenomenon that results in heat transfer from a nonelectrically active instrument tip to adjacent tissue. Practical steps to minimize heat transfer resulting from antenna coupling include reducing the monopolar generator power setting and avoiding of parallel bundling of the telescope and active electrode cords.

Effect of monopolar radiofrequency energy on pacemaker function

BackgroundThis study aimed to quantify the clinical parameters of mono- and bipolar instruments that inhibit pacemaker function. The specific aims were to quantify pacer inhibition resulting from the monopolar instrument by altering the generator power setting, the generator mode, the distance between the active electrode and the pacemaker, and the location of the dispersive electrode.MethodsA transvenous ventricular lead pacemaker overdrive paced the native heart rate of an anesthetized pig. The primary outcome variable was pacer inhibition quantified as the number of beats dropped by the pacemaker during 5xa0s of monopolar active electrode activation.ResultsLowering the generator power setting from 60 to 30xa0W decreased the number of dropped paced events (2.3xa0±xa01.2 vs 1.6xa0±xa00.8 beats; pxa0=xa00.045). At 30xa0W of power, use of the cut mode decreased the number of dropped paced beats compared with the coagulation mode (0.6xa0±xa00.5 vs 1.6xa0±xa00.8; pxa0=xa00.015). At 30xa0W coagulation, firing the active electrode at different distances from the pacemaker generator (3.75, 7.5, 15, and 30xa0cm) did not change the number of dropped paced beats (pxa0=xa00.314, analysis of variance [ANOVA]). The dispersive electrode was placed in four locations (right/left gluteus, right/left shoulder). More paced beats were dropped when the current vector traveled through the pacemaker/leads than when it did not (1.5xa0±xa01.0 vs 0.2xa0±xa00.4; pxa0<xa00.001).ConclusionsClinical parameters that reduce the inhibition of a pacemaker by monopolar instruments include lowering the generator power setting, using cut (vs coagulation) mode, and locating the dispersive electrode so the current vector does not traverse the pacemaker generator or leads.

Vitamin D deficiency does not increase the rate of postoperative hypocalcemia after thyroidectomy

BACKGROUNDnHypocalcemia is a frequent complication of thyroidectomy. Although typically mild and temporary, it can lead to an increased length of stay, readmission, and in some cases be permanent. Controversy exists as to whether vitamin D deficiency (VDD) contributes to post-thyroidectomy hypocalcemia.nnnMETHODSnThis is a retrospective study of 152 patients who underwent thyroidectomy. Patients with or without VDD were compared. Data were analyzed for demographics, operative procedure, calcium levels, and complications of hypocalcemia.nnnRESULTSnThere was no difference in the rates of biochemical or symptomatic hypocalcemia or in the need for readmission between the VDD and non-VDD groups. A multivariate analysis controlling for central neck dissection, parathyroid autotransplant, and preoperative diagnosis confirmed no association between VDD and post-thyroidectomy hypocalcemia.nnnCONCLUSIONSnDespite VDD being common in patients undergoing thyroidectomy, our results do not suggest that this increases the rate of hypocalcemia. Thus, preoperative evaluation/repletion of VDD is unlikely to reduce post-thyroidectomy hypocalcemia rates.

Effect of Radiofrequency Energy Emitted from Monopolar “Bovie” Instruments on Cardiac Implantable Electronic Devices

BACKGROUNDnThe monopolar Bovie instrument emits radiofrequency energy that can disrupt the function of other implanted electronic devices through a phenomenon termed electromagnetic interference. The purpose of this study was to quantify the electromagnetic interference occurring on cardiac implantable devices (CIEDs) resulting from monopolar instrument use in common, modifiable clinical scenarios.nnnSTUDY DESIGNnThree anesthetized pigs underwent CIED placement (1 pacemaker and 2 defibrillators). Electromagnetic interference was quantified when changing the monopolar instrument parameters of generator power, generator mode, surgical technique, orientation of active electrode cord, pathway of current vector, and proximity of active electrode to the CIED.nnnRESULTSnMonopolar instrument parameters that decreased the electromagnetic interference occurring on the CIED included decreasing generator power from 60 W to 30 W (p < 0.001), using cut mode rather than coag mode (p < 0.001), using desiccation technique rather than fulguration technique (p < 0.001), orienting the active electrode cord from the feet rather than across the chest wall (p < 0.001), and avoiding the current vector from crossing the CIED system (p < 0.001). Increasing the distance between the active electrode tool and the CIED system decreased electromagnetic interference occurring on the CIED in a dose-response fashion up to a distance of 10 cm (ANOVA, p < 0.001), after which the magnitude of electromagnetic interference remained constant.nnnCONCLUSIONSnElectromagnetic interference occurring on CIEDs resulting from monopolar instruments is minimized by decreasing generator power, using cut mode, using desiccation technique, orienting the active electrode cord from the feet, avoiding the current vector for crossing the CIED system, and increasing the distance between the active electrode and the CIED. Surgeons and operating room staff can minimize electromagnetic interference on CIEDs during monopolar instrument use by accounting for these modifiable clinical factors.