Faculty Bibliography

BACKGROUND AND OBJECTIVES: Pregabalin is often used as a perioperative analgesic adjunct; some studies show benefit, but others do not. Adverse effects, such as confusion and sedation, have been attributed to perioperative use of pregabalin. We tested the hypothesis that pregabalin, when used as part of a multimodal analgesic regimen, reduces the duration of moderate to severe pain in the first 24 hrs following foot or ankle surgery. Secondary outcomes included measures of opioid and pregabalin adverse effects. METHODS: Sixty patients scheduled for hospital admission after foot or ankle surgery entered this randomized, double-blind, placebo-controlled trial. Patients received a neuraxial anesthetic, a popliteal fossa sciatic nerve block using 30 mL 0.375% bupivacaine with clonidine 100 microg and epinephrine, a saphenous nerve block, postoperative hydromorphone intravenous patient-controlled analgesia, and oral analgesics (oxycodone/acetaminophen). Patients were randomized to receive pregabalin (100 mg preoperatively, then 50 mg every 12 hrs) or a placebo for 3 days. The primary outcome was the number of hours that patients reported moderate to severe pain. RESULTS: Both groups reported a similar number of hours of moderate to severe pain during the first 24 hrs: 4.1 (SD, 4.1) hrs (pregabalin) versus 4.5 (SD, 3.5) hrs (placebo). Pain scores, opioid use, and adverse effects were also similar in both groups. CONCLUSIONS: No clinical benefit was obtained from perioperative administration of pregabalin (100 mg preoperative, then 50 mg every 12 hrs) as part of a multimodal postoperative analgesic regimen following foot and ankle surgery.

Introduction/Statement of the Problem: A 59-year-old male presented to a tertiary care center with a 2-month history of worsening lower back pain. Two months prior to presentation, the patient had gone to Mexico and received multiple stem cell injections from donor placenta into the lumbar intervertebral disc at multiple levels. Since these injections, his back pain had progressively worsened. An MRI was performed and revealed L3-L5 epidural/paravertebral abscess with discitis and osteomyelitis. Results: Bone biopsy results were positive for candida parapsilosis and negative for bacteria. The patient was started on vancomycin, cefipime and fluconazole. An L2-L5 laminectomy and I&D were performed by neurosurgery. Following surgery, the patient was transferred to a rehabilitation unit. He remained on antibiotics and antifungals for 6 weeks. Repeat MRI showed improvement in epidural abscess, discitis and osteomyelitis. Antimicrobials were discontinued and the patient was discharged home. Follow-up gadolineum scan 3 months after discharge verified infection resolution. Conclusion: Stem cell injections have been available for purchase in the global health marketplace in recent years.1 Mexico has a flourishing stem cell industry, utilizing donor placenta as a source for stem cells to treat a variety of ailments, such as chronic discogenic pain, cerebral palsy, autism, and paralysis.2,3 Even though stem cells may be a promising treatment modality, this patient's presentation demonstrates the catastrophic complications that can result from stem cell injections and that medical tourism for the procedure should be considered high risk

BACKGROUND:Esophagomyotomy is the mainstay of treatment for achalasia with proven long-term success. However, in patients with a significantly dilated esophagus, many advocate esophageal resection thus forgoing an esophagomyotomy. The purpose of this study is to determine the esophagomyotomy failure rate in patients with achalasia. METHODS:A retrospective review of all patients with achalasia who underwent an esophagomyotomy from 1996 to 2006; 272 patients were divided into three groups based on their preoperative degree of esophageal dilation for comparison. The endpoint for esophagomyotomy failure was persistent symptoms requiring any intervention. RESULTS:The preoperative characteristics were comparable except for the severely dilated esophagus patients who had a longer duration of preoperative symptoms. Group I (mild dilatation) had 162 patients with 7 failures requiring intervention. Group II (moderate dilatation) had 74 patients with 4 failures and group III (severe dilatation) had 36 patients with 5 patients requiring intervention. For the entire cohort, median follow-up was 37 months (range, 8 to 144 months). There was no statistically significant difference among the groups in the number of patients requiring reintervention. The overall esophagectomy rate was only 2%. However, there was a significantly higher (p = 0.02) esophagectomy rate in the severely dilated patients. CONCLUSIONS:The degree of esophageal dilatation associated with achalasia does not influence the success of an esophagomyotomy. Of the entire patient population in this study, only 6 patients required an esophagectomy. The majority of patients with the most severely dilated esophagus did not require an esophagectomy. Esophagomyotomy should be the first treatment option for patients with achalasia no matter what the degree of esophageal dilatation.

PURPOSE/OBJECTIVE:The clinical significance of epidermal growth factor receptor variant III (EGFRvIII) expression in glioblastoma multiforme (GBM) and its relationship with other key molecular markers are not clear. We sought to evaluate the clinical significance of GBM subtypes as defined by EGFRvIII status. PATIENTS AND METHODS/METHODS:The expression of EGFRvIII was assessed by immunohistochemistry in 649 patients with newly diagnosed GBM. These data were then examined in conjunction with the expression of phospho-intermediates (in a subset of these patients) of downstream AKT and Ras pathways and YKL-40 as well as with known clinical risk factors, including the Radiation Therapy Oncology Group's recursive partitioning analysis (RTOG-RPA) class. RESULTS:The RTOG-RPA class was highly predictive of survival in EGFRvIII-negative patients but much less predictive in EGFRvIII-positive patients. These findings were seen in both an initial test set (n = 268) and a larger validation set (n = 381). Similarly, activation of the AKT/MAPK pathways and YKL-40 positivity were predictive of poor outcome in EGFRvIII-negative patients but not in EGFRvIII-positive patients. Pair-wise combinations of markers identified EGFRvIII and YKL-40 as prognostically important. In particular, outcome in patients with EGFRvIII-negative/YKL-40-negative tumors was significantly better than the outcome in patients with the other three combinations of these two markers. CONCLUSION/CONCLUSIONS:Established prognostic factors in GBM were not predictive of outcome in the EGFRvIII-positive subset, although this requires confirmation in independent data sets. GBMs negative for both EGFRvIII and YKL-40 show less aggressive behavior.

BACKGROUND: This study was undertaken to determine the impact that a resident teaching model for advanced laparoscopic skills has on performance, using outcome for laparoscopic colectomy as an indicator of efficacy. METHODS: Six senior surgical residents took part in a model for teaching advanced laparoscopic procedures over 3 years. Animal laboratory sessions, tutorial sessions, and feedback were the principle components of this model with residents evaluating each component and their operative experiences. Conversion rates, hospital length of stay, and operating time during the 3 years (n = 100) were compared with a previous year (baseline year) where the faculty performed most of a procedure (n = 20). RESULTS: Each resident performed an average of 17 cases, being the primary surgeon after the sixth case. There were no differences in operative time for both right and left colectomies compared with the baseline year. Postoperative length of stay was less than 5 days by year 3, with a 14% conversion rate to open surgery. Feedback and tutorials were deemed most important for strategic planning and for reducing operative time. CONCLUSIONS: Resident participation in advanced laparoscopic surgery, concurrent with structured skills development and feedback, portends very favorable outcomes.