James A. Edney

Hickman catheter-induced thoracic vein thrombosis. Frequency and long-term sequelae in patients receiving high-dose chemotherapy and marrow transplantation

One hundred sixty‐eight bone marrow transplant recipients and 49 patients who received high‐dose chemotherapy were evaluated for symptomatic thrombosis after Hickman catheter placement. The timing of thrombotic complications was different between these two groups, with the transplant group having a significantly lower thrombus‐free survival by 28 days after catheter placement. By 100 days after placement the thrombus‐free survival rates of the two groups were similar. The platelet count at time of catheter placement was significantly lower in the nontransplant group, and the thrombus‐free survival was longer in patients whose catheter was placed when their platelet count was less than 150,000, suggesting that thrombocytopenia delays thrombotic complications. Placement of two Hickman catheters resulted in a 12.9% thrombosis rate (21 of 162 patients) and was significantly more likely to be associated with thrombosis than placement of one catheter. Long‐term follow‐up evaluation of patients treated without successful fibrinolytic therapy showed no residual symptoms of venous obstruction. In those patients presenting with concomitant catheter obstruction resulting from thrombosis, low‐dose fibrinolytic therapy was successful in restoring catheter function 70% of the time. Placement of two Hickman catheters is associated with an inordinate incidence of thrombosis. Thrombocytopenia at the time of catheter placement may delay this complication. Thrombotic catheter obstruction can be treated successfully with low‐dose fibrinolytic therapy. Even without fibrinolytic therapy, catheter‐induced subclavian vein thrombosis rarely causes long‐term disability.

A review of global cancer burden: trends, challenges, strategies, and a role for surgeons.

Cancer is one of the leading causes of death worldwide. The global cancer burden (GCB) is expected to rise significantly and will disproportionately affect the less developed world (LDW). The aim of this review is to analyze the trends in GCB and describe the types, estimates, and causes of new cancer cases. The challenges and strategies associated with tackling this rising GCB are described in which surgeons can play a vital role. J. Surg. Oncol. 2013;107:221–226.

Is there a prognostic difference between functional and nonfunctional islet cell tumors

BACKGROUND Pancreatic islet cell tumors are categorized as either functioning or nonfunctioning. Functioning islet cell tumors (FIT) elaborate a variety of hormones, producing dramatic symptoms, while the initial presentation of non-functioning islet cell tumors (NIT) is commonly an abdominal mass or symptom complex related to invasion of adjacent structures. As a result, NIT are purported to present at a later stage, with lower resectability rates, and an overall poorer prognosis, when compared to FIT. In addition, a number of reports have indicated that the incidence of NIT has increased significantly in recent years. PATIENTS AND METHODS Twenty-eight patients were studied retrospectively. All had islet cell tumors of the pancreas and were seen at the University of Nebraska Medical Center and affiliated Nebraska Methodist Hospital during a 19-year period. RESULTS There were 9 patients (32%) in the NIT group and 19 (68%) in the FIT group. The mean ages at presentation were 61 years for the NIT and 52 years for the FIT group. In the NIT group, all presented with either abdominal pain (n = 7) or jaundice (n = 2). In contrast, over 90% of the patients with FIT had symptoms referable to the specific hormone elaborated by the tumor. Primary tumor size for NIT was 4.1 +/- 0.7 cm versus 5.0 +/- 0.6 cm for the FIT group. No significant difference was found for NIT versus FIT with respect to the incidence of metastatic disease at presentation (44% versus 53%), resectability rate with curative intent (44% versus 53%), or disease-free survival at 2 years (67% versus 40%). CONCLUSIONS This series, in contrast to earlier reports, suggests that nonfunctioning islet cell tumors do not present at a more advanced stage, have lower resectability rates, or an overall poorer long-term prognosis when compared to functioning tumors.

Pancreaticoduodenectomy for suspected but unproven malignancy.

BACKGROUND Pancreaticoduodenectomy is an accepted surgical option for certain benign conditions and biopsy proven cancer. Whether this procedure should be performed when malignancy of the pancreas and periampullary region is suspected but not confirmed represents a fairly common intraoperative dilemma. PATIENTS AND METHODS Sixty-seven patients who had undergone pancreaticoduodenectomy during a 15-year period were evaluated retrospectively. RESULTS The indications for resection were symptomatic benign conditions (n = 10, 15%), proven pancreatic or periampullary cancer (n = 37, 55%), and suspected but unproven malignancy (n = 20, 30%). The patients with suspected malignancy ranged in age from 27 to 73 years. Common findings in this group were abdominal pain (75%), jaundice (70%), weight loss (65%), and alcohol use (45%). There were 14 pancreatic and 6 ampullary masses. Biopsies obtained preoperatively (n = 15) and intraoperatively (n = 11) were nonconfirmatory. Postoperatively 9 patients (45%) were found to have tumors, including 6 pancreatic adenocarcinoma, 2 duodenal adenocarcinoma, and 1 islet cell tumor. Six of the 8 adenocarcinomas (75%) were stage I. Seven patients were alive 11 to 108 months later. The most common benign diagnosis was pancreatitis. There were 8 complications and 1 death. CONCLUSIONS Pancreaticoduodenectomy performed based on suspicion alone frequently reveals malignancy. Immediate and long-term outcomes are acceptable. These findings justify a continued aggressive approach to suspected pancreatic and periampullary malignancy.

Obstructed central venous catheters: Restoring function with a 12‐hour infusion of low‐dose urokinase

Thrombotic obstruction frequently prohibits infusion through or withdrawal of blood from central venous catheters and can occur in conjunction with symptomatic thrombosis of the subclavian vein. Thirty catheters were radiographically proved to be obstructed by thrombus and had not responded to at least one instillation of 5000 units of urokinase. All catheters were treated with a 12‐hour infusion of urokinase at the rate of 40,000 units/hour. the obstructing thrombus was either eliminated or reduced in size in all instances and full function was restored in all but one catheter. No bleeding complications were seen. Six patients with obstructed catheters also had symptoms of subclavian vein thrombosis. All patients with symptoms of subclavian vein obstruction became asymptomatic on anticoagulant therapy even though no attempt at dissolving the thrombus obstructing the subclavian vein was made. A 12‐hour infusion of low doses of urokinase can safely salvage function of obstructed catheters that otherwise may require replacement. Patients with concomitant subclavian vein thrombosis become asymptomatic on anticoagulant therapy without need to dissolve the obstructing thrombus.

Motor vehicle deaths: a rural epidemic

OBJECTIVE To determine the magnitude of the discrepancy in injury death rates between urban and rural counties and which types of injury deaths contribute most to this discrepancy. DESIGN A review of Nebraska death certificates over the period 1985-1989 was undertaken. Counties were divided into four groups according to population. Group I: urban counties (n = 3); group II: counties with a town of greater than 10,000 (n = 9); group III: counties with a total population of greater than 10,000 (n = 19); group IV: counties with a total population of less than 10,000 (n = 62). Age-adjusted death rates for heart disease, cancer, cerebrovascular disease, pneumonia, and injury were tabulated. Injury deaths were further categorized by intentional injury (homicide, suicide), and unintentional injury (motor vehicle-related, falls, drownings, poisoning, farm machinery-related, choking, firearms-related, fire-related and burns). INTERVENTIONS None. RESULTS Age-adjusted death rates per 100,000 population (with 95% confidence intervals) in group IV were lower than in group I for heart disease: 209 (193.9-224.1) vs. 227.4 (216.3-238.5); cancer: 135.9 (123.7-148.1) vs. 176.3 (166.6-186.0); cerebrovascular disease: 39.9 (33.3-46.5) vs. 44.6 (39.7-49.5); pneumonia: 19.6 (15.0-24.2) vs. 23.4 (19.8-27.0); and intentional injury deaths: 13.3 (9.5-17.0) vs. 15.1 (12.2-18.0). However, age-adjusted unintentional injury death rates were 54.2% higher in group IV than in group I: 42.7 (35.9-49.5) vs. 27.7 (23.8-31.6). Motor vehicle-related death rates were 93% higher: 23.3 (18.2-28.4) vs. 12.1 (9.5-14.7); and farm machinery-related deaths were 1250% higher: 2.7 (1.0-4.4) vs. 0.2 (-0.1-0.5). CONCLUSION Age-adjusted unintentional injury death rates are higher in the rural counties of Nebraska, even though death rates for the four other leading causes of death (heart disease, cancer, cerebral vascular disease, and pneumonia) and intentional injury are lower. Although farm machinery-related deaths have the largest percentage difference between rural and urban counties, motor vehicle-related deaths are the major contributor to the unintentional injury death rate discrepancy in rural Nebraska.

Gucagonoma syndrome is an underdiagnosed clinical entity

Glucagonomas, considered among the rarest of the islet cell neoplasms, produce a well-defined clinical syndrome characterized by necrolytic migratory erythema, diabetes mellitus, glossitis, anemia, and weight loss. This report describes seven patients with glucagonoma treated at our institution. All seven had the characteristic dermatologic manifestations, present from 1 to 6 years prior to diagnosis. Five patients had extensive disease at the time of initial operation, three of whom underwent aggressive cytoreductive surgery, whereas the other two had biopsy only. The remaining two patients presented with a single nodule each, underwent distal pancreatectomy and splenectomy, and remain free of disease 2 and 6 years postoperatively. Earlier recognition of the distinctive physical findings peculiar to this syndrome should increase survival. Aggressive cytoreductive surgery results in prolonged remission.

Peritoneovenous shunts palliate malignant ascites

Fifty-five peritoneovenous shunts (PVS) were implanted in 45 patients (29 LeVeen and 26 Denver shunts). Seventy-five percent of patients experienced relief of symptoms referable to their ascites. The mean survival time post-shunt placement was 33 weeks; however, considerable variation was noted in survival times for the various tumor types (pancreas 7 weeks, ovary 71 weeks). Significant alterations in coagulation parameters consistent with subclinical disseminated intervascular coagulation (DIC) were present in all patients with functioning shunts. These coagulation changes have proven reliable indicators of shunt patency. Shunt revision was necessary in 18 percent of patients. No significant difference in shunt patency was detected when Denver and LeVeen shunts were compared. This experience indicates that PVS offers effective palliation without undue morbidity for malignant ascites. The best results can be expected in those patients with ovarian and breast primary tumors. Because of the short time from onset of disabling ascites until death, PVS is not indicated in the majority of patients with pancreatic cancer.

National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development?

BACKGROUND The aim of this study was to analyze national trends in minimally invasive and open cases of all graduating residents in general surgery. METHODS A retrospective analysis was performed on data obtained from Accreditation Council for Graduate Medical Education logs (1999-2008) of graduating residents from all US general surgery residency programs. Data were analyzed using Mantel-Haenszel χ(2) tests and the Bonferroni adjustment to detect trends in the number of minimally invasive and open cases. RESULTS Minimally invasive procedures accounted for an increasing proportion of cases performed (3.7% to 11.1%, P < .0001), with a proportional decrease in open cases. An increase in minimally invasive procedures with a proportional decrease in open procedures was noted in subcategories such as alimentary tract, abdominal, vascular, thoracic, and pediatric surgery (P < .0001). CONCLUSIONS The results of this study demonstrate that general surgery residents in the United States are performing a greater number of minimally invasive and fewer open procedures for common surgical conditions.

Pneumoperitoneum after cardiopulmonary resuscitation: a therapeutic dilemma.

We report a patient who developed pneumoperitoneum after cardiopulmonary resuscitation. Ten cases have been reported in the literature. Despite the patients serious condition, celiotomy was performed to rule out perforation of a hollow viscus and none was found. The likelihood of visceral perforation in this setting is high and despite increasing recognition of pneumoperitoneum that does not require surgical intervention, nonoperative management should not be entertained in this setting unless visceral perforation can be excluded.