Faculty Bibliography

BACKGROUND:Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. METHODS:This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. RESULTS:A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. CONCLUSIONS:When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Immune suppression following major thermal injury directly impacts the recovery potential. Limited data from past reports indicate that natural killer cells might be suppressed due to a putative soluble factor that has remained elusive up to date. Here we comparatively study cohorts of patients with Major and Non-Major Burns as well as healthy donors. MICB and ULBP1 are stress ligands of NKG2D that can be induced by heat stress. Remarkably, serum concentration levels of MICB and ULBP1 are increased by 3-fold and 20-fold, respectively, already within 24h post major thermal injury, and are maintained high for 28 days. In contrast, milder thermal injuries do not similarly enhance the serum levels of MICB and ULBP1. This kinetics coincides with a significant downregulation of NKG2D expression among peripheral blood NK cells. Downregulation of NKG2D by high concentration of soluble MICB occurs in cancer patients and during normal pregnancy due to over production by cancer cells or extravillous trophoblasts, respectively, as an active immune-evasion mechanism. In burn patients this seems an incidental outcome of extensive thermal injury, leading to reduced NKG2D expression. Enhanced susceptibility of these patients to opportunistic viral infections, particularly herpes viruses, could be explained by the reduced NKG2D expression. Further studies are warranted for translation into innovative diagnostic or therapeutic technologies.

INTRODUCTION: Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0% to 14.3%. We investigated the outcomes of NSM at our institution. METHODS: Patients undergoing NSM at our institution from 2006 to 2014 were identified and outcomes were analyzed. RESULTS: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. One-hundered and fourty-one patients (237 breasts) had long-term follow-up available. Average patient age and BMI were 47.78 and 24.63. Eighty-four percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.50 cm with the most common histologic type being invasive ductal carcinoma (62.7%) followed by DCIS (23.7%). Average patient follow-up was 30.73 months. There was one (0.8%) incidence of ipsilateral chest-wall recurrence. There were 0.37 complications per patient. CONCLUSIONS: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.8% with no nipple-areolar complex recurrence. This rate is lower than published rates for both NSM and SSM. J. Surg. Oncol. (c) 2015 Wiley Periodicals, Inc.

This clinical report describes the treatment of a partially dentate patient who presented with dental implants placed in a reconstructed fibula graft in the mandible. A complete mouth rehabilitation with a maxillary complete denture and a mandibular implant-supported fixed complete denture was fabricated with computer-aided design and computer-aided machining technology.

BACKGROUND: Traumatic optic neuropathy is characterized by sudden loss of vision following facial trauma leading to variable visual deficits. The purpose of this study was to evaluate recent institutional trends in the treatment of traumatic optic neuropathy, evaluate the outcomes of different treatment strategies, and identify factors associated with improved vision. METHODS: Institutional review board approval was obtained to retrospectively review patients diagnosed with traumatic optic neuropathy at a high-volume trauma center from 2004 to 2012. Pretreatment and posttreatment visual acuity was compared using quantitative analysis of standard ophthalmologic conversion. RESULTS: A total of 109 patients met inclusion criteria (74.3 percent male patients), with a mean age of 38.0 +/- 17.5 years (range, 8 to 82 years). Management of traumatic optic neuropathy involved intravenous corticosteroids alone in 8.3 percent of patients (n = 9), 56.9 percent (n = 62) underwent observation, 28.4 percent (n = 31) had surgical intervention, and 6.4 percent (n = 7) underwent surgery and corticosteroid administration. Only 19.3 percent of patients returned for follow-up. Vision improved in 47.6 percent of patients, with a mean follow-up of 12.9 weeks. Patients younger than 50 years had a trend toward higher rates of visual improvement, 60 percent versus 16.7 percent (p = 0.15). CONCLUSIONS: The majority of traumatic optic neuropathy patients are unlikely to return for a follow-up examination. Optic nerve decompression has fallen out of favor in the authors' institution, and observation is the most common management strategy. Outcomes following corticosteroid administration and observation are comparable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Importance: Limited data exist on performing major oral cavity resections and reconstructions without elective tracheotomy. Objectives: To describe a group of patients who successfully underwent major microvascular mandibular reconstruction without an elective tracheotomy and to perform a literature review to identify commonalities between our group and the available literature to identify potential common factors that might contribute to the success of this approach. Design, Setting, and Participants: Case series with retrospective medical chart review of 15 patients who underwent fibula microvascular free flap reconstruction of mandibular defects without tracheotomy between 2000 and 2014 (the most common indication was osteoradionecrosis) conducted at a tertiary referral hospital center. Exposures: Mandibular reconstruction with fibula free flap without elective tracheotomy. Main Outcomes and Measures: Perioperative morbidity and mortality with a focus on airway management and perioperative complications. Results: The median age of 15 patients (11 males and 4 females) at the time of reconstruction was 42 years (range, 10-64 years). The indication for surgery was nonmalignant pathologic abnormalities in 8 patients (53%), osteosarcoma in 4 patients (27%), and oral cavity squamous cell carcinoma in 3 patients (20%). All patients were intubated endonasally and, excepting 1 pediatric case, were extubated the day following surgery. The fibula spanned the parasymphysis and/or symphysis in 2 patients, and was limited to the mandibular body in others (mean length, 7.6 cm [range, 4.0-15.0 cm]). The flap design was osteocutaneous in 3 patients and osseous in the rest. No patient required reintubation or tracheotomy. No complications due to endonasal intubation occurred. The average hospital length of stay was 11 days. Conclusions and Relevance: Major oral cavity resection and reconstruction with microvascular free flaps can be performed safely without elective tracheotomy in a select group of patients. Limited data exist on patient selection criteria. Further studies are needed to identify favorable factors and develop protocols for safe patient selection.

A clinical case demonstrating the use of a free fibula osteoseptocutaneous flap for reconstruction of a high-energy ballistic mandible defect is detailed. The surgical videos highlight key nuances and pearls of flap design, harvest, dissection, and execution of microsurgical anastomosis. Attention is also given to preoperative surgical planning and postoperative care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.