- Dr. Gumbs has recently moved to France to develop the Department of Surgical Oncology at the Centre Hospitalier Inter... moreDr. Gumbs has recently moved to France to develop the Department of Surgical Oncology at the Centre Hospitalier Intercommunal Poissy/St. Germaine en Laye in France. Dr. Gumbs was previously Director of the Minimally Invasive Hepatic-Pancreatic-Biliary Surgery Program at SMG-MD Anderson Cancer Center and prior to that the Director of Minimally Invasive Hepatobiliary Surgery and at Fox Chase Cancer Center in Philadelphia, Pennsylvania. He has been Instructor of Clinical Surgery at Cornell-Weill Medical College, Instructor of Clinical Surgery at Columbia University College of Physicians and Surgeons, and Assistant Professor of Surgery in the Department of Surgical Oncology at Fox Chase Cancer Center. He is the Editor-in-Chief of Artificial Intelligence Surgery (aisjournal.net) and is a member of the editorial boards for Journal of Gastrointestinal Cancer, Mini-Invasive Surgery and Digestive Medicine Research. He is certified in general surgery, hepatic-pancreatic and biliary surgery and in laparoscopic surgery. He has delivered local, regional, national, and international invited presentations primarily devoted to minimally invasive surgical techniques for the liver, pancreas, and digestive organs. His articles have been published in Annals of Surgery, Journal of the American College of Surgeons and the Proceedings of the National Academy of Science. He volunteers for Doctors Without Borders.edit
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Among women with early-stage breast cancer treated with lumpectomy and radiation therapy, 30% to 40% will develop metastatic disease, which is often fatal. A need exists therefore for biomarkers that distinguish patients at high risk of... more
Among women with early-stage breast cancer treated with lumpectomy and radiation therapy, 30% to 40% will develop metastatic disease, which is often fatal. A need exists therefore for biomarkers that distinguish patients at high risk of relapse. We performed a retrospective correlative analysis of BAG-1 protein expression in breast tumors derived from a cohort of early-stage breast cancer patients. Archival paraffin blocks from 122 women with stages I to II breast cancer treated with lumpectomy and radiation therapy (median follow-up, 12.1 years) were analyzed by immunohistochemical methods using monoclonal antibodies recognizing BAG-1 and other biomarkers, including Bcl-2, estrogen receptor, progesterone receptor, p53, and HER2/Neu. Immunostaining data were correlated with distant metastasis-free survival (DMFS) and overall survival (OS). Cytosolic immunostaining for BAG-1 was upregulated in 79 (65%) of 122 invasive breast cancers (P <.001) compared with normal breast. Elevated BAG-1 was significantly associated with longer DMFS and OS, overall (stages 1 and II) and in node-negative (stage I only) patients, on the basis of univariate and multivariate analyses (DMFS, P =.005; OS, P =.01, in multivariate analysis of all patients; DMFS, P =.005; OS, P =.001, in multivariate analysis of node-negative patients). All other biomarkers failed to reach statistical significance in multivariate analysis. Clinical stage was an independent predictor of OS (P =.04) and DMFS (P =.02). These findings provide preliminary evidence that BAG-1 represents a potential marker of improved survival in early-stage breast cancer patients, independent of the status of axillary lymph nodes.
Research Interests: Oncology, Breast Cancer, Immunohistochemistry, Transcription Factors, Medicine, and 15 moreMultivariate Analysis, Humans, Internal Medicine, Female, Clinical oncology, Aged, Middle Aged, Adult, Retrospective Studies, DNA binding proteins, Univariate Analysis, Lumpectomy, Combined Modality Therapy, Breast Neoplasms, and Disease Free Survival
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Previous studies have determined that the frequency of germ-line p53 mutations in familial breast cancer patients is 1% or less, but these reports have not investigated the importance of polymorphic intron base changes in the p53 gene.... more
Previous studies have determined that the frequency of germ-line p53 mutations in familial breast cancer patients is 1% or less, but these reports have not investigated the importance of polymorphic intron base changes in the p53 gene. Therefore, we investigated the frequency of both exon and intron germ-line p53 base changes in 42 breast cancer patients with a strong family history of breast cancer. The mean age of presentation of these patients was 44.0 years (range, 29-69), and 12 of 42 (29%) were of known Ashkenazi ancestry. Purified DNA obtained from the 42 index cases was screened for germ-line p53 mutations in exons 2-11 and surrounding introns using a combination of intron based primers for PCR-single strand conformation polymorphism analysis, direct sequencing, and microarray sequencing using the Affymetrix p53 gene chip methodology. Morphological analysis of apoptosis and cell survival determination were performed on EBV-immortalized lymphoblastoid cell lines from two patients with the p53 intron 6 mutation. A germ-line mutation in the p53 gene at nucleotide 13964 with a G to C base change (13964GC) was identified in 3 of 42 (7.1%) hereditary breast cancer patients. Two patients were heterozygous for this mutation, and one patient had a homozygous mutation. In comparison, 0 of 171 (0%) of sporadic breast cancer patients had the p53 13964GC mutation (P = 0.0003). We found that 0 of 42 (0%) of these hereditary breast cancer patients had other germ-line p53 mutation in exons 2-11. However, pedigree analysis demonstrated that all three patients had strong family histories of multiple types of cancers consistent with Li-Fraumeni syndrome but with late age of onset. Comprehensive BRCA1 and BRCA2 nucleotide analysis from patients with the p53 13964GC mutation revealed no concomitant deleterious BRCA1 or BRCA2 mutations, although they were found in the other hereditary breast cancer patients. Functional analysis of two immortalized lymphoblastoid cell lines derived from patients with the p53 13964GC mutation demonstrated prolonged in vitro survival in response to cisplatinum treatment and showed decreased chemotherapy-induced apoptosis. Immunohistochemical analysis of breast tumors from these patients revealed high levels of mutant p53 protein, suggesting a functional mutation in the p53 gene. In summary, we have identified a single p53 intron mutation in familial breast cancer patients that is present at elevated frequency and has functional activity.
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The AP-2 transcription factors are required for normal growth and morphogenesis during mammalian development. Previous in vitro studies have also indicated that the AP-2 family of proteins may be involved in the etiology of human breast... more
The AP-2 transcription factors are required for normal growth and morphogenesis during mammalian development. Previous in vitro studies have also indicated that the AP-2 family of proteins may be involved in the etiology of human breast cancer. The AP-2 genes are expressed in many human breast cancer cell lines, and critical AP-2-binding sites are present in both the ERBB-2 (HER2/neu) and estrogen receptor promoters. We have now characterized immunological reagents that enable specific AP-2 family members, including AP-2alpha and AP-2gamma, to be detected in human breast cancer epithelium. Data obtained with these reagents demonstrate that whereas AP-2alpha and AP-2gamma are both present in benign breast epithelia, there is a significant up-regulation of AP-2gamma expression in breast cancer specimens (P = 0.01). There was also a significant correlation between the presence of the AP-2alpha protein and estrogen receptor expression (P = 0.018) and between specimens containing both AP-2alpha/AP-2gamma proteins and ERBB-2 expression (P = 0.003). Furthermore, we detected an association (P = 0.04) between the expression of AP-2gamma and the presence of an additional signal transduction molecule implicated in breast cancer, the insulin-like growth factor I receptor. Analysis of the proximal promoter of the insulin-like growth factor I receptor revealed a novel AP-2-binding site. Thus, AP-2 proteins may directly regulate the transcription of this growth factor receptor. Taken together, these data strongly support a role for the AP-2 gene family in the control of cell growth and differentiation in breast cancer.
Research Interests: Cancer, Breast Cancer, Biology, Immunohistochemistry, Cancer Research, and 15 moreTranscription Factors, Medicine, Gene expression, Signal Transduction, Estrogen Receptor, Humans, Female, Pubmed, Breast, Transcription Factor, Epithelium, Prognosis, DNA binding proteins, Breast Neoplasms, and binding sites
The insulin-like growth factor-I receptor (IGF-IR) plays a critical role in cell growth regulation and transformation. The radiosensitivity of NIH 3T3 fibroblasts overexpressing either wild-type or mutant IGF-IR was examined. High levels... more
The insulin-like growth factor-I receptor (IGF-IR) plays a critical role in cell growth regulation and transformation. The radiosensitivity of NIH 3T3 fibroblasts overexpressing either wild-type or mutant IGF-IR was examined. High levels of wild-type IGF-IR conferred radioresistance, and mutational analysis revealed that this effect correlated with the transforming capacity but not the mitogenic activity of the receptor. The radioresistant phenotype was reversed when the cells were incubated with antisense oligonucleotides targeted to IGF-IR mRNA, demonstrating that IGF-IR directly influences radioresistance. The clinical significance of these findings was examined in an immunohistochemical analysis of primary breast tumors, revealing that high levels of IGF-IR in tumor samples were highly correlated with ipsilateral breast tumor recurrence (IBTR) following lumpectomy and radiation therapy (P = 0.001). Subgroup analysis revealed that, for early breast tumor relapses (within 4 years of initial breast tumor diagnosis), elevated levels of IGF-IR were strongly associated with IBTR (P = 0.004) but IGF-IR expression was not prognostic for IBTR from breast cancer patients with late relapses (P was not significant). These studies provide evidence for the influence of IGF-IR on cellular radioresistance and response to therapy and raise the possibility that the radiocurability of selected tumors may be improved by pharmaceutical strategies directed toward the IGF-IR.
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Laparoendoscopic single-site (LESS) surgery has emerged as a viable and widely applicable minimally invasive technique. Presented here are the steps necessary to perform LESS cholecystectomy using a readily available gelport device. To... more
Laparoendoscopic single-site (LESS) surgery has emerged as a viable and widely applicable minimally invasive technique. Presented here are the steps necessary to perform LESS cholecystectomy using a readily available gelport device. To perform LESS cholecystectomy we make a 2 cm incision through the umbilicus until the fascia is identified. The fascia is opened 2 cm and a wound protector is inserted. Through the gelport we insert a 5 mm trocar with a balloon tip for the insufflation and three 5 mm trocars as working ports. Three of the trocars are placed in the lower third in a semilunar configuration before mounting the gelport onto the wound protector. A fourth trocar can then be placed at the superior aspect of the gelport. Intra-abdominal visualization is obtained with an articulating 5 mm laparoscope. At our institution 19 patients have undergone LESS cholecystectomy out of 20 attempts (5% conversion rate), with the first 15 patients undergoing a single skin incision, multifascial incision approach and the last 5 done using a gelport device and single fascial incision. One patient in the multifascial group required conversion to a dual incision laparoscopic cholecytectomy due to cystic duct bleeding. Overall, procedures averaged 81 minutes (range, 43 to 181 min), the average length of stay was <1 day (range, 0 to 2 d). To date, 1 patient developed a wound infection that responded to oral antibiosis (5% overall complication rate), and no hernias have developed with a mean follow-up of 9 months (range, 3 to 12 mo). The gelport may allow for the widespread use of this exciting technology even in nonspecialized centers because of the familiarity of minimally invasive surgeons with this device. The elasticity of this device seems to facilitate the use of 4 trocars, thus, replicating the "critical view" of the structures of the triangle of Calot seen in standard multi-incision laparoscopic cholecystectomy.
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Research Interests: Conceptual change, Adolescent, Medicine, Laparoscopic Surgery, General Surgery, and 15 moreHumans, Female, Male, Clinical Sciences, Endoscopic Surgery, Aged, Adult, Conceptual Change, Appendectomy, Abdominal Surgery, Abscess, Laparoscopy, Acute Appendicitis, Appendicitis, and Medical and Health Sciences
The macrophage colony-stimulating factor receptor (CSF-1R), the product of the c-fms proto-oncogene, regulates normal proliferation and differentiation of macrophages and trophoblasts. Recent research found abnormal expression of CSF-1R... more
The macrophage colony-stimulating factor receptor (CSF-1R), the product of the c-fms proto-oncogene, regulates normal proliferation and differentiation of macrophages and trophoblasts. Recent research found abnormal expression of CSF-1R in human carcinomas of the breast, endometrium, and ovary. Furthermore, activation of CSF-1R by its ligand has been shown to regulate invasiveness and anchorage-independent growth in breast carcinoma cells. To study the significance of CSF-1R expression in breast cancer, we designed a case-controlled immunohistochemical study. We chose 80 patients from a database of 1200 early stage I or II breast cancer patients treated with conservative surgery and radiation therapy. Expression of CSF-1R in the tumors of 40 patients who experienced an ipsilateral breast tumor recurrence (IBTR) as a primary site of relapse were compared with 40 patients who had not experienced an IBTR. The index and control patients were matched by age, clinical stage, nodal status, and follow-up. Paraffin-embedded sections were immunostained with antibodies directed toward CSF-1R. For the CSF-1R antibody, a total of 28 index cases (70%) demonstrated strong staining, whereas only 16 control cases (40%) demonstrated high immunoreactivity (P = 0.007). The CSF-1R antibody showed a positive correlation for local relapse, but no correlation was found between CSF-1R expression and distant metastasis. In summary, our findings provide evidence for the poor prognostic role of CSF-1R in IBTR.
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Research Interests: Computed Tomography, Immunohistochemistry, Pancreatitis, Medicine, Case Report, and 15 moreHumans, Autoimmune Disease, Autoimmune diseases, Pancreas, Female, Chronic Pancreatitis, Clinical Sciences, Aged, Edema, Gallbladder, JOP, Abdominal Pain, Autoimmune Pancreatitis, immunoglobulin G, and Acute Disease
Annular pancreas (AP) is a rare anomaly due to malrotation of the pancreatic ventral bud during embryologic development. AP has been extensively described in the pediatric population; however, in adults, the incidence has been reported to... more
Annular pancreas (AP) is a rare anomaly due to malrotation of the pancreatic ventral bud during embryologic development. AP has been extensively described in the pediatric population; however, in adults, the incidence has been reported to be only 1 in 22,000 patients with only a few cases presenting with simultaneous mucinous cystadenoma described in the recent literature. We report the case of a 72-year-old female patient with a mucinous cystadenoma, who was found to have a concomitant AP during laparoscopic distal pancreatectomy. The dual presentation of annual pancreas and mucinous cystoadenoma is an infrequent condition and can be managed with minimally invasive techniques; bypass in adults should only be performed in patients with symptomatic duodenal compression or recurrent bouts of pancreatitis.
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Research Interests: Ovarian Cancer, Medicine, Biopsy, Humans, Female, and 6 moreClinical Sciences, Aged, Peritonitis, Laparoscopy, Abdomen, and Sclerosis
Research Interests: Medicine, Adhesion, Humans, Female, Male, and 15 moreObesity Surgery, Clinical Sciences, Middle Aged, Intestinal Obstruction, Adult, Public health systems and services research, Morbid Obesity, Gastric Bypass, Biocompatible Materials, Bowel Obstruction, Polyethylene Terephthalates, Laparoscopy, Anastomosis, Absorbable Suture, and small bowel
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Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches... more
Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer. Like the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy. Six patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1-6). The minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage.
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When behavioral or anatomic issues are not present, revisional surgery should be approached with a goal of treating malnutrition or enhancing excess weight loss. Unfortunately, no randomized controlled trials currently exist to help the... more
When behavioral or anatomic issues are not present, revisional surgery should be approached with a goal of treating malnutrition or enhancing excess weight loss. Unfortunately, no randomized controlled trials currently exist to help the practicing bariatric surgeon choose which revisional procedure to perform. A review of the available literature was undertaken and compared with our standard practices to see if any guidelines could be devised. At our institution, patients who have failed jejunal-ileal bypass are reversed in the setting of malnutrition and converted to a sleeve gastrectomy (SG) followed by duodenal switch (DS) as a second stage procedure in the setting of inadequate weight loss. After failed vertical banded gastroplasty (VBG), patients are converted to a Roux-en-Y gastric bypass (RYGBP). After failed adjustable gastric band (AGB) placement, we perform RYGBP. In the super-obese, we leave the band in place or convert to a DS with band removal. In patients with failed RYGBP, we convert our patients to DS, but placement of an AGB may be an acceptable option.
Research Interests: Surgery, Bariatric Surgery, Obesity, Medicine, Malnutrition, and 12 moreHumans, Weight Loss, Gastric banding, Obesity Surgery, Clinical Sciences, Public health systems and services research, Randomized Controlled Trial, Gastric Bypass, Roux-en-y Gastric Bypass, Reoperation, Sleeve gastrectomy, and Treatment Failure
Research Interests: Obesity, Incidence Geometry, Enzyme Inhibitors, Medicine, Prospective studies, and 15 moreComplication, Humans, Female, Male, Incidence, Body Mass Index, Clinical Sciences, Middle Aged, Gastrointestinal Endoscopy, Adult, Gastric Bypass, Laparoscopy, Proton Pump Inhibitors, Postoperative Complications, and proton pump
Research Interests: Surgery, Bariatric Surgery, Medicine, Humans, Weight Loss, and 12 moreObesity Surgery, Clinical Sciences, Public health systems and services research, Morbid Obesity, SURGICAL TECHNIQUE, Laparoscopy, Long Term Study, Biliopancreatic diversion, Surgical Treatment, Sleeve gastrectomy, Gastrectomy, and Sleeve
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Uterine papillary serous carcinoma (UPSC) is a morphologically distinct variant of endometrial carcinoma that is associated with a poor prognosis, high recurrence rate, frequent clinical understaging, and poor response to salvage... more
Uterine papillary serous carcinoma (UPSC) is a morphologically distinct variant of endometrial carcinoma that is associated with a poor prognosis, high recurrence rate, frequent clinical understaging, and poor response to salvage treatment. We retrospectively analyzed local control, actuarial overall survival (OS), actuarial disease-free survival (DFS), salvage rate, and complications for patients with Federation International of Gynecology and Obstetrics (FIGO) (1988) Stage I UPSC. This retrospective analysis describes 38 patients with FIGO Stage I UPSC who were treated with the combinations of radiation therapy, chemotherapy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy (TAH/BSO), with or without a surgical staging procedure. Twenty of 38 patients were treated with a combination of low dose-rate (LDR) uterine/vaginal brachytherapy using 226Ra or 137Cs and conventional whole-abdomen radiation therapy (WART) or whole-pelvic radiation therapy (WPRT). Of 20 patients (10%) in this treatment group, 2 received cisplatin chemotherapy. Eighteen patients were treated with high dose-rate (HDR) vaginal apex brachytherapy using 192Ir with an afterloading device and cisplatin, doxorubicin, and cyclophosphamide (CAP) chemotherapy (5 of 18 patients). Only 6 of 20 UPSC patients treated with combination LDR uterine/vaginal brachytherapy and conventional external beam radiotherapy underwent complete surgical staging, consisting of TAH/BSO, pelvic/para-aortic lymph node sampling, omentectomy, and peritoneal fluid analysis, compared to 15 of 18 patients treated with HDR vaginal apex brachytherapy. The 5-year actuarial OS for patients with complete surgical staging and adjuvant radiation/chemotherapy treatment was 100% vs. 61% for patients without complete staging (p = 0.002). The 5-year actuarial OS for all Stage I UPSC patients treated with postoperative HDR vaginal apex brachytherapy and systemic chemotherapy was 94% (18 patients). The 5-year actuarial OS for Stage I UPSC patients treated with HDR vaginal apex brachytherapy and chemotherapy who underwent complete surgical staging was 100% (15 patients). The 5-year actuarial OS for the 20 Stage I UPSC patients treated with combinations of pre- and postoperative LDR brachytherapy and postop WART was 65%. None of the 6 surgically staged UPSC patients treated with LDR radiation and WART/WPRT developed recurrent disease. For patients with FIGO Stage IA, IB, and IC UPSC who underwent complete surgical staging, the 5-year actuarial DFS by depth of myometrial invasion was 100, 71, and 40%, respectively (p = 0.006). The overall salvage rate for local and distant recurrence was 0%. Complications following HDR vaginal apex brachytherapy included only Radiation Therapy Oncology Group (RTOG) grade 1 and 2 toxicity in 16% of patients. However, complications from patients treated with WART/WPRT, and/or LDR brachytherapy, included RTOG grade 3 and 4 toxicity in 15% of patients. Patients with UPSC should undergo complete surgical staging, and completely surgically staged FIGO Stage I UPSC patients can be effectively and safely treated with HDR vaginal apex brachytherapy and chemotherapy. Both OS and DFS of patients with UPSC are dependent on depth of myometrial invasion. The salvage rate for both local and distant UPSC recurrences is extremely poor. Complications from HDR vaginal apex brachytherapy were minimal.
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Background The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute... more
Background The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. Methods Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. Results A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were n...
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Objective: To develop and update evidence- and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery,... more
Objective: To develop and update evidence- and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. Methods: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, t...
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This white paper documents the consensus opinion of the Artificial Intelligence Surgery (AIS) task force on Artificial Intelligence (AI) Ethics and the AIS Editorial Board Study Group on Ethics on the ethical considerations and current... more
This white paper documents the consensus opinion of the Artificial Intelligence Surgery (AIS) task force on Artificial Intelligence (AI) Ethics and the AIS Editorial Board Study Group on Ethics on the ethical considerations and current trustworthiness of artificial intelligence and autonomous actions in surgery. The ethics were divided into 6 topics defined by the Task Force: Reliability of robotic and AI systems; Respect for privacy and sensitive data; Use of complete and representative (i.e., unbiased) data; Transparencies and uncertainties in AI; Fairness: are we exacerbating inequalities in access to healthcare?; Technology as an equalizer in surgical education. Task Force members were asked to research a topic, draft a section, and come up with several potential consensus statements. These were voted on by members of the Task Force and the Study Group, and all proposals that received > 75 % agreement were adopted and included in the White Paper.
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Protective ileostomy may be a risk factor for the development of Clostridium difficile (CD) infection (CDI). In the postoperative period signs of CDI may be particularly difficult to differentiate from intra-abdominal sepsis. Presented... more
Protective ileostomy may be a risk factor for the development of Clostridium difficile (CD) infection (CDI). In the postoperative period signs of CDI may be particularly difficult to differentiate from intra-abdominal sepsis. Presented here are 2 cases that developed CDI after ileostomy reversal. Two patients who underwent low anterior resections after neoadjuvant chemoradiation with protective ileostomy developed fever, leukocytosis and elevated serum C-reactive protein (CRP) levels. The first patient also had negative CD stool toxins and his signs were so severe that he underwent a negative diagnostic laparoscopy and re-creation of ileostomy. The second patient who presented in a similar fashion was more fortunate in that her CD stool toxin was positive and she was treated successfully with oral vancomycin. CDI after ileostomy reversal after low anterior resection can be difficult to diagnose. In the first patient, the situation was so misleading that diagnostic laparoscopy was re...
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Purpose Minimally invasive liver surgery (MILS) is a feasible and safe procedure for benign and malignant tumors. There has been an ongoing debate on whether conventional laparoscopic liver resection (LLR) or robotic liver resection (RLR)... more
Purpose Minimally invasive liver surgery (MILS) is a feasible and safe procedure for benign and malignant tumors. There has been an ongoing debate on whether conventional laparoscopic liver resection (LLR) or robotic liver resection (RLR) is superior and if one approach should be favored over the other. We started using LLR in 2010, and introduced RLR in 2013. In the present paper, we report on our experiences with these two techniques as early adopters in Germany. Methods The data of patients who underwent MILS between 2010 and 2020 were collected prospectively in the Magdeburg Registry for Minimally Invasive Liver Surgery (MD-MILS). A retrospective analysis was performed regarding patient demographics, tumor characteristics, and perioperative parameters. Results We identified 155 patients fulfilling the inclusion criteria. Of these, 111 (71.6%) underwent LLR and 44 (29.4%) received RLR. After excluding cystic lesions, 113 cases were used for the analysis of perioperative parameter...
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Aim: We aimed to evaluate the knowledge, attitude and practices in the application of artificial intelligence in the emergency setting among international acute care and emergency surgeons. Methods: An online questionnaire composed of 30... more
Aim: We aimed to evaluate the knowledge, attitude and practices in the application of artificial intelligence in the emergency setting among international acute care and emergency surgeons. Methods: An online questionnaire composed of 30 multiple choice and open-ended questions was sent to the members of the World Society of Emergency Surgery between 29th May and 28th August 2021. The questionnaire was developed by a panel of 11 international experts and approved by the WSES steering committee. Results: 200 participants answered the survey, 32 were females (16%). 172 (86%) surgeons thought that artificial intelligence will improve acute care surgery. Fifty surgeons (25%) were trained on robotic surgery and can perform it. Only 19 (9.5%) were currently performing it. 126 (63%) surgeons do not have a robotic system in their institution, and for those who have it, it was mainly used for elective surgery. Only 100 surgeons (50%) were able to define different artificial intelligence term...
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BACKGROUND Complex abdominal wall repair (CAWR) remains challenging, especially in contaminated fields where the use of a synthetic mesh is associated with prohibitively complication rates. Consequently, biological mesh has been proposed... more
BACKGROUND Complex abdominal wall repair (CAWR) remains challenging, especially in contaminated fields where the use of a synthetic mesh is associated with prohibitively complication rates. Consequently, biological mesh has been proposed as an alternative. The aim of our study was to evaluate the safety and efficacy of using Permacol® in patients who had CAWR. METHODS We retrospectively reviewed the files of patients who had CAWR using the Permacol® mesh. Analysis included patients' preoperative characteristics, procedural parameters, and early and late post-operative complications including mainly recurrence. A multivariate regression model was performed to determine factors that influence 24-months recurrence rate. RESULTS Between January 2009 and December 2018, 75 patients. The most common indication was hernia in a contaminated field (48.0%) and abdominal wall defect greater than 10 cm in diameter (36%). Overall, 44% of our patients were Centers for Disease Control (CDC) class II or III and 81.3% fall into category II or III according to the Ventral Hernia Working Group (VHWG) classification. Recurrence rate of our series was 9.3%. Complete fascial closure was achieved in 60 patients (80%). Upon univariate analysis complete fascial closure, posterior component separation, seroma drainage, BMI >30 kg/m2 and age >65 years, VHWD grade >2, DINDO CLAVIEN class > 2 affected the recurrence rate at 2 years follow up. When subcutaneous drains are placed prophylactically, recurrence rates drop from 38.7% (5/14) to 3.3% (2/61 patients) when drains are placed at the time of operation (p=0.02). Only fascial closure affected the 24-months recurrence rate on multivariate analysis (p<0.001). CONCLUSIONS Permacol® surgical implant use for CAWR is safe with a relatively low rate of hernia recurrence at 2 years. Prophylactic subcutaneous drain placement may reduce the risk of hernia recurrence. The presence of contaminated fields does not appear to influence hernia recurrence when Permacol® is used, in fact, the only factor that affects recurrence rate at 24-months on multivariate analysis is completeness of the fascial closure.
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BACKGROUND In 2019, women accounted for 46% of surgical residents. Despite the international debate on gender disparities, no literature regarding the experience in Italy is available. The aim of this survey study was to assess... more
BACKGROUND In 2019, women accounted for 46% of surgical residents. Despite the international debate on gender disparities, no literature regarding the experience in Italy is available. The aim of this survey study was to assess satisfaction among female surgeons in Italy, and whether they encounter gender-based discrimination. STUDY DESIGN An anonymous 83-item web-based survey was distributed among female surgeons working in Italy, from November 18 to December 31st, 2020. Gender equity, satisfaction and factors associated with higher satisfaction and work-life balance were explored. RESULTS There were 3,242 volunteer respondents, out of which 1,833 completed at least 50% of the specific questions and were included in the study. Approximately 54% of female Italian surgeons reported being satisfied with their job, but only 34% with their work-life balance. Among residents, 67% thought they were not adequately trained. The majority of respondents were responsible for most of the housekeeping (60%) and childcare duties (53%), regardless of their partner's workload, and 62% reported that gender affects the way they are treated at work with most of them experiencing microaggressions. Sexual harassment was common (59%), but only 10% of women reported it. CONCLUSIONS Most Italian female surgeons are satisfied with their professional choice. However, they face gender discrimination, including incidents of sexual harassment and microaggressions. Due to the fact that half of surgeons working in Italian hospitals will be females in the next few years, actions are urgently required to build a culture that supports a gender-neutral environment.