Faculty Bibliography

Purpose: Primary and metastatic sarcoma involving the hepatopancreaticobiliary structures is rare. Surgical resection is examined for its role in cure or palliation. Methods: From 1997 to 2011, 151 patients were treated surgically for sarcoma involving the retroperitoneum, abdomen and pelvis. Sixty-four (42%) had primary or locally advanced/metastatic sarcoma involving the pancreas and/or liver. Results: Fifty-two of 64 (81%) patients underwent en bloc pancreas and/or liver resection. 34/52 (65%) had recurrent disease. Pancreatectomy was performed in 23 (44%), hepatectomy in 17 (33%), and combined resection in 12 (23%). The average lesion size was 12.2 +/- 8.9 cm. The average number of tumors resected at once was 4.8 +/- 7.9. Intraoperative blood loss averaged 2200 +/- 2600 cc with a mean number of blood transfusions 3.0 +/- 3.3 units. There were 4 operative deaths and 18 non-lethal perioperative complications. Pathology included gastrointestinal stromal tumor in 18 (34%), leiomyosarcoma in 16 (30%), liposarcoma in 11 (21%), and various other soft tissue sarcomas in 7 (13%). Mean follow-up was 35 +/- 41 months. 33/52 patients had tumor recurrence at a mean 15 +/- 18 months (range 2-71) after surgery. Recurrence occurred in the liver (n = 11), retroperitoneum (7), abdomen (6), pancreas (3), lung (3) and other multiple sites (3). Sixteen patients remain alive: 5 with and 11 without evidence of disease. The median survival has been 27 +/- 7 months with overall survival at 5 and 10 years 36% and 19%, respectively. Conclusions: En bloc pancreas/liver resection for sarcoma is feasible, and complete resection seems to provide worthwhile palliation or long-term survival

BACKGROUND: Excess use of intravenous fluid can increase post-operative complications. We examined the influence of intra-operative crystalloid (IOC) administration on complications following pancreaticodudenectomy (PD) for pancreatic adenocarcinoma. METHODS: We categorized 188 patients who underwent PD for adenocarcinoma (1990-2009) into two groups: Group I received <6,000 ml and Group II received >/=6,000 ml IOC. Differences between groups in length of stay, overall morbidity, and 30-day mortality were evaluated. RESULTS: There were 86 patients in Group I and 102 in Group II. Group I patients were older and with higher percentage of women, but similar in regards to performance status, ASA score, underlying comorbidities, and administration of neo-adjuvant treatment. Group II patients had longer operations, increased blood loss, and higher rates of intra-operative blood transfusions. There were two post-operative deaths, both in the Group II (P = 0.5). Post-operative overall morbidity was 45.7%, without differences between the two groups (44.2% vs. 47.1%, P = 0.7). Likewise, length of post-operative stay was similar in both groups (13.8 days vs. 14.5 days, P = 0.5). CONCLUSIONS: The volume of IOC increased with duration of surgery, intra-operative blood losses, and intra-operative blood transfusion, but did not correlate with post-operative morbidity. J. Surg. Oncol (c) 2011 Wiley-Liss, Inc

BACKGROUND: Teaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture. METHODS: The goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents' perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group. RESULTS: Study 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents' skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as 'slightly better' or 'much better' compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department's leadership view toward professionalism as 'much better' compared with 5 years ago. CONCLUSIONS: All 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago

BACKGROUND: Simulation-based training provides a low-stress learning environment where real-life emergencies can be practiced. Simulation can improve surgical education and patient care in crisis situations through a team approach emphasizing interpersonal and communication skills. OBJECTIVE: This study assessed the effects of simulation-based training in the context of trauma resuscitation in teams of trainees. METHODS: In a New York State-certified level I trauma center, trauma alerts were assessed by a standardized video review process. Simulation training was provided in various trauma situations followed by a debriefing period. The outcomes measured included the number of healthcare workers involved in the resuscitation, the percentage of healthcare workers in role position, time to intubation, time to intubation from paralysis, time to obtain first imaging study, time to leave trauma bay for computed tomography scan or the operating room, presence of team leader, and presence of spinal stabilization. Thirty cases were video analyzed presimulation and postsimulation training. The two data sets were compared via a 1-sided t test for significance (p < 0.05). Nominal data were analyzed using the Fischer exact test. RESULTS: The data were compared presimulation and postsimulation. The number of healthcare workers involved in the resuscitation decreased from 8.5 to 5.7 postsimulation (p < 0.001). The percentage of people in role positions increased from 57.8% to 83.6% (p = 0.46). The time to intubation from paralysis decreased from 3.9 to 2.8 minutes (p < 0.05). The presence of a definitive team leader increased from 64% to 90% (p < 0.05). The rate of spine stabilization increased from 82% to 100% (p < 0.08). After simulation, training adherence to the advanced trauma life support algorithm improved from 56% to 83%. CONCLUSIONS: High-stress situations simulated in a low-stress environment can improve team interaction and educational competencies. Providing simulation training as a tool for surgical education may enhance patient care

Neuroendocrine tumors (NETs) have a high predilection for metastasizing to the liver and can cause severe debilitating symptoms adversely affecting quality of life. Although surgery remains the treatment of choice, many liver metastases are inoperable at presentation. Hepatic arterial embolization procedures take advantage of the arterial supply of NET metastases. The goals of these therapies are twofold: to increase overall survival by stabilizing tumor growth, and to reduce the morbidity in symptomatic patients. Patients treated with hepatic arterial embolization demonstrate longer progression-free survival and have 5-year survival rates of nearly 30%. The safety of repeat embolizations has also been proven in the setting of recurrent symptoms or progression of the disease. Despite not being curative, hepatic arterial embolization should be used in the management of NETs with liver metastases. Long-term survival is not uncommon, making aggressive palliation of symptoms an important component of treatment.

BACKGROUND: : Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. METHODS: : Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. RESULTS: : Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. CONCLUSION: : Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians

BACKGROUND & AIMS: The cellular mediators of acute pancreatitis are incompletely understood. Dendritic cells (DCs) can promote or suppress inflammation, depending on their subtype and context. We investigated the roles of DC in development of acute pancreatitis. METHODS: Acute pancreatitis was induced in CD11c.DTR mice using caerulein or L-arginine; DCs were depleted by administration of diphtheria toxin. Survival was analyzed using Kaplan-Meier method. RESULTS: Numbers of major histocompatibility complex II(+)CD11c(+) DCs increased 100-fold in pancreata of mice with acute pancreatitis to account for nearly 15% of intrapancreatic leukocytes. Intrapancreatic DCs acquired a distinct immune phenotype in mice with acute pancreatitis; they expressed higher levels of major histocompatibility complex II and CD86 and increased production of interleukin-6, membrane cofactor protein-1, and tumor necrosis factor-alpha. However, rather than inducing an organ-destructive inflammatory process, DCs were required for pancreatic viability; the exocrine pancreas died in mice that were depleted of DCs and challenged with caerulein or L-arginine. All mice with pancreatitis that were depleted of DCs died from acinar cell death within 4 days. Depletion of DCs from mice with pancreatitis resulted in neutrophil infiltration and increased levels of systemic markers of inflammation. However, the organ necrosis associated with depletion of DCs did not require infiltrating neutrophils, activation of nuclear factor-kappaB, or signaling by mitogen-activated protein kinase or tumor necrosis factor-alpha. CONCLUSIONS: DCs are required for pancreatic viability in mice with acute pancreatitis and might protect organs against cell stress

Acetaminophen (APAP) overdose is one of the most frequent causes of acute liver failure in the United States and is primarily mediated by toxic metabolites that accumulate in the liver upon depletion of glutathione stores. However, cells of the innate immune system, including natural killer (NK) cells, neutrophils, and Kupffer cells, have also been implicated in the centrilobular liver necrosis associated with APAP. We have recently shown that dendritic cells (DCs) regulate intrahepatic inflammation in chronic liver disease and, therefore, postulated that DC may also modulate the hepatotoxic effects of APAP. We found that DC immune-phenotype was markedly altered after APAP challenge. In particular, liver DC expressed higher MHC II, costimulatory molecules, and Toll-like receptors, and produced higher interleukin (IL)-6, macrophage chemoattractant protein-1 (MCP-1), and tumor necrosis factor alpha (TNF-alpha). Conversely, spleen DC were unaltered. However, APAP-induced centrilobular necrosis, and its associated mortality, was markedly exacerbated upon DC depletion. Conversely, endogenous DC expansion using FMS-like tyrosine kinase 3 ligand (Flt3L) protected mice from APAP injury. Our mechanistic studies showed that APAP liver DC had the particular capacity to prevent NK cell activation and induced neutrophil apoptosis. Nevertheless, the exacerbated hepatic injury in DC-depleted mice challenged with APAP was independent of NK cells and neutrophils or numerous immune modulatory cytokines and chemokines. Conclusion: Taken together, these data indicate that liver DC protect against APAP toxicity, whereas their depletion is associated with exacerbated hepatotoxicity. (HEPATOLOGY 2011;)