Faculty Bibliography

Purpose of Review Pancreatic cancer continues to be a disease associated with poor long-term survival. Surgical resection is associated with high morbidity and delays in systemic therapy. Recent Findings Recognition of pancreatic cancer as a systemic disease has led to the increased utilization of multimodality therapy and shifting paradigms in the sequence of care. Identification of biomarkers and improved understanding of tumor biology have allowed for improved patient stratification and an individualized approach to treatment planning. Additionally, introduction of minimally invasive approaches to pancreatic resection have improved rates of significant post-operative morbidity. Summary Cumulatively, these new developments have altered the approach to surgical resection and aid in improving patient survival.

BACKGROUND: Pathologic analysis of deep tissue obtained during debridement of venous ulcers is often unnoticed in its importance. We previously reported pathologic findings on 139 patients with venous ulcers. The objective of this study was to correlate the pathologic findings in venous ulcers with wound healing to establish a negative margin for debridement. STUDY DESIGN: Consecutive patients with a lower extremity venous ulcer present for at least 4 weeks, presenting to a single wound healing center, were included. Wounds underwent aggressive surgical debridement beyond the subcutaneous level until judged to have a viable base. Specimens were scored based on cellularity, vascularity, collagen composition, inflammation, and dense fibrosis, with a highest possible score of 13. Healing was the primary outcome for analysis. RESULTS: Of the 26 patients who met inclusion criteria, only 50% of them (13 patients) with a total of 18 venous ulcers underwent surgical debridement available for pathologic analysis. Mean ulcer area was 34.7 cm(2) at initial presentation, and 89% of patients had a continuous positive healing curve as measured by decreasing wound area (from 34.7 cm(2) to 14.3 cm(2)). However, specimens with dense fibrosis, decreased cellularity, mature collagen, and pathology score less than 10 were predominantly nonhealing ulcers. CONCLUSIONS: Presence of dense fibrosis and high levels of mature collagen in deep tissue specimens are significant correlative factors in nonhealing of venous ulcers. We recommend deep debridement on all venous ulcers that are refractory to healing until the level of absence of dense fibrosis and mature collagen is reached to promote venous ulcer healing.

BACKGROUND: The aim of this study was to calculate and analyze the cost of treatment for stage IV pressure ulcers. METHODS: A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed up for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated. RESULTS: Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts were reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during 1 admission, and $124,327 for community-acquired ulcers over an average of 4 admissions. CONCLUSIONS: The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce health care expenditures by millions of dollars

Wound patients commonly have multiple comorbidities, which should be optimized before anesthesia. These factors contribute not only to skin breakdown but also other causes of mortality and morbidity. Skin becomes more vulnerable to damage from pressure, friction, shear, and moisture when the skin is dry, less elastic, and less perfused. Careful assessment and implementation of an anesthetic plan using regional or general techniques can improve outcomes. The anesthesiologist plays a vital role in maintaining homeostasis during the surgically stressful perioperative period of the wound patient. Aggressive wound management in the early stages is likely to prevent wound progression to deeper levels. Policies are being implemented to decrease the risk of pressure ulcers by prevention