Ronald S. Chamberlain

A Comprehensive Review of Single-Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) Techniques for Cholecystectomy

IntroductionSurgery of the gallbladder has evolved tremendously over the last century. Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. In recent times, innovative techniques of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been applied in gallbladder removal as a step towards even more less-invasive procedures.DiscussionWhile NOTES and SILS represent the advent of essentially scarless surgery, limited applications of these technologies in human subjects exists. In this article, we present a comprehensive review of the potential benefits, limitations and risks of these novel techniques.ConclusionWhile much remains unknown and unanswered surrounding these procedures, it is clear that extensive research and development with regards to the ethics and the technical aspects of these procedures as well as randomized studies to compare them with traditional laparoscopy are essential.

Daptomycin for the treatment of surgical site infections

BACKGROUNDnThe increasing frequency of methicillin-resistant Staphylococcus aureus (MRSA) as a cause of surgical site infections, and decreased susceptibility to vancomycin, highlight the need for alternative therapies.nnnMETHODSnAll patients with a surgical site infection enrolled in the Cubicin Outcomes Registry and Experience (CORE 2007 retrospective multicenter registry were studied. Outcome was assessed at the end of daptomycin therapy using protocol-defined criteria. Success was defined as cured or improved. Non-evaluable patients were excluded from the efficacy analysis but were included in the safety analysis.nnnRESULTSnOf 962 patients in the CORE registry in 2007, 104 (11%) had a surgical infection and met the criteria for the efficacy analysis. The overall success rate was 91% (95/104). The distribution of surgical site infections by depth was 36% (38/104) superficial incisional, 36% (38/104) deep incisional, and 27% (28/104) organ/space. Success rates by infection depth were 92% for superficial incisional, 92% deep incisional, and 89% organ/space (P = .9). Success in patients with and without surgery was 89% (49/55) and 94% (46/49) (P = .5). The median final daptomycin dose was 5.5 mg/kg. The median duration of daptomycin therapy was 14 days. Prior antibiotic therapy was given to 79% of patients; 35% failed. Prior vancomycin was used in 45% of patients; 24% failed. Among vancomycin failures, the daptomycin success rate was 91% (10/11). Of those with a positive culture, common pathogens were S. aureus (68%; MRSA 61%) and enterococci (26%; vancomycin-resistant 36%). There were 9 possible treatment-related adverse events (AEs) in 8 of 118 (7%) patients; 2 serious AEs were reported in 1 patient.nnnCONCLUSIONnSuccess rates for patients with a surgical site infection treated with daptomycin were high and did not differ based on the need for surgical intervention. High success rates were achieved in patients with infection caused by MRSA as well as in patients who had failed to respond to previous antibiotic therapies, including vancomycin, regardless of the depth of the infection.

Atypical teratoid rhabdoid tumors: a population-based clinical outcomes study involving 174 patients from the Surveillance, Epidemiology, and End Results database (1973–2010)

Introduction Atypical teratoid rhabdoid tumors (ATRTs) are rare, highly malignant embryonal tumors of the central nervous system (CNS) accounting for 20% of CNS tumors in children under the age of 3. This study examines a large cohort of ATRT patients to determine demographic, clinical, and pathologic factors which impact prognosis and survival. Methods Demographic and clinical data were abstracted on 174 ATRT patients (171 pediatric patients age <20 and 3 adult patients age ≥20) from the Surveillance, Epidemiology, and End Results database (1973–2010). Standard statistical methodology was used. Results A total of 174 ATRT cases (mean age of 2.84 years) were identified. ATRT had a higher incidence in males (56.3%), Caucasians (59.1%), and children <3 years of age (80.5%), P<0.001. The most common primary sites were the cerebellum (17.8%), ventricles (16.1%), and frontal lobe (12.6%). Mean overall survival was 3.2±0.4 years, while overall and cancer-specific mortality were 63.2% and 56.3%, respectively, P=0.005. Most ATRT cases were treated with surgery alone (58.0%), followed by a combination of surgery and radiation (34.3%), no treatment (6.5%), and radiation alone (1.2%). The use of combination therapy has increased significantly (16.1%) since 2005 (P<0.001), while primary surgical resection and radiation therapy rates remain relatively unchanged. The longest survival was observed among ATRT patients receiving combination therapy (5.9±0.7 years), followed by radiation alone (2.8±1.2 years), and surgery alone (1.9±0.4 years), P<0.001. Multivariable analysis identified only distant metastases (OR =4.6) as independently associated with increased mortality, whereas combination therapy (OR =0.4) was associated with reduced mortality, P<0.005. Conclusion ATRT is a rare and highly aggressive embryonal malignancy of the CNS that presents more often as locoregional tumors >4 cm in male Caucasian children of age <3 years, involving the cerebellum, ventricles, or frontal lobe. Combination therapy significantly improves survival, and its use has been increasing since 2005.

Rapid progression of multiple splanchnic artery aneurysms

THAT INCLUDED LONG-STANDING MUSCULAR DYSTROPHY presented with moderate-to-severe epigastric and mid-back pain. Family history was noncontributory. The patient worked as a full-time computer instructor. He was a social drinker and denied a history of cigarette smoking or illicit drug use. At initial presentation, vital signs were normal except for a blood pressure of 148/105 mm Hg. Physical examination revealed moderate epigastric tenderness without rebound or guarding. Laboratory findings were unremarkable, and the hemoglobin was 12.4 g/dL (hematocrit, 37%). A computed tomography of the abdomen and pelvis demonstrated a retroperitoneal hemorrhage that involved the mesenteric circulation. A mesenteric arteriogram (Fig 1) was performed that revealed high-grade stenosis of the celiac artery origin with retrograde filling via superior mesenteric artery (SMA) collaterals as well as aneurysms of the celiac artery trifurcation and inferior pancreaticoduodenal artery (IPDA)

Pediatric Burns: A Single Institution Retrospective Review of Incidence, Etiology, and Outcomes in 2273 Burn Patients (1995-2013).

Unintentional burn injury is the third most common cause of death in the U.S. for children age 5 to 9, and accounts for major morbidity in the pediatric population. Pediatric burn admission data from U.S. institutions has not been reported recently. This study assesses all pediatric burn admissions to a State wide Certified Burn Treatment Center to evaluate trends in demographics, burn incidence, and cause across different age groups. Demographic and clinical data were collected on 2273 pediatric burn patients during an 18-year period (1995–2013). Pediatric patients were stratified by age into “age 0 to 6,” “age 7 to 12,” and “age 13 to 18.” Data were obtained from National Trauma Registry of the American College of Surgeons and analyzed using standard statistical methodology. A total of 2273 burn patients under age 18 were treated between 1995 and 2013. A total of 1663 (73.2%) patients were ages 0 to 6, 294 (12.9%) were 7 to 12, and 316 (13.9%) were age 13 to 18. A total of 1400 (61.6%) were male and 873 (38.4%) were female (male:female ratio of 1.6:1). Caucasians had the highest burn incidence across all age groups (40.9%), followed by African-Americans (33.6%), P < .001. Caucasian teenagers formed 62.1% of patients age 13–18, P < .001. A total of 66.3% of all pediatric burns occurred at home, P < .001. Mean TBSA burned was 8.9%, with lower extremity being the most common site (38.5%). Scald burns constituted the majority of cases (71.1%, n = 1617), with 53% attributable to hot liquids related to cooking, including coffee or tea, P < .001. In the teenage group, flame burns were the dominant cause (53.8%). Overall mean length of stay was 10.5u2009±u200910.8 days for all patients, and15.5u2009±u200912 for those admitted to the intensive care unit, P < .005. One hundred (4.4%) patients required ventilator support (P = .02), and average duration of mechanical ventilation was 11.9u2009±u200914.5 days. Skin grafting was performed for 520 (22.9%) patients, P < .001. Overall mortality was 0.9% (n = 20), with mean TBSA involved of 61.5%. The majority of pediatric burn injuries are scald burns that occur at home and primarily affect the lower extremities in Caucasian and African-American males. Among Caucasian teenagers flame burns predominate. Mean length of stay was 10 days, 23% of patients required skin grafting surgery, and mortality was 0.9%. The results of this study highlight the need for primary prevention programs focusing on avoiding home scald injuries in the very young, as well as fire safety training for teenagers.

Management of Enteropathy-Associated T-Cell Lymphoma: An Algorithmic Approach.

Perforation of the small intestine is the most lethal complication following induction chemotherapy for enteropathy-associated T-cell lymphoma (EATL). We report a case of EATL with a near perforated jejunal ulcer, and suggest a novel approach towards its management. Surgical resection followed by aggressive chemotherapy should limit chemotherapy-associated gastrointestinal toxicity, thus allowing patients to receive adequate dose and duration of chemotherapy. The presented case highlights potential benefits of surgical intervention prior to chemotherapy for EATL.

Acute progression of multiple visceral artery aneurysms

A 62-year-old male with multiple medical problems including a long-standing history of muscular dystrophy presented with recurrent abdominal and back pain of 2-month duration. Two consecutive mesenteric arteriograms were performed 3 weeks apart as part of the work-up and treatment. The latest study revealed a significant progression in the size and number of visceral artery aneurysms. No association between the patients muscular dystrophy and rapid development of these aneurysms has been previously reported. The patients overall health and vascular anatomy prohibited any therapeutic intervention. This case represents the highest number of visceral artery aneurysms (13 in total) reported in a single patient.

Disease Severity, Presentation and Clinical Outcomes among Adolescents with Malignant Breast Neoplasms: A 20-year Population-based Outcomes Study from the SEER Database (1973-2009).

Introduction Primary breast cancer in adolescents is extremely rare and thus is not widely studied. This study aimed to evaluate trends, characteristics, and outcomes among a cohort of adolescents with breast cancer. Patients and Methods A total of 657,712 female patients with breast cancer from Surveillance Epidemiology and End Results (SEER) database (1973‐2009) were analyzed, and 91 adolescents were identified. Three age groups (under 20 years, 20‐50 years or premenopausal, and > 50 years or postmenopausal) were compared for tumor size, stage, receptor status, and outcomes. Categorical data were compared by chi‐square (Fisher) test and continuous data with Students t test. Results Median age was 19 years (range, 10‐20 years). A total of 52.7% (n = 48) and 5.5% (n = 5) of patients presented with invasive and in‐situ cancers, respectively, and 37.3% (n = 34) with sarcomas. Median tumor size of invasive cancers was 3.2 cm (range, 0.1‐12.5 cm). Sixty percent of patients presented with regional disease, and the majority (28%) of those tested were receptor negative. Mortality rates in adolescents were higher than pre‐ and postmenopausal patients in localized and regional stage. Overall median survival was 106 months. Conclusion Although rare, breast cancer does occur in adolescent girls and must be considered in differential of breast masses in females under 20, especially with strong breast cancer family history. Prognosis maybe worse than in older patients; however, the sample size is small. Delay in diagnosis, aggressive tumor biology, and negative receptor status may affect prognosis. Routine breast examination in high‐risk older adolescents may permit early identification and avoid delay in diagnosis and treatment. Micro‐Abstract Very little is known about the pattern of breast cancer disease in adolescent girls. Age at presentation, family history of breast cancer or BRCA mutation carriers, screening and diagnosis, type of surgery and reconstruction, long term effects of chemotherapy and radiation are all questions that have not been fully investigated in this age group. In the present manuscript, we present the patterns of malignant breast disease in the adolescent group.

Chronic diaphragmatic hernia: a delayed problem requiring urgent response.

Traumatic rupture of the diaphragm is a serious injury that can present in a variety of forms, and many may go undetected, presenting later as gradual herniation of the abdominal organs into the thorax because of negative intrathoracic pressure. Our patient suffered a motor vehicle accident (MVA) at the age 4 and presented with a chronic diaphragmatic hernia (CDH) 43 years later, which is the longest interval reported. The possibility of lethal complications from CDH mandates prompt repair after diagnosis. CDH repair presents a unique challenge as several surgical techniques have been described, yet no standard procedure currently exists. We describe a trans-abdominal, tension-free prosthetic repair of a large CDH and review other approaches. A 47-year-old man with a history of gastro-oesophageal reflux disease and a prior MVA (43 years earlier) presented with chest and abdominal pain accompanied by vomiting. On chest auscultation left-sided breath sounds were diminished. A computed tomography (Fig. 1) and small bowel series (Fig. 2) revealed a diaphragmatic hernia with significant mediastinal shift secondary to the presence of stomach and bowel loops in the left chest cavity. The diaphragmatic hernia was attributed to the patient’s 43-year-old MVA. Surgical exploration and repair was performed through a midline abdominal incision without thoracotomy. The left diaphragmatic hernial defect (6 ¥ 11 cm) involved muscular as well as tendinous portions of the diaphragm (Fig. 3). Using ultrasonic coagulation and blunt dissection dense pleural adhesions were divided, the edges were mobilized, and hernial contents were reduced into the abdomen. Positioning the patient in steep reverse trendelenburg aided in the reduction of hernia contents and in the retraction of the viscera, which reduced the ventilatory peak pressures from 28 to