Thomas A. Broughan

Primary Breast Lymphoma: The Role of Mastectomy and the Importance of Lymph Node Status

Objective:To construct and analyze a database comprised of all reported cases of primary breast lymphoma (PBL) that include treatment and follow-up information published during the last 3 decades. Summary Background Data:PBL accounts for 0.4% of breast malignancies and 2% of extranodal lymphomas. Surgical therapy has varied from biopsy to radical mastectomy. Chemotherapy and radiation therapy have been used as adjuvant or primary therapy. A standard consensus treatment of PBL is not available. Methods:We reviewed all published PBL reports from June 1972 to March 2005. A database was compiled by abstracting individual patient information, limiting our study to those reports that contained specific treatment and outcome data. Patient demographics such as survival, recurrence, and time to follow-up were recorded, in addition to surgical, radiation, and/or chemotherapy treatment(s). Results:We found 465 acceptable patients reported in 92 publications. Age range was 17 to 95 years (mean, 54 years). Mean tumor size was 3.5 cm. Diffuse large cell (B) lymphoma was the most common histologic diagnosis (53%). Disease-free survival was 44.5% overall. Follow-up ranged from one to 288 months (mean, 48 months). Treatment by mastectomy offered no survival benefit or protection from recurrence. Treatment that included radiation therapy in stage I patients (node negative) showed benefit in both survival and recurrence rates. Treatment that included chemotherapy in stage II patients (node positive) showed benefit in both survival and recurrence rates. Histologic tumor grade predicted survival. Conclusions:Mastectomy offers no benefit in the treatment of PBL. Nodal status predicts outcome and guides optimal use of radiation and chemotherapy.

Laparoscopic exploration for the clinically undetected hernia in infancy and childhood

BACKGROUND Routine contralateral groin exploration in infants and children with a clinically detected inguinal hernia is the subject of much debate. The detection of a patent processus vaginalis by transinguinal laparoscopy has proven advantageous. However, controversy remains regarding the true incidence of a contralateral patent processus vaginalis as well as which of these will actually develop into a clinically apparent hernia. METHODS From January 1997 through December 1999, 358 infants and children (aged 1 to 157 months, mean 32) were treated in the three University of Oklahoma teaching hospitals in Tulsa, Oklahoma, for inguinal hernia. The findings at laparoscopic exploration of the contralateral side were recorded to determine the incidence of contralateral patency as it relates to a childs age, gender, and side of the initial clinical diagnosis. RESULTS The overall incidence of a patent processus vaginalis on contralateral examination was 33% (117 of 358). All patent processus vaginalis were repaired. Bilateral inguinal hernia was significantly more common in younger patients (present in 50% if less than 1 year, 45% if less than 2 years, 37% if less than 5 years, and 15% if greater than 5 years of age; P <0.05). In boys, the incidence was 49%, 45%, and 32% in those under 1 year of age, under 2 years of age, and in total, respectively. In girls, the incidence was 59%, 50%, and 37% in those under 1 year of age, under 2 years of age, and in total, respectively. The side of the clinically detected hernia did not influence the laparoscopic findings of a contralateral hernia with 30% (50 of 169) positive findings on left inguinal exploration versus 31% (28 of 90) positive findings on right inguinal exploration. CONCLUSIONS The high incidence of a contralateral patent processus vaginalis warrants routine laparoscopic exploration in infants and children undergoing unilateral inguinal hernia repair, especially those less than 5 years of age. The use of transinguinal laparoscopic explorations avoids unnecessary open exploration in 66% of infants and children undergoing inguinal hernia repair.

Brachial vein transposition arteriovenous fistulas for hemodialysis access

BACKGROUND An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis, offering lower morbidity, mortality, and cost compared with grafts or catheters. Patients with a difficult access extremity have often lost all superficial veins, and even basilic veins may be obliterated. We have used brachial vein transposition AVFs (BVT-AVFs) in these challenging patients and review our experience in this report. METHODS The study reviewed consecutive patients in whom BVT-AVFs were created from September 2006 to March 2009. Most BVT-AVFs were created in staged procedures, with the second-stage transposition operations completed 4 to 6 weeks after the first-stage AVF operation. A single-stage BVT-AVF was created when the brachial vein diameter was > or =6 mm. RESULTS We identified 58 BVT-AVF procedures, comprising 41 women (71.0%), 28 diabetic patients (48.3%), and 29 (50.0%) had previous access surgery. The operation was completed in two stages in 45 operations (77.6%) and was a primary transposition in 13 patients. However, five of these were secondary AVFs with previous distal AV grafts or AVFs placed elsewhere; effectively, late staged procedures. Follow-up was a mean of 11 months (range, 2.0-31.7 months). Primary patency, primary-assisted patency, and cumulative (secondary) patency were 52.0%, 84.9%, and 92.4% at 12 months and 46.2%, 75.5%, and 92.4% at 24 months, respectively. Harvesting the brachial vein was tedious and more difficult than harvesting other superficial veins. No prosthetic grafts were used. CONCLUSION BVT-AVFs provide a suitable option for autogenous access when the basilic vein is absent in patients with difficult access extremities. Most patients required intervention for access maturation or maintenance. Most BVT-AVFs were created with staged procedures. Cumulative (secondary) patency was 92.4% at 24 months.

Creating Radiocephalic Arteriovenous Fistulas: Technical and Functional Success

BACKGROUND The radiocephalic arteriovenous fistula (RC-AVF) at the wrist is the recommended first choice for hemodialysis access. Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients. We report a consecutive series of individuals in whom physical and ultrasonography (US) examinations predicted success with RC-AVFs. STUDY DESIGN Records of all patients who underwent vascular access operations by the communicating author from June 2003 through June 2008 were reviewed to identify those individuals with RC-AVF procedures. Physical examination and US screening criteria for creating a RC-AVF included a continuous and uninterrupted outflow vein diameter > or = 2.5 mm and a normal radial artery inflow examination with vessel diameter > or = 2.0 mm. A venous branching point at the wrist was identified to create a broad patch for the RC-AVF anastomosis. RESULTS We reviewed 796 consecutive vascular access operations, identifying 75 RC-AVFs created in 74 patients. Patient ages were 20 to 82 years (mean 57 years). Eighteen were women and 42 were diabetic. Mean followup was 14.5 months. Primary, primary-assisted, and cumulative (secondary) patency were 58.3%, 96.2%, and 100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months. CONCLUSIONS RC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and United States examinations. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs.

Effects of Hepatic Zonal Oxygen Levels on Hepatocyte Stress Responses

BACKGROUND Hepatocytes spend their lifetimes in a gradient of oxygen, hormones, and enzymes. We used a three-dimensional Matrigel model to determine whether hepatocytes cultured at perivenous (zone 3) oxygen levels differed in susceptibility to anoxia-induced cell injury compared with hepatocytes cultured at periportal (zone 1) oxygen levels. MATERIALS AND METHODS Hepatocytes were harvested from Sprague Dawley rats and cultured at 9% oxygen (hepatic zone 1) or 5% oxygen (hepatic zone 3) and stressed at 0% oxygen. Microscopy, real-time reverse transcriptase-polymerase chain reaction, and enzyme-linked immunosorbent assay were used to assess cell viability, mitochondrial potential, acute phase responses, and membrane blebbing. RESULTS Hepatocytes cultured in Matrigel with HepatoZyme medium at zone 1 and zone 3 oxygen conditions were viable for 1 wk and showed acute phase responses as measured by interleukin-6-induced fibrinogen production. In response to 3 h anoxia, cells maintained at the perivenous oxygen level showed increased membrane blebbing and increased loss of mitochondrial membrane potential in comparison to the periportal oxygen cultured cells. Cells at perivenous oxygen also showed a reduced ability to recover following reoxygenation. CONCLUSIONS Hepatocytes can remain viable and functional for extended periods in culture at low oxygen levels that mimic the hepatic perivenous environment, yet these cells are more susceptible to anoxia-induced damage than hepatocytes cultured at the periportal oxygen level. The small population of perivenous hepatocytes may be critical in determining the fate of the liver during ischemia/reperfusion since hepatocytes cultured at that concentration appear to be more labile in response to anoxia.

Differential IL-7 responses in developing human thymocytes.

Interleukin (IL)-7 is a factor essential for mouse and human thymopoiesis. Mouse thymocytes have altered sensitivities to IL-7 at different developmental stages. CD4/CD8 double positive (DP) mouse thymocytes are shielded from the influence of IL-7 because of loss of CD127 (IL-7Ralpha). In this study, we assessed IL-7 receptor expression and IL-7 signaling in human thymocytes. We found human DP cells to be severely limited in their ability to phosphorylate STAT-5 in response to IL-7. The relative expression levels of the IL-7-inducible proteins Bcl-2 and Mcl-1 were also lower in human DP cells, consistent with a stage-specific decrease in IL-7 responsiveness. IL-7 responses were restored in a subset of cells that matured past the DP stage. Unlike the regulation of IL-7 signaling in mouse thymocytes, loss of IL-7 signaling in human DP cells was not due to absence of CD127, but instead correlated with downregulation of CD132 (common gamma chain).

SAGES 2007 rural surgery panel.

Rural surgery: 59 million rural American citizens (2000 Census). Who cares? In 1999, SAGES President L. William Traverso articulated the importance of rural surgery and created the rural surgery task force. During the 2007 SAGES annual meeting in Las Vegas, the rural surgery task force, now turned into the rural surgery liaison group, presented a panel discussion that examined rural surgery manpower demographics, SAGES’ relationship with the rural surgeon, the American College of Surgeons’ advisory council for general surgery subcommittee on rural surgery, the challenges facing the practising rural surgeon, rural surgery contributions to medical education, and the education of the rural surgeon. It was the first SAGES public forum on rural surgery, and it may possibly be its last. In recent years, the SAGES rural surgery liaison group has conducted three internet surveys to understand the practice circumstances and needs of its rural members. In addition, SAGES’ rural surgery liaison group members made rural surgery presentations at the American College of Surgeons Washington/Oregon and Oklahoma 2006 chapter meetings and the Mithoefer Center for Rural Surgery second annual rural surgery symposium in Cooperstown, NY in September 2006. Members of the SAGES rural surgery liaison group also independently studied the use of endoscopy and laparoscopy in Wyoming, Montana, and Oklahoma. Here is what we know. Rural surgeons perform more procedures than their urban counterparts, nearly double the laparoscopic procedures and triple the number of endoscopies [1]. From the SAGES rural surgery surveys, we find that the nearest gastroenterologist is more than 20 miles distant in 50% of rural surgery practice situations. For screening colonoscopy, the rural general surgeon is the physician of first choice in 65% of rural surgery environments and second choice in 32%. Two-thirds of rural surgeons received their flexible endoscopy training during residency, and this trend will surely increase as the accreditation council for graduate medical education (ACGME) minimum-defined category numbers for endoscopy continue to increase. Only 42% of SAGES rural surgery members attend a SAGES meeting once every 5 years, and unfortunately 26% never attend a SAGES meeting. The most common (45%) referral population for a rural general surgeon is 0–25,000 people. The nearest tertiary hospital is C50 miles in 69% of rural surgery practices. At least two-thirds of SAGES rural surgeons take advantage of SAGES benefits (practice guidelines, privileging guidelines, or outcome case logs in conjunction with the American College of Surgeons). Three-quarters of rural surgeons are not interested in a PAC, but would like to see rural surgery better represented in the hierarchy of national surgical societies. We have significant gaps in our knowledge of rural surgery. Who is the rural surgeon: even a frontier surgeon? Rural surgeons have been defined by population [2] and rural–urban commuting codes [3]. Perhaps hospital size, numbers, and specialities of local supporting physicians, Health Professional Shortage Areas (HPSAs) as defined by the Department of Health and Human Services Health Resources and Services Administration for federal grants eligibility, specialty Physician Scarcity Areas (PSAs) created by the Centers for Medicare and Medicaid Services (CMS) for 5% physician bonus payments, and access to a skilled health care workforce would be equally important Presented at the Annual Meeting of the Society of American, Gastrointestinal and Endoscopic Surgeons (SAGES), Las Vegas, Nevada, USA, April 18, 2007.