The American Journal of Surgery

Liver transplantation and resective surgery lessons learned: the case for a systems approach

Charles H. Scudamore — 2012-05-01

The challenges facing today's general surgeon are daunting, if not overwhelming. We all are too familiar with changes in governance, hierarchy, privileges, liability, surgical competency, remuneration, and quality of life, to name just a few. The journey to become a competent general surgeon starts with 15 or more years of higher education, which often is highly competitive and frequently exhausting. One trades one's youth to become a surgeon. In my opinion, the 2 most important aspects of practice that makes it all worthwhile is the special bond between the patient, their families, and the specialized knowledge and technical ability that leads to professional proficiency.

Dr Robert McKechnie: Vancouver's pioneer surgeon and a patron of British Columbia sports & education

Preston L. Carter — 2012-05-01

Abstract: Robert E. McKechnie, M.D.C.M. (1861–1944), was a distinguished graduate of McGill Medical School and a pioneer in the early days of surgery in Vancouver, Canada. He was a long-standing Canadian leader in both clinical and academic surgery. In addition, he played an important role in the founding of the University of British Columbia. He also commissioned an important challenge cup for the British Columbia rugby championship team in the same time and place as the establishment of hockey's Stanley Cup.

Temporal trends in the treatment of severe traumatic hemorrhage

2012-03-15

Abstract: Background: This study examined the evolution of damage control resuscitation (DCR) and outcomes in severe traumatic hemorrhage (STH) at a large Canadian trauma center. Methods: This was a retrospective cohort study of trauma patients admitted to a level 1 trauma center between 2005 and 2010, who received 10 or more units of packed red blood cells within 24 hours of admission. Demographic and clinical findings were compared between survivors and nonsurvivors. Results: Forty-five patients were included. Twenty-five percent of patients were coagulopathic at admission. Early crystalloid use declined over the study period. The mean 24-hour fresh-frozen plasma:platelets:packed red blood cells ratio was 1:1:2. Hemorrhage-related mortality was 69%. No pedestrians survived STH. A total of 1,032 blood product units were used in the first day for nonsurvivors. Conclusions: Principles of DCR crept into clinical practice even before the implementation of a formal STH protocol. DCR appeared to reduce the intensive care unit length of stay but not mortality. STH is associated with heavy use of blood bank resources and high mortality rates. Futility of resuscitative efforts may be predictable by mechanism and early physiological markers.

Factors influencing humanitarian care and the treatment of local patients within the deployed military medical system: casualty referral limitations

Marlin Causey, Robert M. Rush, Randy J. Kjorstad, James A. Sebesta — 2012-05-01

Abstract: Background: Humanitarian medical care is an essential task of the deployed military health care system. The purpose of this study was to analyze referral acceptance in treating injured local national patients during Operation Enduring Freedom. Methods: A prospective observation study of local nationals who were referred for humanitarian trauma care in Afghanistan from March through August 2009. Results: Sixty-six patients were referred for evacuation for suspected non–coalition-caused injuries. The bed status at the receiving hospital was defined as green (able to accept patients), amber (nearing capacity), and red (at capacity). The only factor associated with acceptance was the accepting hospital bed status (odds ratio = 1.57%, 95% confidence interval, 1.11–2.22; P = .009). Factors not significant were age, the province of origin, the type of referring facility, a prior operation before the request, patient status/affiliation, or the mechanism of injury. Conclusions: Humanitarian medical care is directly related to the capacity for high-acuity care because bed availability is the predominate reason for acceptance or rejection.

Acute care surgery: the impact of an acute care surgery service on assessment, flow, and disposition in the emergency department

2012-03-09

Abstract: Background: Acute care surgery (ACS) services are becoming increasingly popular. Methods: Assessment, flow, and disposition of adult ACS patients (acute, nontrauma surgical conditions) through the emergency department (ED) in a large health care system (Calgary) were prospectively analyzed. Results: Among 447 ACS ED consultations over 3 centers (70% admitted to ACS), the median wait time from the consultation request to ACS arrival was 36 minutes, and from ACS arrival to the admission request it was 91 minutes. The total ACS-dependent time was 127 minutes compared with 261 minutes for initial ED activities and 104 minutes for transfer to a hospital ward (P < .05). Forty percent of patients underwent computed tomography (CT) imaging (76% before consultation). The time to ACS consultation was 305 minutes when a CT scan was performed first. Conclusions: An ACS service results in rapid ED assessment of surgical emergencies. Patient waiting is dominated by the time before requesting ACS consultation and/or waiting for transfer to the ward.

Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury

2012-03-19

Abstract: Background: The purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury. Methods: Patients admitted with a traumatic brain injury were enrolled prospectively and admission blood samples were obtained for kaolin-activated thrombelastogram and standard coagulation assays. Demographic and clinical data were obtained for analysis. Results: Sixty-nine patients were included in the analysis. A total of 8.7% of subjects showed hypocoagulability based on a prolonged time to clot formation (R time, > 9 min). The mortality rate was significantly higher in subjects with a prolonged R time at admission (50.0% vs 11.7%). Patients with a prolonged R time also had significantly fewer intensive care unit–free days (8 vs 27 d), hospital-free days (5 vs 24 d), and increased incidence of neurosurgical intervention (83.3% vs 34.9%). Conclusions: Hypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.

An assessment of different scoring systems in cirrhotic patients undergoing nontransplant surgery

2012-05-01

Abstract: Background: Determining surgical risk in cirrhotic patients is difficult and multiple scoring systems have sought to quantify this risk. The purpose of our study was to assess the impact of Childs-Turcotte-Pugh (CTP), Model of End-Stage Liver Disease (MELD), and MELD-Sodium (MELD-Na) scores on postoperative morbidity and mortality for cirrhotic patients undergoing nontransplant surgery. Methods: We performed a single-center retrospective review of all cirrhotic patients who underwent nontransplant surgery under general anesthesia over a 6-year period of time to analyze outcomes using the 3 scoring systems. Results: Sixty-four cirrhotic patients (mean age, 57 y; 62 men) underwent nontransplant surgery under general anesthesia. A CTP score of ≥7.5 was associated with an 8.3-fold increased risk of 30-day morbidity, a MELD score of ≥14.5 was associated with a 5.4-fold increased risk of 3-month mortality, and a MELD-Na score ≥14.5 was associated with a 4.5-fold increased risk of 1-year mortality. Emergent surgery, the presence of ascites, and low serum sodium level were associated significantly with morbidity and 1-year mortality. Conclusions: The major strengths of the 3 scoring systems are for CTP in estimating 30-day morbidity, MELD for estimating 3-month mortality, and MELD-Na for estimating 1-year mortality.

Bioprosthetic mesh use for the problematic thoracoabdominal wall: outcomes in relation to contamination and infection

2012-03-26

Abstract: Background: Limited controlled data exist regarding the role of bioprosthetic meshes for hernia repair. Often the only option available in contaminated cases, their high cost calls for an evaluation of their utility and indications for use. Methods: A retrospective review of cases in which human acellular dermal matrix (HADM) was used to reconstruct a thoracoabdominal wall defect at the Foothills Medical Centre of Calgary was conducted. Attention was placed to identify the need for surgical reintervention postoperatively. Results: Over 2 years, 13 patients required the use of HADM for reconstruction of their thoracoabdominal wall; 69.2% of the cases were contaminated or infected. Three patients (23.1%) presented postoperative infectious complications; only 1 required reoperation. No patients required removal of their prosthesis. Two patients presented recurrences (median follow-up = 126 days). Conclusions: The use of HADM for complex thoracoabdominal wall defects in contaminated or infected settings is a reliable option available for surgeons.

Incidence of deep vein thrombosis is increased with 30 mg twice daily dosing of enoxaparin compared with 40 mg daily

2012-05-01

Abstract: Background: The purpose of this study was to analyze whether 2 standard dosing regimens of enoxaparin (30 mg twice daily vs 40 mg once daily) would result in different deep vein thrombosis (DVT) rates and anti-factor Xa activity (anti-Xa) in surgical patients. Methods: Patients who required enoxaparin for prophylaxis were followed prospectively. Demographics were recorded. Patients underwent standardized duplex screening. Peak anti-Xa levels were drawn on 4 consecutive days. Results: Sixty-three patients were followed up (28 patients on 30 mg twice daily, 35 patients on 40 mg once daily). There was no significant difference in demographics between groups. Twenty-five percent of patients on 30 mg twice daily developed a DVT, whereas 2.9% of patients on 40 mg once daily developed a DVT. Patients on 30 mg twice daily had significantly lower anti-Xa levels. Conclusions: The incidence of DVT is increased in surgical patients who receive 30 mg twice daily dosing of enoxaparin compared with 40 mg daily. Dosing of 40 mg once daily results in significantly higher peak anti-Xa levels compared with 30 mg twice daily.

The duodenal switch for morbid obesity: modification of cardiovascular risk markers compared with standard bariatric surgeries

Daniel Nelson, Rees Porta, Kelly Blair, Preston Carter, Matthew Martin — 2012-03-14

Abstract: Background: Obesity is associated with cardiovascular risk factors such as lipid levels and increased levels of C-reactive peptide (CRP). We hypothesized that duodenal switch (DS) would show equivalent or superior risk reduction compared with standard bariatric surgeries. Methods: Patients underwent DS, sleeve gastrectomy (SG), or gastric bypass (GB) over a 2-year period. Body mass index (BMI), lipid panel, and CRP were measured preoperatively and then 3, 6, and 12 months postoperatively. Results: A total of 130 patients were identified; 42 underwent DS, 40 underwent SG, and 48 underwent GB. All groups had similar sex and comorbidity profiles, but the mean preoperative BMI was greatest in the DS group (mean = 52). At all intervals weight loss was greater in the DS group (P < .01), with a final BMI of 31 for the DS group, 31 for the SG group, and 28 for the GB group. Cholesterol and low-density lipoprotein showed significantly greater improvement at all time points with DS compared with SG and GB (P < .01). Baseline CRP levels among DS patients were double that of SG and GB, but rapidly declined to equivalent levels by 3 months and normalized in 79%. Conclusions: The DS procedure resulted in a superior reduction in cardiovascular and proinflammatory risk markers compared with GB and SG.

The benefits of laparoscopic appendectomies in obese patients

2012-03-26

Abstract: Background: Systematic reviews and randomized controlled trials comparing laparoscopic appendectomy (LA) with open appendectomy (OA) show a reduction in wound infections associated with LA but a 3-fold increase in intra-abdominal abscess with LA. Surgical time and operation costs are higher with LA. The advantage of LA over OA is small. Although these patients have not been specifically analyzed in the report, the systematic review recommends the routine use of LA in young women and obese people. The purpose of this study is to determine if obese patients benefit in a shorter length of stay (LOS) by having LA versus OA surgery compared with their nonobese counterparts. Methods: A retrospective chart review of 315 adult patients who have undergone appendectomies at Royal Columbian and Burnaby Hospitals between April 1, 2010 and March 31, 2011. Appendectomies performed in pregnant women combined with other surgeries and those converted to OA were excluded. Outcomes and the postoperative stay for obese and nonobese patients were assessed. Results: The LOS is shorter with LAs than with OAs (2.06 vs 4.13 days, P < .05). The LOS, in obese patients, is much shorter with LAs than with OAs (1.69 vs 6.82 days, P < .05). The variability in LOS is much higher in obese patients as compared with nonobese patients (standard deviation = 8.57 vs 2.67). The body mass index and the type of surgery contribute to a significant difference in LOS. Conclusions: Obese patients who undergo LA have a decreased LOS as compared with obese patients who undergo OA for appendicitis. This is the first study showing specifically that LA benefits obese patients and the health care system.

Results of routine shunting and patch closure during carotid endarterectomy

2012-03-19

Abstract: Background: The role of shunting and patching during carotid endarterectomy remains controversial. Methods: This is a retrospective case series evaluating consecutive patients undergoing carotid endarterectomy with routine shunting and patching. The primary endpoints were perioperative stroke, arterial injury, and lesion recurrence by duplex. Results: Of the 220 operations performed, 43% were for symptomatic disease. Successful shunt placement occurred in 98%, with no shunt-related injuries. There was 1 minor perioperative stroke and no major strokes. At a mean follow-up of 24 months (median = 12 months), there was 1 restenosis potentially related to shunt placement. The incidence of asymptomatic >50% stenosis in the patched segment was 8%. Conclusions: A combined policy of routine shunting and patching simplifies intraoperative decision making with results that rival or exceed those of trials in which their use was not standardized. Shunts need not be avoided because of concern of arterial injury.

Impact of American College of Surgeons Oncology Group Z0011 and National Surgical Adjuvant Breast and Bowel Project B-32 trial results on surgeon practice in the Pacific Northwest

2012-03-26

Abstract: Background: Recent clinical trials have suggested no survival benefit for completion axillary node dissection (CALND) after sentinel lymph node biopsy (American College of Surgeons Oncology Group Z0011) and no clinically meaningful benefit for the routine use of immunohistochemistry (National Surgical Adjuvant Breast and Bowel Project B-32) in clinically node-negative breast cancer. Methods: A 12-question electronic survey was distributed to members of 3 Pacific Northwest surgical societies. Surgeons were queried regarding the impact of the trial results on their surgical management of breast cancer. Results: The 181 respondents reported performing fewer CALNDs (63%), fewer intraoperative frozen sections (21%), and no immunohistochemistry (12%) because of trial data. However, 28% of surgeons continued to perform CALND in patients with 1 to 2 positive sentinel lymph nodes undergoing lumpectomy and postoperative radiation. Conclusions: Recent trial data have impacted the performance of CALNDs and the pathological evaluation of sentinel lymph nodes among Pacific Northwest surgeons. Our results suggest a need for regional surgical societies to disseminate practice-changing trial data to members.

Revisiting the “10% rule” in breast cancer sentinel lymph node biopsy: an approach to minimize the number of sentinel lymph nodes removed

2012-05-01

Abstract: Background: Sentinel lymph node (SLN) biopsy (SLNB) is an accurate and proven axillary staging procedure for early breast cancer. The aim of this study was to determine if the “10% rule” is applicable to the performance of SLNB at the investigators' institution and if the criteria used for SLNB at their institution could be refined to minimize the number of SLNs removed. Methods: Retrospective analysis was conducted of a prospectively collected breast cancer SLNB database. Standard statistical methods were used for data analysis. Results: Five hundred nine patients underwent a SLNB for breast cancer over a 5 year period. A mean of 2.5 SLNs were removed per patient. All patients with SLN metastasis were identified within the 1st 4 SLNs removed. Conclusions: The “10% rule” is best used as a guide at the investigators' institution. Strict adherence to this rule appears to result in the removal of an excessive number of lymph nodes, which may contribute to excessive health care costs and patient morbidity.

Laparoscopic surgical exploration is an effective strategy for locating occult primary neuroendocrine tumors

Kristen P. Massimino, Esther Han, SuEllen J. Pommier, Rodney F. Pommier — 2012-03-29

Abstract: Background: Many patients with neuroendocrine tumors (NETs) have metastases at diagnosis. Despite extensive metastases the primary tumors remain small and difficult to locate. Methods: Records of patients diagnosed with metastatic abdominal NETs from 2006 to 2010 were reviewed retrospectively. Results of preoperative imaging, procedures, and surgical explorations were compared for their efficacy at finding primary tumors. Results: Sixty-three patients were identified. Seventeen percent (11 of 63) of tumors were located by preoperative testing. The sensitivities of preoperative colonoscopy (23% [n = 26]), computed tomography scan (6.7% [n = 60]), and somatostatin receptor scintigraphy (2.0% [n = 52]) were low. No tumors were found by magnetic resonance imaging (n = 9), upper endoscopy (n = 24), capsule endoscopy (n = 2), or bronchoscopy (n = 4). Surgical exploration was the most sensitive (79% [n = 63]) method of tumor detection. Seventy-two percent of surgical localizations were laparoscopic. Conclusions: Surgical exploration was superior to all other modalities for locating primary NETs. Laparoscopy had a high probability of finding occult primary neuroendocrine tumors.

Practice referral patterns and outcomes in patients with primary retroperitoneal sarcoma in British Columbia

2012-03-15

Abstract: Background: We examined practice referral patterns for primary retroperitoneal sarcoma (PRS) in British Columbia (BC) and associations between the timing of referral to tertiary care and patient outcomes. Methods: Using ICD-10 coding, the Cancer Agency Information System was used to identify patients with PRS from 2000 to 2009 who had been referred to tertiary care and had undergone a surgical resection. Results: Eighty-two patients were included. Those referred before surgery were significantly more likely to receive a complete resection (P = .0002) and adjuvant radiation (P = .0000) compared with patients referred after surgery. Referral before surgery was associated with a significantly increased overall (P = .0619) and recurrence-free (P = .0400) survival; however, in the multivariate model this was not significant. Conclusions: Referral before surgery is associated with higher rates of complete resection and the use of adjuvant radiation; furthermore, it is associated with prolonged survival in the univariate but not in the multivariate model.

Use and outcomes of emergent laparoscopic resection for acute diverticulitis

Jennifer D. Rea, Daniel O. Herzig, Brian S. Diggs, Molly M. Cone, Kim C. Lu — 2012-03-26

Abstract: Background: The use and outcomes of laparoscopic sigmoid resection during emergency admissions for diverticulitis are unknown. Methods: The Nationwide Inpatient Sample was queried for colorectal resections performed for diverticulitis during emergent hospital admissions (2003–2007). Univariate and multivariate analyses including patient, hospital, and outcome variables were performed. Results: A national estimate of 67,645 resections (4% laparoscopic) was evaluated. The rate of conversion to open operation was 55%. Ostomies were created in 66% of patients, 67% open and 41% laparoscopic. Laparoscopy was not a predictor of mortality (odds ratio [OR] =.70; confidence interval [CI], .32–1.53). Laparoscopy predicted routine discharge (OR = 1.31; CI, 1.06–1.63) and a decreased length of stay (absolute days = −.78; CI, −1.19 to −.37). There was no difference in the cost of hospitalization between the 2 groups (P = .45). Conclusions: In acute diverticulitis, urgent laparoscopic resection decreases the length of stay. However, it is associated with a high conversion rate, no cost savings, and no difference in mortality.

Expediting return of bowel function after colorectal surgery

2012-03-29

Abstract: Background: Postoperative ileus is the main determinant of the length of hospital stay after colorectal surgery. Our objective was to analyze modifiable factors, including polyethylene glycol administration, associated with the return of bowel function. Methods: A retrospective review of all patients who underwent elective open partial colectomy from 2004 to 2006 at a single institution. Results: The time to the first bowel movement with and without oral intake within 48 hours postoperatively was 76 hours versus 134 hours (P < .001); with and without polyethylene glycol administration it was 73 hours versus 94 hours (P = .001); and with and without frequent ambulation it was 78 hours versus 95 hours (P = .012). With postoperative nasogastric tube drainage, the time to the first bowel movement was 22 hours longer (P = .002). Conclusions: These data confirm previous findings supporting no nasogastric tube drainage, early feeding, and frequent ambulation after colorectal surgery. Additionally, our data suggest a strong association (P = .001) between the use of polyethylene glycol and the early return of bowel function.

Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer

2012-03-14

Abstract: Background: Colorectal cancer (CRC) progression is mediated by cancer stem cells (CSCs). We sought to determine if the expression of the CSC marker aldehyde dehydrogenase 1 (ALDH1) in CRC tumors varies by American Joint Committee on Cancer stage or correlates to clinical outcomes. Methods: Primary and metastatic CRC samples from 96 patients were immunostained with antibodies to ALDH1 and imaged to evaluate marker expression. The percentage of ALDH1+ cells was correlated to clinical outcomes. Results: ALDH1 was overexpressed in CRC tumors compared with nonneoplastic tissue. Marker expression was highest in nonmetastatic tumors. The loss of expression was associated with advanced stage and metastatic disease. No significant correlation was found between ALDH1 expression and metastasis, recurrence, or survival. Conclusions: ALDH1 was highly expressed in nonmetastatic CRC, but expression was lost with advancing stage. ALDH1 could be an effective therapeutic target in early CRC but not late-stage disease. No correlation was found between ALDH1 and disease prognosis.

Beta-catenin expression is prognostic of improved non–small cell lung cancer survival

2012-03-09

Abstract: Introduction: The objectives of this study were to determine the frequency and prognostic significance of beta-catenin expression in a cohort of non-small cell lung cancer (NSCLC) patients. Methods: Tissue microarrays were constructed using clinically annotated formalin-fixed paraffin-embedded tumor samples from individuals diagnosed with NSCLC who underwent surgical resection with curative intent and had beta-catenin expression status determined by immunohistochemistry. Results: Negative beta-catenin expression was seen in 28% (103/370) of NSCLC cases and was prognostic of a reduced overall patient survival (P = .008) and also was significantly correlated with the presence of lymphatic invasion (P = .015). In multivariate analysis, the loss of beta-catenin expression retained independent prognostic significance and showed an adjusted hazard ratio of 3.18 (confidence interval, 1.46-6.91, P = .004) for reduced patient survival when adjusting for the presence of lymphatic invasion, tumor grade, nodal status, and tumor stage. Conclusions: Beta-catenin represents an important prognostic marker in individuals diagnosed with surgically resectable NSCLC.

Correlating Haller Index and cardiopulmonary disease in pectus excavatum

2012-03-15

Abstract: Background: The Haller Index (HI) has become standard for determining the severity of pectus excavatum. We compared patterns of cardiopulmonary dysfunction and their relationship with HI in patients with pectus excavatum. Methods: We performed cardiopulmonary exercise testing and chest computed tomography scans on 90 patients with pectus excavatum deformities at a regional pediatric hospital. Results: The median HI was 4.9 in patients with combined dysfunction, 4.4 in patients with isolated pulmonary dysfunction, 3.6 in patients with isolated cardiac dysfunction, and 3.4 in patients with normal function. HI varied significantly by disease group (P < .009). HI was significantly lower in patients with normal forced vital capacity than with abnormal forced vital capacity (P = .001). However, HI was similar in patients with normal and abnormal oxygen pulse (P = .24) or peak oxygen consumption (P = .37). Conclusions: Fifty-nine percent of patients had cardiac and/or pulmonary limitation. A HI greater than 3.6 is associated with pulmonary dysfunction, but not cardiac dysfunction.

Outcomes associated with type of intervention and timing in complex pediatric empyema

2012-03-29

Abstract: Background: The presence of effusion/empyema in pediatric pneumonia can increase treatment complexity by possibly requiring pleural drainage. Currently, no data support the superiority of any drainage modalities in children. Methods: We performed a retrospective cohort study using the Pediatric Health Information System database from 2003 to 2008. Results: A total of 14,936 children were hospitalized with effusion/empyema. Fifty-two percent of children were treated with antibiotics alone. Compared with patients receiving a chest tube, patients receiving antibiotics alone, thoracotomy, and video-assisted thoracoscopic surgery had a shorter length of stay, lower mortality rates, and fewer re-interventions. Delaying drainage by 1 to 3 days was associated with a lower mortality rate, and a delay of more than 7 days was associated with a higher mortality rate. Conclusions: Half of all children with effusion/empyema are treated with antibiotics alone with low morbidity and mortality. Initial video-assisted thoracoscopic surgery or thoracotomy had improved outcomes compared with other interventions. Intervention should not be delayed beyond 7 days.

Editorial Board

2012-05-01

The American Journal of Surgery

Liver transplantation and resective surgery lessons learned: the case for a systems approach

Dr Robert McKechnie: Vancouver's pioneer surgeon and a patron of British Columbia sports & education

Temporal trends in the treatment of severe traumatic hemorrhage

Factors influencing humanitarian care and the treatment of local patients within the deployed military medical system: casualty referral limitations

Acute care surgery: the impact of an acute care surgery service on assessment, flow, and disposition in the emergency department

Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury

An assessment of different scoring systems in cirrhotic patients undergoing nontransplant surgery

Bioprosthetic mesh use for the problematic thoracoabdominal wall: outcomes in relation to contamination and infection

Incidence of deep vein thrombosis is increased with 30 mg twice daily dosing of enoxaparin compared with 40 mg daily

The duodenal switch for morbid obesity: modification of cardiovascular risk markers compared with standard bariatric surgeries

The benefits of laparoscopic appendectomies in obese patients

Results of routine shunting and patch closure during carotid endarterectomy

Impact of American College of Surgeons Oncology Group Z0011 and National Surgical Adjuvant Breast and Bowel Project B-32 trial results on surgeon practice in the Pacific Northwest

Revisiting the “10% rule” in breast cancer sentinel lymph node biopsy: an approach to minimize the number of sentinel lymph nodes removed

Laparoscopic surgical exploration is an effective strategy for locating occult primary neuroendocrine tumors

Practice referral patterns and outcomes in patients with primary retroperitoneal sarcoma in British Columbia

Use and outcomes of emergent laparoscopic resection for acute diverticulitis

Expediting return of bowel function after colorectal surgery

Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer

Beta-catenin expression is prognostic of improved non–small cell lung cancer survival

Correlating Haller Index and cardiopulmonary disease in pectus excavatum

Outcomes associated with type of intervention and timing in complex pediatric empyema

Editorial Board

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