Journal Article Highlights

Breast Surgery

Improving Access to Care: Breast Surgeons, the Gatekeepers to Breast Reconstruction

It is well documented that surgery to reconstruct the breast after mastectomy for breast cancer is an important factor in women's quality of life and well-being in the long term. Because this is so important, the state of New York passed a law in 2010 requiring that general surgeons and oncologists discuss options and insurance coverage for breast reconstruction with their patients before performing cancer surgery.

Now, a study published in the March 2012 issue of the Journal of the American College of Surgeons has found that patients referred by general surgeons or surgical oncologists for consultations with plastic surgeons are significantly more likely to undergo breast reconstruction after mastectomy than those patients not referred.

"Not all mastectomy patients will be candidates for breast reconstruction, and some may prefer not to undergo the surgery for personal reasons. However, our study findings indicate that general surgeons who have this discussion with patients, and ultimately refer them, play a very important role in the decision to undergo reconstruction as well as in access to this type of care," said Christine H. Rohde, MD, senior author of the study.

"It is incumbent upon the general surgeon to refer mastectomy patients for consultations with plastic surgeons," added Beth Aviva Preminger, MD, MPH, lead author. "Doing this for all mastectomy patients can ultimately improve patient care, as it has been well-documented that patients who receive breast reconstruction often experience an overall improved quality of life."

Do you have a question about breast reconstruction surgery or treatment for breast cancer? Read about reconstruction after breast surgery at http://columbiaplastics.org/breast.html

Sheldon M. Feldman, MD, is first author of a study published January 11, 2011 in the journal Cancer. The article, titled A novel automated assay for the rapid identification of metastatic breast carcinoma in sentinal lymph nodes, reports the results of a study investigating a new method of detecting cancer in lymph nodes. The novel method, called 'one-step nucleic acid amplification,' or OSNA, uses molecular testing to detect whether breast cancer has metastasized, or spread, to the lymph nodes. Confirming whether breast cancer has spread to the lymph nodes is an important factor in determining treatment and prognosis. The study found this new method to be highly sensitive and accurate, paving the way for its use during breast cancer surgery. This objective method allows a more complete evaluation of lymph nodes without microscopic evaluation. Its technician-based automated platform can be utilized at smaller hospitals that may not have expertise in breast pathology, while still providing highly accurate results.

Dr. Feldman is Chief, Breast Surgery Section, NewYork-Presbyterian Hospital/Columbia University Medical Center. For more information, see www.breastmd.org or call 800.543.2782.

Cardiothoracic Surgery

Approximately 300,000 patients in the United States have aortic stenosis (narrowing of the aortic heart valve), and about one third of these patients are too sick or too old to undergo surgical replacement. Under the leadership of NewYork-Presbyterian Hospital's Division of Cardiothoracic Surgery, Transcatheter aortic valve implantation (TAVI) has been under study as a less invasive alternative for these patients.

According to the most recent results of the landmark PARTNER study, TAVI is as good as open surgery in terms of long-term survival. Craig R. Smith, MD, Principal Investigator of the PARTNER study, presented long-awaited results of cohort A to the American College of Cardiology 2011 Scientific Summit in New Orleans April 3, 2011. This arm of the study compared long-term outcomes of traditional aortic valve replacement with the catheter-based method of replacing the aortic valve.

The study found the two methods equal in terms of long term survival. Patients who underwent transcatheter aortic valve replacement were at higher risk of stroke and vascular complications, while those undergoing open surgery were at greater risk of major bleeding.

Results of the first phase of the PARTNER trial, cohort B, were presented in December 2010. This phase found that compared with medical therapy (including balloon valvuloplasty), patients who were too sick or too old for surgery had a 20% improvement in survival after one year with transcatheter aortic valve replacement. In addition to living longer, patients also felt much better and experienced fewer hospitalizations.

The pivotal results from both cohorts of the PARTNER trial mean that patients with aortic disease now have a new therapeutic option that works exceedingly well. Craig R. Smith, MD, who presented the newest results at a special showcase session at the ACC summit, said in a statement that transcatheter aortic valve replacement "is the most exciting new treatment for aortic stenosis in the past two to three decades."

At this time, transcatheter aortic valves are investigational devices in the US. Already approved and on the market in other countries, it is expected that TAVI may gain FDA approval as early as late 2011, at least for patients ineligible for surgery.

Dr. Smith is Chairman, Department of Surgery, Columbia University College of Physicians and Surgeons; Chief, Division of Cardiothoracic Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center; and Surgeon-in-Chief, NewYork-Presbyterian Hospital/Columbia University Medical Center/ Vivian and Seymour Milstein Family Heart Center. Other PARTNER investigators at NewYork-Presbyterian Hospital include Martin Leon, MD, Jeffrey Moses, MD, Susheel Kodali, MD, and Mathew Williams, MD.

Results of PARTNER cohort B

Interviews with Craig Smith, MD, about Transcatheter Aortic Valve Replacement

Colorectal Surgery

Allendorf JD. Oncologic impact of surgery in the early postoperative period. Seminars in Colorectal Surgery. (accepted for publication).

Georges C, Lo T, Alkofer B, Whelan RL, Allendorf JD. The effects of surgical trauma on colorectal liver metastasis. Surg Endosc. 2007; 21: 1817-19.

GI/Endocrine Surgery

Gumbs AA, Gayet B. Totally Laparoscopic Central Hepatectomy. J Gastrointest Surg. 2007 Oct 20.

This video will show the pertinent steps to perform a totally laparoscopic central hepatectomy. The main steps of this procedure include control of the hepatic inflow, mobilization of the right liver, control of the hepatic outflow, and specimen removal. This technique is feasible and safe via laparoscopic techniques, but should currently be performed at high volume centers by surgeons with expertise in both HPB surgery and minimally invasive techniques.

Gumbs AA, Grès P, Madureira F and Gayet B. Laparoscopic vs. Open Resection of Intraductal Pancreatic Mucinous Neoplasms: Single-Institution's Experience Over 10-Years. J Gastointestinal Surg. 2007 Oct 2.

Required resection margins for noninvasive intraductal papillary mucinous neoplasms (IPMNs) are a controversial issue. Over a 10-year period we have resected IPMNs from the entire pancreatic gland with minimally invasive techniques and compared our survival and complication rates with open controls to see if any difference in resection margins and outcomes could be observed. Data were collected retrospectively, including our first cases of advanced laparoscopic resections. Five-year Kaplan-Meier curves were calculated and statistical analysis was performed using the log rank and Student's T test for continuous variables. Chi square and Fisher's exact tests were used for analyzing categorical variables. From March 1997 to Febuary 2006, we operated on 22 patients with noninvasive IPMNs, of which 9 (41%) were operated on laparoscopically and 13 (59%) using open techniques. Three patients underwent laparoscopic duodenopancreatectomy, compared to five in the open group. All resection margins were negative, but two patients required total pancreatectomy, both of which were performed laparoscopically. One of these was converted to open (11%) because of difficulty in reconstructing the biliary anastomosis. The overall complication rates were 56% for the laparoscopic group and 85% for the open group. Twenty-two percent of the laparoscopic group required reoperation and 11% required percutaneous drainage, compared to 15 and 23% in the open group, respectively. All patients are alive after a mean of 20 months (range = 2-43) in the laparoscopic group and 37 months (range = 1-121) in the open one (p > 0.05). Laparoscopic resection of noninvasive IPMNs of the entire pancreatic gland has similar complication and survival rates as open procedures. As a result, the laparoscopic approach is appropriate for noninvasive IPMNs of the entire pancreatic gland; however, larger cohorts are needed to see if any approach has superior outcomes. Because of these favorable results, studies are currently underway to see if the minimally invasive approach is also appropriate for invasive IPMNs.

Gumbs AA, Gumbs MA. Why Doctors Without Borders Has Particular Relevance to Today's Graduating Surgeons. J Surg Ed. 2007 Sep/Oct; 64(5).

Allendorf JD, DiGiorgi M, Spanknebel K, Inabnet WB, Chabot JA, LoGerfo P. One thousand, one hundred and twelve consecutive bilateral neck explorations for primary hyperparathyroidism. World J Surg. 2007; 31: 2075-80.

Background
Bilateral neck exploration has been the standard approach for patients with primary hyperparathyroidism. Improved localization studies and the availability of intraoperative parathyroid hormone monitoring have challenged the necessity of four-gland exploration. In this series we report a single surgeon's experience with bilateral neck exploration for primary hyperparathyroidism in an effort to establish benchmark outcomes from which to evaluate minimally invasive protocols.

Methods
The charts of 1112 consecutive patients who underwent neck exploration for primary hyperparathyroidism by a single surgeon over a 17-year period were reviewed. All patients underwent bilateral neck exploration under either general (n = 264) or local (n = 848) anesthesia.

Results
The overall cure rate was 97.4% with a complication rate of 3.4%. Morbidity included recurrent laryngeal nerve injury (0.2%), postoperative bleeding (0.8%), and transient hypocalcemia (1.8%). There was no mortality. Overall mean operating time was 52.5 +/- 30.2 minutes. A single gland was removed in 78.4% of patients, and 22.3% of patients underwent concomitant thyroidectomy. The cure rate was lower for patients undergoing reexploration (89.2% vs. 97.9%, p < 0.05). Choice of anesthetic approach did not affect the cure or complication rate. The overall conversion rate from local to general anesthesia was 1.5%. Patients undergoing general anesthesia were operated on earlier in the series and were less likely to be managed on an ambulatory basis (local 87.5% vs. general 38.4%, p < 0.05). During the last 5 years of the series, more than 90% of patients underwent exploration under local anesthesia.

Conclusion
This large modern series of neck explorations for primary hyperparathyroidism confirms the safety, feasibility, and efficacy of the bilateral approach. It further demonstrates that individual surgeons can achieve outcomes equivalent to those with four-gland explorations under local anesthesia.

Allendorf JD, Lauerman M, Bill A, DiGiorgi M, Goetz N, Vakiani E, Remotti H, Schrope B, Sherman W, Hall M, Fine RL, Chabot JA. Neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic adenocarcinoma: Feasibility, efficacy and survival. J Gastrointest Surg. Published Online First. 2007 Sept.

Background
We evaluated the feasibility and efficacy of neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic cancer.

Materials And Methods
From October 2000 to August 2006, 245 patients with pancreatic adenocarcinoma underwent surgical exploration at our institution. Of these, 78 patients (32%) had undergone neoadjuvant therapy for initially unresectable disease, whereas the remaining patients (serving as the control group) were explored at presentation (n = 167). All neoadjuvant patients received gemcitabine-based chemotherapy, often in conjunction with docetaxal and capecitabine in a regimen called GTX (81%). Seventy-five percent of neoadjuvant patients also received preoperative abdominal radiation (5,040 rad).

Results
Neoadjuvant patients were younger than control-group patients (60.8 vs 66.2 years, respectively, p < 0.002). Seventy-six percent of neoadjuvant patients were resected as compared to 83% of control patients (NS). Concomitant vascular resection was required in 76% of neoadjuvant patients but only 20% of NS (p < 0.01). Complications were more frequent in the neoadjuvant group (44.1 vs 30.9%, p < 0.05), and mortality was higher (10.2 vs 2.9%, p < 0.03). Among the neoadjuvant patients, all but one of the deaths were in patients that underwent arterial reconstruction. Mortality for patients undergoing a standard pancreatectomy without vascular resection was 0.8% in this series. Of patients resected, negative margins were achieved in 84.7% of neoadjuvant patients and 72.7% of NS. Within the cohort of neoadjuvant patients, radiation significantly increased the complication rate (13.3 vs 54.6%, p < 0.006), but did not affect median survival (512 vs 729 days, NS). Median survival for patients who received neoadjuvant therapy (503 days) was longer than NS that were found to be unresectable at surgery (192 days, p < 0.001) and equivalent to NS that were resected (498 days).

Conclusions
Resection rate, margin status, and median survivals were equivalent when neoadjuvant patients were compared to patients considered resectable by traditional criteria, demonstrating equal efficacy. Surgical resection with venous reconstruction following neoadjuvant therapy for patients with locally advanced pancreatic cancer can be performed with acceptable morbidity and mortality. This approach extended the boundaries of surgical resection and greatly increased median survival for the "inoperable" patient with advanced pancreatic cancer.

Schönleben F, Qiu W, Bruckman KC, Ciau NT, Li X, Lauerman MH, Frucht H, Chabot JA, Allendorf JD, Remotti HE, Su GH. BRAF and KRAS Mutations in Intraductal Papillary Mucinous Neoplasm/Carcinoma (IPMN/IPMC) of the Pancreas. Cancer Lett 2007; 249:242-8.

The Raf/MEK/ERK (MAPK) signal transduction is an important mediator of a number of cellular fates including growth, proliferation, and survival. The BRAF gene is activated by oncogenic RAS, leading to cooperative effects in cells responding to growth factor signals. Our study was performed to elucidate a possible role of BRAF in the development of IPMN (Intraductal Papillary Mucinous Neoplasm) and IPMC (Intraductal Papillary Mucinous Carcinoma) of the pancreas. Mutations of BRAF and KRAS were evaluated in 36 IPMN/IPMC samples and two mucinous cystadenomas by direct genomic sequencing. Exons 1 for KRAS, and 5, 11, and 15 for BRAF were examined. Totally we identified 17 (47%) KRAS mutations in exon 1, codon 12 and one missense mutation (2.7%) within exon 15 of BRAF. The mutations appear to be somatic since the same alterations were not detected in the corresponding normal tissues. Our data provide evidence that oncogenic properties of BRAF contribute to the tumorigenesis of IPMN/IPMC, but at a lower frequency than KRAS.

Allendorf JD, Schrope B, Inabnet WB, Chabot JA. Postoperative Glycemic Control in Patients Undergoing Central Pancreatectomy for Mid-Gland Lesions. World J Surg. 2007; 31:164-8.

Introduction
Patients undergoing partial pancreatectomy are at risk for developing surgically induced diabetes. Patients with lesions in the neck and body of the pancreas are at increased risk because traditional resectional approaches (pancreaticoduodenectomy or distal pancreatectomy) must be extended to remove the tumor with adequate margins. Increasingly, we have been performing pancreatic parenchyma-sparing resections (central pancreatectomy with pancreaticogastrostomy) in an effort to reduce the risk of postpancreatectomy endocrine insufficiency.

Methods
The operative records of patients who underwent pancreatectomy at our institution from 1999 to 2005 were reviewed. We identified 26 patients who underwent central pancreatectomy with pancreaticogastrostomy reconstruction for cystic lesions (n = 23), neuroendocrine tumors (n = 2), and Frantz's tumor (n = 1). Charts were reviewed for patient demographics, volume of resection, complications, and evaluation of postoperative glycemic control.

Results
The mean follow-up was 33 months (range 3-72 months). The average volume of pancreas resected was 49.6 +/- 38.6 cm(3), and the mean diameter of the lesions was 2.6 +/- 1.5 cm. Nine complications occurred in eight patients (overall morbidity 31%), and the average length of stay was 6.9 +/- 2.7 days. Pancreatic leaks (n = 2; 7.7%) were successfully managed nonoperatively. There was no operative mortality, and there has been no tumor recurrence. None of the patients were diabetic preoperatively. Postoperatively, two (7.7%) developed endocrine insufficiency with a mean postoperative hemoglobin A1c (HbA1c) value of 7.65%. Neither patient has required exogenous insulin. HbA1c in the remaining patients was 5.9% +/- 0.5%.

Conclusions
Pancreatic parenchyma-sparing surgery for lesions in the midportion of the gland can be performed with acceptable morbidity. Postoperative glycemic control after pancreatic parenchyma-sparing surgery compares favorably with that reported for patients with traditional resections.

Inabnet WB, Shifrin A, Ahmed L, Sinha P. Safety of Same Day Discharge in Patients Undergoing Sutureless Thyroidectomy: A Comparison of Local and General Anesthesia. Thyroid. 2007 Nov. [Epub ahead of print].

Background
The thyroid gland is one of the most vascular organs in the body and surgical resection mandates meticulous surgical technique and hemostasis. The aim of this study was to assess the safety and efficacy of the electrothermal bipolar vessel sealing system in permitting ambulatory thyroid surgery under local anesthesia.

Methods
From January 1, 2004, to December 31, 2005, 224 consecutive patients underwent thyroid surgery using the LigaSure for hemostasis. Whenever possible, local/regional anesthesia with conscious sedation was utilized during the procedure. A descriptive analysis was performed to evaluate patient characteristics and outcome measures.

Results
Eighty-two percent (n = 184) of all unselected patients presenting for thyroid surgery had their procedure performed under local/regional anesthesia with conscious sedation whereas 18% (n = 40) received general anesthesia. When comparing these two groups, the local anesthesia patients were more likely to be female (85% vs. 68%, p

Conclusions
The electrothermal bipolar vessel sealing system permits safe, same day discharge in patients undergoing thyroid surgery with a low complication rate irrespective of the type of anesthesia.

Liver Disease

Siegel AB, Cohen E, Ocean A, Goldenberg A, Knox J, Chen H, Garvey S, Lehrer D, Weinberg A, John Mandeli J, Jin D, Rafii S, Schwartz J. Bevacizumab in Unresectable HCC: a Phase II Study (NCI 5611). Submitted.

Siegel AB, El-Serag H, McBride R, Zablotska L, Hershman, D, Neugut A. Secondary HCC after other primary cancers. Presentation, GI ASCO 2007, accepted, Cancer Investigation.

Siegel AB, McBride R, El-Serag H, Hershman D, Brown R, Renz J, Neugut A. Racial disparities in utilization of liver transplantation for hepatocellular carcinoma. Presentation, GI ASCO 2006, accepted, American Journal of Gastroenterology.

El-Serag HB, Siegel AB, Davila JA, Shaib YH, Cayton-Woody M, McBride R, McGlynn, KA . Treatment and outcomes of Hepatocellular carcinoma among Medicare recipients in the United States: A population-based study. J. Hepatol. 2006 Jan;44(1):158-66. Epub 2005 Nov 2.

Lung Transplant

Russo MJ, Sternberg DI, Hong KN, Sorabella RA, Moskowitz AJ, Gelijns AC, Wilt JR, D'Ovidio F, Kawut SM, Arcasoy SM, Sonett JR. Postlung transplant survival is equivalent regardless of cytomegalovirus match status. Ann Thorac Surg. 2007 Oct;84(4):1129-34; discussion 1134-5.

Background
The purpose of this study was to assess (1) the relationship between donor-recipient cytomegalovirus (CMV) serologic status and posttransplant survival in the current era and (2) temporal changes in posttransplant survival by CMV matching status.

Methods
De-identified data were obtained from the United Network for Organ Sharing. Based on pretransplant CMV serologic status (+ or -) of recipients (R) and donors (D), posttransplant survival was compared among three groups: D+ /R-, D+/- /R+, and D- /R-. Primary analysis focused on transplants performed January 1, 2000 to December 31, 2004, in recipients 18 years of age or older. To assess temporal trends in survival among groups, all lung transplants occurring between January 1, 1990, and December 31, 2004, were considered and divided into three periods based on transplant year: 1990 through 1994, 1995 through 1999, and 2000 through 2004. The primary outcome measure was survival, reported as rate of death per 100 patient-years. Kaplan-Meier analysis with log-rank test was used for time-to-event analysis.

Results
During the current era (2000 through 2004), D+ /R- (n = 951), D+/- /R+ (n = 2,676), and D- /R- (n = 772) exhibited no differences in survival (p = 0.561), with rates of death per 100 patient-years of 16.6 (95% confidence interval, 14.9 to 18.5), 15.0 (95% confidence interval, 14.0 to 16.0), and 14.7 (95% confidence interval, 13.0 to 16.6), respectively. However, survival was significantly different for groups in the earlier eras of 1990 through 1994 (p < 0.001) and 1995 through 1999 (p < 0.001). During the three periods, survival improved significantly in D+ /R- (p < 0.001) and D+/- /R+ (p < 0.001), but survival in D- /R- (p = 0.351) did not change significantly with time.

Conclusions
In the current era, survival after lung transplantation is statistically equivalent regardless of CMV match status. Although in previous eras survival was worse among the D+/- /R+ and D+ /R- groups, in this era of aggressive CMV prophylaxis, CMV mismatch should not be sufficient grounds to decline a lung allograft offer.

Kawut SM, Lederer DJ, Keshavjee S, Wilt JS, Daly T, D'Ovidio F, Sonett JR, Arcasoy SM, Barr ML. Outcomes After Lung Retransplantation in the Modern Era. Am J Respir Crit Care Med. 2007 Sep 27; [Epub ahead of print].

Rationale
Characteristics of and survival estimates for recipients of lung retransplantation in the modern era are unknown.

Objectives
To compare lung retransplant patients in the modern era to historical retransplant patients. To compare retransplant patients to initial transplant patients in the modern era and to determine the predictors of the risk of death after lung retransplantation.

Methods
We performed a retrospective cohort study of patients who underwent lung retransplantation between January 2001 and May 2006 in the United States (modern retransplant cohort). The characteristics and survival of this cohort were compared to those of patients who underwent first lung retransplantation between January 1990 and December 2000 (historical retransplant cohort) and patients who underwent initial lung transplantation between January 2001 and May 2006 (modern initial transplant cohort).

Measurements And Main Results
Modern retransplant recipients (N = 205) had a lower risk of death compared to that of the historical retransplant cohort (N = 184) (hazard ratio = 0.7, 95% confidence interval 0.5-0.9, p = 0.006). However, modern retransplant recipients had a higher risk of death than that of patients who underwent initial lung transplantation (N = 5657) (hazard ratio = 1.3, 95% confidence interval 1.2-1.5, p = 0.001), which appeared to be explained by a higher prevalence of certain comorbidities. Retransplantation < 30 days after the initial transplant procedure was associated with worse survival.

Conclusions
Outcomes after lung retransplantation have improved, however retransplantation continues to pose an increased risk of death compared to the initial transplant procedure. Retransplantation early after the initial transplant poses a particularly high mortality risk.

Yegen HA, Lederer DJ, Barr RG, Wilt JS, Fang Y, Bagiella E, D'Ovidio F, Okun JM, Sonett JR, Arcasoy SM, Kawut SM. Risk factors for venous thromboembolism after lung transplantation. Chest. 2007 Aug;132(2):547-53. [Epub 2007 Jun 15].

Background
The risk factors for venous thromboembolism (VTE) following lung transplantation are not well established. We aimed to estimate the incidence of VTE and to identify the risk factors for VTE after lung transplantation.

Methods:
We performed a nested case-control study within the cohort of 121 patients who underwent lung transplantation at our center between August 2001 and July 2005. Control subjects were matched to case patients on the number of days from the time of transplant. Cox proportional hazards models were used to identify risk factors for VTE.

Results
Twenty-four patients had deep vein thromboses, and 6 patients had pulmonary emboli (3 patients had both) [22% of the cohort]. In multivariate models, older age (p < 0.05), diabetes mellitus (p = 0.03), and pneumonia (p = 0.02) were associated with a higher rate of VTE.

Conclusions
VTE is a frequent complication of lung transplantation. Older age, diabetes, and pneumonia increase the rate of VTE. Future studies of intensive VTE prophylaxis may be warranted.

Obesity Surgery

Bessler M, Stevens PD, Milone L, Parikh M, Fowler D. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc. 2007 Sep 22; [Epub ahead of print]
(Case Report)

Gagner M, Gumbs AA. Gastric banding: conversion to sleeve, bypass, or DS. Surg Endosc. 2007 Nov;21(11):1931-5. 2007 Aug 20.

A review of conversions of gastric banding for obesity to Roux-en-Y gastric bypass, gastric sleeve, or duodenal switch attempts to determine which revisional procedure best enhances weight loss. Indications for these conversions are multiple and include hardware problems, motility problems, and miscellaneous like inadequate weight loss. Analysis of band conversions to band of 193 patients, and bands to gastric bypass in 214 patients reveals better weight loss with the latter strategy. Smaller cohorts of patients who underwent a biliopancreatic diversion or simply a sleeve gastrectomy are too small to conclude on their efficacy. Prospective randomized trials are needed to determine which revisional procedure is best in the setting of inadequate weight loss of excessive weight regain after gastric adjustable banding for severe obesity.

Bessler M, Daud A, Kim T, DiGiorgi M. Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results. Surg Obes Relat Dis. 2007 Jul-Aug; 3(4):480-4; discussion 484-5. [Epub 2007 Jun 4].

Background
Banded gastric bypass has been reported to result in superior weight loss compared with standard nonbanded gastric bypass. However, an adequate comparison of these procedures has not yet been reported.

Methods
A total of 90 patients were enrolled in this prospective randomized double-blind trial comparing banded and nonbanded open gastric bypass for the treatment of super obesity. The banding technique involved placement of a 1.5 x 5.5-cm polypropylene band around the proximal gastric pouch of a standard gastric bypass procedure using the technique of Capella. Chi-square testing and analysis of variance were performed to find any differences in patient characteristics (gender, age, and initial body mass index), percentage of excess weight lost at 6, 12, 24, and 36 months postoperatively, improvement or resolution of co-morbidities, and complications in the banded versus nonbanded gastric bypass groups.

Results
As expected, no differences were present in the patient characteristics or incidence of co-morbidities between the banded (n = 46) and nonbanded (n = 44) groups. The body mass index, percentage of women, and mean age was 59.5 and 56.5 kg/m2, 64% and 73.8% (P = .09), and 40.6 +/- 7.4 and 42.6 +/- 7.2 years for the banded and nonbanded groups, respectively; all differences were nonsignificant. No significant differences were found in the resolution of co-morbidities. No significant difference was present in the percentage of excess weight loss at 6, 12, and 24 months (43.1% versus 24.7%, 64.0% versus 57.4%, and 64.2% versus 57.2%, respectively) postoperatively; however, the banded patients had achieved a significantly greater percentage of excess weight loss at 36 months (73.4% versus 57.7%; P <.05). The incidence of intolerance to meat and bread was greater in the banded patients. The overall number of complications was 12 (26%) in the banded and 13 (29.5%) in the nonbanded group, a nonsignficant difference. No band erosions had occurred at the last follow-up visit, and no patients in either group died.

Conclusion
These results suggest that although the initial weight loss was not significantly different between the 2 groups, the banded patients continued to lose weight for < or = 3 years. The polypropylene band appeared to be well tolerated. We plan longer follow-up to confirm the possibility of additional weight loss and the prevention of weight regain in the banded group, as well as to document any long-term band complications.

Herron DM, Birkett DH, Thompson CC, Bessler M, Swanström LL. Gastric bypass pouch and stoma reduction using a transoral endoscopic anchor placement system: A feasibility study. Surg Endosc. 2007 Nov 20; [Epub ahead of print]

Background
Weight regain after Roux-en-Y gastric bypass may be caused by pouch enlargement or dilatation of the gastrojejunostomy (stoma). In order to avoid the substantial morbidity of revisional bariatric surgery, investigators have recently demonstrated the feasibility of reducing stoma diameter using transoral endoscopic suturing techniques. Our aim was to demonstrate the feasibility of performing both pouch and stomal reduction using transoral endoscopically placed tissue anchors in an ex vivo and acute animate model.

Methods
Part I: We created an ex vivo model of a dilated gastric pouch and stoma using four explanted porcine stomachs. The stomach was divided to create an upper pouch of approx. 100 ml volume, which was reconnected to the lower portion of the stomach (gastric remnant) via an anastomosis of 18 to 20 mm diameter. Endoscopically placed anchors were then used to create plications of the stoma and reduce its diameter. In two stomachs, anchor plications were also used to decrease pouch volume. Pouch volumes and stoma diameters were measured pre- and post-procedure. Part II: A similar experimental model was created in vivo using three pigs. Anchors were placed in the stoma and pouch. The animals were immediately sacrificed and similar measurements were obtained.

Results
In the ex vivo model, stoma diameter was successfully reduced in all four stomachs by a mean of 8 mm (41%). This represented a mean decrease in cross-sectional area of 65%. Pouch volume was reduced by a mean of 28 ml (30%) in two stomachs. Stomal plications were successfully placed in two of the live animals, with a mean stoma diameter reduction of 11.5 mm (53%). Feasibility of pouch reduction using plicating anchors was confirmed.

Conclusions
This is the first study to demonstrate the feasibility of using endoscopically placed tissue anchors to reduce both stoma diameter and pouch volume. This technique may ultimately be clinically useful in treating weight regain after gastric bypass surgery.

Bessler M. Editorial comment. Surg Obes Relat Dis. 2007 Sep-Oct;3(5):502.

Milone L, Daud A, Durak E, Olivero-Rivera L, Schrope B, Inabnet WB, Davis D, Bessler M. Esophageal dilation after laparoscopic adjustable gastric banding. Surg Endosc. 2007 Nov 20; [Epub ahead of print]

Background Esophageal dilation can occur after laparoscopic adjustable gastric banding (LAGB). There are few studies in the literature that describe the outcomes of patients with esophageal dilation. The aim of this article is to evaluate weight loss and symptomatic outcome in patients with esophageal dilation after LAGB.

Methods We performed a retrospective chart review of all LAGBs performed at Columbia University Medical Center from March 2001 to December 2006. Patients with barium swallow (BaSw) at 1 year after surgery were evaluated for esophageal diameter. A diameter of 35 mm or greater was considered to be dilated. Data collected before surgery and at 6 months and 1, 2 and 3 years after surgery were weight, body mass index (BMI), status of co-morbidities, eating parameters, and esophageal dilation as evaluated by BaSw.

Results Of 440 patients, 121 had follow-up with a clinic visit and BaSw performed at 1 year. Seventeen patients (10 women and 7 men) (14%) were found to have esophageal dilation with an average diameter of 40.9 +/- 4.6 mm. There were no significant differences in percent of excess weight lost at any time point; however, GERD symptoms and emesis were more frequent in patients with dilated esophagus than in those without dilation. Intolerance of bread, rice, meat, and pasta was not different at any time during the study.

Conclusions In our experience the incidence of esophageal dilation at 1 year after LAGB was 14%. The presence of dilation did not affect percent excess weight loss (%EWL). GERD symptoms and emesis are more frequent in patients who develop esophageal dilation.

Korner J, Bessler M, Inabnet WB, Taveras C, Holst JJ. Exaggerated glucagon-like peptide-1 and blunted glucose-dependent insulinotropic peptide secretion are associated with Roux-en-Y gastric bypass but not adjustable gastric banding. Surg Obes Relat Dis. 2007 Nov-Dec;3(6):597-601. Epub 2007 Oct 23.

Background
The aim of this study was to measure the circulating levels of glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide (GIP), and glucagon in patients who had undergone adjustable gastric banding (BND) or Roux-en-Y gastric bypass (RYGB) to understand the differences in glucose and insulin regulation after these procedures.

Methods
This was a cross-sectional study of 3 groups of women matched for age and body mass index: group 1, overweight controls (n = 13); group 2, BND (n = 10); and group 3, RYGB (n = 13). Venous blood was drawn with the patient in the fasted state and throughout a 3-hour period after a liquid meal.

Results
The fasting glucose level was similar between the 2 surgery groups; however, the fasting insulin concentrations were greater in the BND (10.0 muU/mL) than in the RYGB (6.2 muU/mL; P <0.05) group. The glucose level at 60 minutes was significantly lower in the RYGB group (70 mg/dL, range 38-82) than in the BND group (83 mg/dL, range 63-98). The GLP-1 levels at 30 minutes were more than threefold greater in the RYGB group (96 pmol/L) compared with the BND and overweight control (28 pmol/L) groups. The GLP-1 and insulin concentrations correlated at 30 minutes only in the RYGB group (r = .66; P = .013). The glucose-dependent insulinotropic peptide levels at 30 minutes were lower in the RYGB group (20 pmol/L) than in the BND group (31 pmol/L) or overweight control group (33 pmol/L). The peak glucagon levels were similar among the 3 groups.

Conclusion
Exaggerated postprandial GLP-1 and blunted glucose-dependent insulinotropic peptide secretion after RYGB might contribute to the greater weight loss and improved glucose homeostasis compared with BND.

Plastic Surgery

Strauch B, Rohde C, Patel M, Patel S. Back contouring in weight loss patients. Plast Recon Surg. 2007; 120: 1692.

Surgical Oncology

Suciu-Foca N, Feirt N, Zhang Q, Vlad G, Liu Z, Lin H, Chang C, Ho EK, Colovai AI, Kaufman H, D'Agati VD, Thaker HM, Remotti H, Galluzzo S, Cinti P, Rabitti C, Allendorf JD, Chabot JA, Caricato M, Coppola R, Berloco P, Cortesini R. Soluble Ig-like transcript 3 inhibits tumor allograft rejection in humanized SCID mice and T cell responses in cancer patients. J Immunol. 2007; 178: 7432-7441.

Attempts to enhance patients' immune responses to malignancies have been largely unsuccessful. We now describe an immune-escape mechanism mediated by the inhibitory receptor Ig-like transcript 3 (ILT3) that may be responsible for such failures. Using a humanized SCID mouse model, we demonstrate that soluble and membrane ILT3 induce CD8(+) T suppressor cells and prevent rejection of allogeneic tumor transplants. Furthermore, we found that patients with melanoma, and carcinomas of the colon, rectum, and pancreas produce the soluble ILT3 protein, which induces the differentiation of CD8(+) T suppressor cells and impairs T cell responses in MLC. These responses are restored by anti-ILT3 mAb or by depletion of soluble ILT3 from the serum. Immunohistochemical staining of biopsies from the tumors and metastatic lymph nodes suggests that CD68(+) tumor-associated macrophages represent the major source of soluble ILT3. Alternative splicing, resulting in the loss of the ILT3 transmembrane domain, may contribute to the release of ILT3 in the circulation. These data suggest that ILT3 depletion or blockade is crucial to the success of immunotherapy in cancer. In contrast, the inhibitory activity of soluble ILT3 on T cell alloreactivity in vitro and in vivo suggests the potential usefulness of rILT3 for immunosuppressive treatment of allograft recipients or patients with autoimmune diseases.

Thoracic Surgery

Borczuk AC, Papanikolaou N, Toonkel RL, Sole M, Gorenstein LA, Ginsburg ME, Sonett JR, Friedman RA, Powell CA. Lung adenocarcinoma invasion in TGFbetaRII-deficient cells is mediated by CCL5/RANTES. Oncogene. 2007 Jul 23; [Epub ahead of print]

Recently, we identified a lung adenocarcinoma signature that segregated tumors into three clades distinguished by histological invasiveness. Among the genes differentially expressed was the type II transforming growth factor-beta receptor (TGFbetaRII), which was lower in adenocarcinoma mixed subtype and solid invasive subtype tumors compared with bronchioloalveolar carcinoma. We used a tumor cell invasion system to identify the chemokine CCL5 (RANTES, regulated on activation, normal T-cell expressed and presumably secreted) as a potential downstream mediator of TGF-beta signaling important for lung adenocarcinoma invasion. We specifically hypothesized that RANTES is required for lung cancer invasion and progression in TGFbetaRII-repressed cells. We examined invasion in TGFbetaRII-deficient cells treated with two inhibitors of RANTES activity, Met-RANTES and a CCR5 receptor-blocking antibody. Both treatments blocked invasion induced by TGFbetaRII knockdown. In addition, we examined the clinical relevance of the RANTES-CCR5 pathway by establishing an association of RANTES and CCR5 immunostaining with invasion and outcome in human lung adenocarcinoma specimens. Moderate or high expression of both RANTES and CCR5 was associated with an increased risk for death, P=0.014 and 0.002, respectively. In conclusion, our studies indicate RANTES signaling is required for invasion in TGFbetaRII-deficient cells and suggest a role for CCR5 inhibition in lung adenocarcinoma prevention and treatment.Oncogene advance online publication, 23 July 2007; doi:10.1038/sj.onc.1210662.

Mattioli S, Ruffato A, Di Simone MP, Corti B, D'Errico A, Lugaresi ML, Mattioli B, D'Ovidio F. Immunopathological patterns of the stomach in adenocarcinoma of the esophagus, cardia, and gastric antrum: gastric profiles in Siewert type I and II tumors. Ann Thorac Surg. 2007 May;83(5):1814-9.

Background
The morphologic and immunohistochemical profiles of gastric mucosa and of the tumor were assessed in Siewert type I, type II, and gastric antrum adenocarcinomas.

Methods
Sixty-two patients, prospectively operated upon, were included in the study: 37 type II, 15 type I, and 10 antrum adenocarcinoma. Samples of the tumor, the surrounding area, and the gastric corpus and antrum were analyzed histologically, and immunostained for cytokeratins (CK)7/20 (staining positive for cells labeled > or = 50%).

Results
Among the 37 type II adenocarcinomas were the following: (1) 13 of 37 (35%) had intestinal metaplasia (IM) in the stomach; (2) 24 of 37 (65%) did not show IM at any level; (3) 34 of 37 (92%) had Helicobacter pylori (HP) infection; (4) 13 of 37(35%) had CK7/20 expression of "Barrett's type" (CK7+/20-); 24 of 37 (65%) had a "no Barrett's type" profile (10 of 37 with CK7-/CK20+ and 14 of 37 with CK7+/CK20+); (5) 100% showed the same CK immunoprofile, both in IM and adenocarcinoma (measure of agreement k = 1, p = 0.000). Type I adenocarcinomas showed the following: (1) 87.5% CK Barrett's type, both in the tumor, and in the surrounding IM; (2) 100% gastric samples devoid of both IM and HP infection. Comparison between CK immunoprofiles in type I and type II tumors showed a difference within the two groups (p = 0.002). One hundred percent of antrum adenocarcinomas showed a no Barrett's type CK profile, both in the tumor and in the IM of the entire stomach.

Conclusion
Data suggest that type II adenocarcinoma cannot be always considered a gastroesophageal reflux disease-related tumor; other pathogenetic pathways should be taken into consideration.

Vascular Surgery

Derubertis BG, Trocciola SM, Ryer EJ, Pieracci FM, McKinsey JF, Faries PL, Kent KC. Abdominal aortic aneurysm in women: prevalence, risk factors, and implications for screening. J Vasc Surg. 2007 Oct;46(4):630-635.

Objective
Accurate data regarding the prevalence and associated risk factors for aneurysmal disease is essential when determining the appropriateness of screening for abdominal aortic aneurysms (AAA). Although women are poorly represented in most large studies of AAA prevalence, the US Preventative Services Task Force recently recommended against primary screening for AAA in women. The purpose of this analysis was to define the prevalence and risk factors associated with the development of AAA in women.

Methods
A free duplex ultrasound screening was offered to men and women with cardiovascular risk factors or a family history of AAA. Patients were recruited through advertising at local screening centers and screenings were performed between 2004 and 2006. Demographic information and cardiovascular and aneurysmal disease risk factors were obtained for each patient through a questionnaire. A total of 17,540 subjects were screened for AAA, including 10,012 women (mean age 69.6 years) and 7528 men (mean age 70.0 years). Univariate and multivariable logistic regression analysis was performed on the subset of women that were screened to determine risk factors for and prevalence of AAA.

Results
Seventy-four aneurysms were detected in women (including four aneurysms >5 cm diameter and 70 aneurysms 3 to 5 cm diameter) while 291 were detected in men, resulting in prevalence rates of 0.7% and 3.9%, respectively. Increasing age (odds ratio [OR]= 4.57, 95% confidence interval [CI] 1.98 to 10.54, P < .0001), history of tobacco use (OR = 3.29, 95% CI 1.86 to 5.80, P < .0001), and cardiovascular disease (OR= 3.57, 95% CI 2.19 to 5.84, P < .0001) were independently associated with AAA in women on univariate and multivariable analysis. Women with multiple atherosclerotic risk factors were more commonly found to have AAAs and had a prevalence rate of AAA as high as 6.4%.

Conclusion
Although the medical literature suggests a low prevalence rate of AAA in women in the general population, specific risk factors are associated with the development of AAA, and subgroups of women can be identified that are at a substantially increased risk of aneurysmal disease. In particular, elevated rates of AAA were found among women of advanced age (> or =65 years) with a history of smoking or heart disease. These data support the notion that women with such risk factors should be considered for AAA screening.

Read the NYP press release regarding this research.

Morrissey NJ. Biological treatment of vein grafts and stents in lower-extremity arterial reconstruction. Perspect Vasc Surg Endovasc Ther. 2007 Sep;19(3):293-7.

Longevity of lower-extremity revascularization procedures has typically been limited because of restenosis of grafts, as well as stents and other percutaneous techniques. The ability to prevent or ameliorate neointimal hyperplasia and improve durability of lower-extremity arterial reconstruction is the focus of significant scientific and clinical research. The transcription factor decoy edifoligide was investigated as a potential inhibitor of neointimal hyperplasia, but the results of the pivotal clinical trial did not demonstrate significant improvement in graft reintervention, although secondary patency was improved. Similar to the coronary circulation, drug-eluting stents are a potential tool for prevention of restenosis after percutaneous arterial reconstruction. The SIROCCO study did not demonstrate improvement in superficial femoral artery stent patency with sirolimus-eluting stents. Studies are underway that are investigating paclitaxel-eluting stents for use in the superficial femoral artery. Other potential mediators of restenosis include absorbable drug-eluting stents and antibody-coated stents designed to promote endothelialization of the stent or graft surface. In addition, absorbable wraps eluting paclitaxel can be used at arterial and arteriovenous anastomoses to prevent restenosis. Clinical trials investigating these novel technologies are underway.

DeRubertis BG, Faries PL, McKinsey JF, Chaer RA, Pierce M, Karwowski J, Weinberg A, Nowygrod R, Morrissey NJ, Bush HL, Kent KC. Shifting paradigms in the treatment of lower extremity vascular disease: a report of 1000 percutaneous interventions. Ann Surg. 2007 Sep;246(3):415-22; discussion 422-4.

Objectives
Catheter-based revascularization has emerged as an alternative to surgical bypass for lower extremity vascular disease and is a frequently used tool in the armamentarium of the vascular surgeon. In this study we report contemporary outcomes of 1000 percutaneous infra-inguinal interventions performed by a single vascular surgery division.

Methods
We evaluated a prospectively maintained database of 1000 consecutive percutaneous infra-inguinal interventions between 2001 and 2006 performed for claudication (46.3%) or limb-threatening ischemia (52.7%; rest pain in 27.7% and tissue loss in 72.3%). Treatments included angioplasty with or without stenting, laser angioplasty, and atherectomy of the femoral, popliteal, and tibial vessels.

Results
Mean age was 71.4 years and 57.3% were male; comorbidities included hypertension (84%), coronary artery disease (51%), diabetes (58%), tobacco use (52%), and chronic renal insufficiency (39%). Overall 30-day mortality was 0.5%. Two-year primary and secondary patencies and rate of amputation were 62.4%, 79.3%, and 0.5%, respectively, for patients with claudication. Two-year primary and secondary patencies and limb salvage rates were 37.4%, 55.4%, and 79.3% for patients with limb-threatening ischemia. By multivariable Cox PH modeling, limb-threat as procedural indication (P < 0.0001), diabetes (P = 0.003), hypercholesterolemia (P = 0.001), coronary artery disease (P = 0.047), and Transatlantic Inter-Society Consensus D lesion complexity (P = 0.050) were independent predictors of recurrent disease. For patients that developed recurrent disease, 7.5% required no further intervention, 60.3% underwent successful percutaneous reintervention, 11.7% underwent bypass and 20.5% underwent amputation. Patency rates were identical for the initial procedure and subsequent reinterventions (P = 0.97).

Conclusion
Percutaneous therapy for peripheral vascular disease is associated with minimal mortality and can achieve 2-year secondary patency rates of nearly 80% in patients with claudication. Although patency is diminished in patients with limb-threat, limb-salvage rates remain reasonable at close to 80% at 2 years. Percutaneous infra-inguinal revascularization carries a low risk of morbidity and mortality, and should be considered first-line therapy in patients with chronic lower extremity ischemia.

Morrissey NJ, Giacovelli J, Egorova N, Gelijns A, Moskowitz A, McKinsey J, Kent KC, Greco G. Disparities in the treatment and outcomes of vascular disease in Hispanic patients. J Vasc Surg. 2007 Nov;46(5):971-8.

Background
The Hispanic population represents the fastest growing minority in the United States. As the population grows and ages, the vascular surgery community will be providing increasing amounts of care to this diverse group. To appropriately administer preventive and therapeutic care, it is important to understand the incidence, risk factors, and natural history of vascular disease in Hispanic patients.

Methods
We analyzed hospital discharge databases from New York and Florida to determine the rate of lower extremity revascularization (LER), carotid revascularization (CR), and abdominal aortic aneurysm (AAA) repair in Hispanics relative to the general population. The rates of common comorbidities, the indications for the procedures, and outcomes during the same hospitalization as the index procedure were determined. Multivariate logistic regression analysis was used to determine the differences between Hispanics and white non-Hispanics with respect to rate of procedure, symptoms at presentation, and outcome after procedure. Demographic variables and length of stay were also analyzed.

Results
The rate of LER, CR, and AAA repair was significantly lower in Hispanic patients than in white non-Hispanics. Despite this lower rate of intervention, Hispanics were significantly more likely than whites to present with limb-threatening lower extremity ischemia (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.91 to 2.29), symptomatic carotid artery disease (OR, 1.57; 95% CI, 1.4 to 1.75), and ruptured AAA (OR, 1.26; 95% CI, 1.04-1.52) than white non-Hispanics These differences were maintained after controlling for the presence of diabetes mellitus and other comorbidities. Hispanic patients had higher rates of amputation during the same hospitalization after LER (6.2% vs 3.4%, P < .0001) and higher mortality after elective AAA repair (5% vs 3.4%, P = .0032). Length of stay after LER, CR, and AAA repair was longer for Hispanic patients than white non-Hispanics.

Conclusion
Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society.

Read the NYP press release regarding this research.