[Show abstract][Hide abstract] ABSTRACT: Background:
Despite evidence that activated macrophages act in an inflammatory microenvironment to promote gastric tumorigenesis via β-catenin signaling, the effects of β-catenin signaling on gastric cancer cell metastasis and the relationship of these cells with surrounding tumor associated macrophages have not been directly studied.
Immunohistochemical staining was employed to analyze 103 patients. An invasion assay was used to evaluate the relationship between macrophages and gastric cancer cells. β-catenin gain-of-function and loss-of-function approaches were performed. To assess the β-catenin regulation mechanism in gastric cancer cells, Western blotting and reverse-transcription polymerase chain reaction were used.
Increased density of macrophages was associated with advanced stage and poor survival. Gastric cancer cell lines co-cultured with macrophages conditioned medium showed increased nuclear accumulation of β-catenin and increased invading ability. AKT but not ERK regulated β-catenin translocation. MMP7 and CD44, both β-catenin downstream genes, were involved in macrophage-activated gastric cancer cell invasion.
Collectively, the clinical data suggest that macrophage infiltration is correlated with increased grade and poor prognosis for gastric cancer patients who underwent radical resection. Macrophages may induce invasiveness by activating the β-catenin pathway.
PLoS ONE 08/2015; 10(7):e0134122. DOI:10.1371/journal.pone.0134122 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Preoperative tumor aggressiveness biomarkers may help surgeons decide the extent of an operation. However, whether serum angiogenetic factors can be used to predict the prognosis of patients with differentiated thyroid cancer is still unclear.
Seventy-six DTC patients were prospectively recruited. Preoperative serum samples were collected and measured for Tie-2, Ang-1, Ang-2, VEGF-A, and VEGF-D levels. The potential correlations between their serum levels and clinicopathologic features as well as their prognoses were analyzed.
Older age (>45 years old) and higher VEGF-A serum levels were independent predictors of extrathyroidal extension. The VEGF-D serum level was an independent factor for lymph node metastases and VEGF-A was an independent factor for distant metastases. None of these serum angiogenetic factors were significantly different between patients who were disease free and those with recurrences. The presence of lymph node metastases was the only independent factor for recurrence over the 2-year follow-up.
Preoperative serum VEGF-A and VEGF-D levels were significantly elevated in DTC patients with distant and lymph node metastases. These findings, when combined with other clinicopathological factors, may help in surgical decisions.
World Journal of Surgery 02/2015; 39(7). DOI:10.1007/s00268-015-3016-6 · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A lipid emulsion composed of soybean oil (long-chain triglycerides, LCT), medium-chain triglycerides (MCT) and n-3 poly-unsaturated fatty acids (PUFAs) was evaluated for immune-modulation efficacy, safety, and tolerance in patients undergoing major surgery for gastric and colorectal cancer.
In a prospective, randomized, double-blind study, 99 patients with gastric and colorectal cancer receiving elective surgery were recruited and randomly assigned to either the study group, receiving the n-3 PUFAs enriched intravenous fat emulsion (IVFE), or the control group, receiving a lipid emulsion comprised of soybean oil and MCTs (0.8 - 1.5 g . kg-1 . day-1) as part of total parenteral nutrition (TPN) regimen from surgery (day -1) up to post-operative day 7. Safety and efficacy parameters were assessed on day -1 and post-operative visits on day 1, 3, and 7. Adverse events were documented daily and compared between the groups.
Pro-inflammatory markers, laboratory parameters, and adverse events did not differ prominently between the 2 groups, with the exception of net changes (day 7 minus day -1) of free fatty acids (FFAs), triglyceride, and high-density lipoprotein (HDL). Net decrease of FFAs was remarkably higher in the study group, while the net increase of triglyceride and decrease of HDL was significantly lower.
The n-3 PUFA-enriched IVFE showed improvements in lipid metabolism. In respect of efficacy, safety and tolerance both IVFE were comparable. In patients with severe stress, there is an inflammation-attenuating effect of n-3 PUFAs. Further, adequately powered clinical trials will be necessary to address this question in postsurgical GI cancer patients.Trial registration: US ClinicalTrials.gov NCT00798447.
[Show abstract][Hide abstract] ABSTRACT: To test whether computerized quantification of ultrasonic heterogeneity can be of help in the diagnosis of thyroid malignancy, we evaluated ultrasonic heterogeneity with an objective and quantitative computerized method in a prospective setting. A total of 400 nodules including 271 benign thyroid nodules and 129 malignant thyroid nodules were evaluated. Patient clinical data were collected, and the grading of heterogeneity on conventional gray-scale ultrasound images was retrospectively reviewed by a thyroid specialist. Quantification of ultrasonic heterogeneity (heterogeneity index, HI) was performed by a proprietary program implemented with methods proposed in this article. HI values differed significantly between benign and malignant nodules, diagnosed by a combination of fine-needle aspiration and surgical pathology results (p < 0.001, area under the curve = 0.714). The ultrasonic heterogeneity of these samples, as assessed by an experienced clinician, could not significantly differentiate between benign and malignant thyroid nodules. However, nodules with marked ultrasonic heterogeneity had higher HI values than nodules with homogeneous nodules. These results indicate that the new computer-aided diagnosis method for evaluation of the ultrasonic heterogeneity of thyroid nodules is an objective and quantitative method that is correlated with conventional ultrasonic heterogeneity assessment, but can better aid in the diagnosis of thyroid malignancy.
Ultrasound in Medicine & Biology 09/2014; 40(11). DOI:10.1016/j.ultrasmedbio.2014.06.009 · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Migration of T cells into the colon plays a major role in the pathogenesis in inflammatory bowel disease. This study investigated the effects of glutamine (Gln) supplementation on chemokine receptors and adhesion molecules expressed by T cells in mice with dextran sulfate sodium- (DSS-) induced colitis.
C57BL/6 mice were fed either a standard diet or a Gln diet replacing 25% of the total nitrogen. After being fed the diets for 5 days, half of the mice from both groups were given 1.5% DSS in drinking water to induce colitis. Mice were killed after 5 days of DSS exposure.
DSS colitis resulted in higher expression levels of P-selectin glycoprotein ligand- (PSGL-) 1, leukocyte function-associated antigen- (LFA-) 1, and C-C chemokine receptor type 9 (CCR9) by T helper (Th) and cytotoxic T (Tc) cells, and mRNA levels of endothelial adhesion molecules in colons were upregulated. Gln supplementation decreased expressions of PSGL-1, LFA-1, and CCR9 by Th cells. Colonic gene expressions of endothelial adhesion molecules were also lower in Gln-colitis mice. Histological finding showed that colon infiltrating Th cells were less in the DSS group with Gln administration.
Gln supplementation may ameliorate the inflammation of colitis possibly via suppression of T cell migration.
Mediators of Inflammation 05/2014; 2014(1):837107. DOI:10.1155/2014/837107 · 3.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
SMOFlipid 20% is intravenous lipid emulsion (ILE) containing long-chain triglycerides (LCT), medium-chain triglycerides (MCT), olive oil, and fish oil as a mixed emulsion containing α-tocopherol. The aim was to assess the efficacy of this new ILE in gastrointestinal surgery compared with MCT/LCT.
In this prospective study, 40 patients were randomized to SMOFlipid 20% or MCT/LCT (Lipovenoes 20%) group. Clinical and biochemistry data were collected. Inflammatory markers (CRP, IL-6, IL-10, TNF-α, TGF-β1) and oxidative stress (ROS and superoxide) were measured.
Thirty-five patients (17 males and 18 females) with a mean age of 57 years completed the study. The patients' demographic characteristics (age, gender, height, body weight, and BMI) were similar without significant differences between groups. The increment of triglyceride on day 6 from baseline was significantly lower in SMOFlipid group than in Lipovenoes MCT/LCT group. Inflammatory markers, as well as superoxide radical and total oxygen radical were not different between groups.
Despite the comparable effect on inflammatory response, because of its well-balanced fatty acid pattern, relatively low n-6:n-3 ratio, and high vitamin E content, SMOFlipid had a better triglyceride-lowering effect as compared with MCT/LCT in adult patients undergoing gastrointestinal surgery.
Journal of Parenteral and Enteral Nutrition 11/2013; 38(7). DOI:10.1177/0148607113512869 · 3.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To clarify and determine whether power Doppler sonograms are useful for the detection of malignant thyroid nodules, a computerized quantification method was used to evaluate the vascular density of a thyroid nodule in a prospective setting. Sonographic power Doppler images were collected in consecutive frames (45 frames of images), and a proprietary program (AmCAD-UV) was implemented using methods proposed in this article automatically calculated a quantified power Doppler vascular index (PDVI). The minimum PDVI value (PDVImin) was suggested as a measure of the vascular density of the nodule. The vascular densities of the peripheral and central areas of the nodule, referred to as central PDVImin and Ring PDVImin, respectively, were also evaluated. For 238 tumors (79 malignant and 159 benign) from 208 patients, all of the proposed indices of benign lesions were significantly higher than those of the malignant lesions. The area under the receiver operating characteristic curve (AUC) reaches 71% with the PDVImin. When the vascular patterns were further classified into intra-nodular and peripheral vascularity types, no vascularity type was observed significantly more frequently in malignant nodules than in benign nodules. These proposed computerized vascular indices provide a quantification method to objectively evaluate thyroid nodules and have potential as predictors of thyroid malignancy. The conventional vascular characterizations of malign nodules, that is, more vessels are observed in malignant nodules than in benign nodules, are shown to be unreliable in our study. Instead, a higher value of the quantified power Doppler vascular density was observed in benign nodules.
Ultrasound in medicine & biology 06/2013; 39(9). DOI:10.1016/j.ultrasmedbio.2013.03.009 · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/aims:
It has been a matter of debate whether the advantage of gasless laparoscope setting is obvious when compared with the conventional operation. Thus, we compare the systemic response of proinflammatory markers and the adhesion molecules in serum levels after surgery between these two procedures.
There were 23 patients in the gasless laparoscopy (GL) group, and 12 patients in the open surgery (OS) group.
The created wound length was smaller in the GL group (5.3±0.3cm vs. 8.9±0.5cm), the post operative recovery including the visual analog pain score on op day and day 1, flatus day, and hospital stay were also shown less in GL group. The levels of IL-6, IL-8 and ICAM were significantly lower in the GL group.
Immune response is less in gasless laparoscopy-assisted gastrectomy (GLAG) when compared with traditional approach, and the difference may have effects on the post operative recovery.
[Show abstract][Hide abstract] ABSTRACT: Background/aims:
Exogenous glutamine supplement is known to improve morbidity and mortality of critically-ill patients. This study was conducted to elucidate the role of glutamine in minimally invasive surgery.
We retrospectively reviewed subtotal gastrectomy patients in National Taiwan University Hospital from Dec 2005 to Dec 2008. The patients were divided into three groups. Group 1 underwent subtotal gastrectomy by laparotomy without glutamine supplement, group 2 underwent subtotal gastrectomy by laparotomy with glutamine supplement and group 3 underwent gasless laparoscopy-assisted subtotal gastrectomy with parenteral glutamine supplement.
There were 155 patients in total; 85 patients in group 1, 17 in group 2 and 53 in group 3. The mean flatus days after operation are 3.6, 3.1 and 2.8 for groups 1, 2 and 3, respectively (p=0.001). Oral intake after operation was commenced after 6.7, 5.0 and 4.7 days (p=0.006). The body temperature had borderline differences between groups 3 and 1. There were significant differences in postoperative systemic responses including heart rates (p<0.001) and tenderness (p=0.011) 5 days after operation for group 3 vs. group 1. Minimally invasive surgery was a negative factor for postoperative body temperature change. Glutamine was a significant factor for postoperative heart rate change and reduction of tenderness.
Glutamine supplement may have synergic effects of rapid recovery in minimal invasive surgery for subtotal gastrectomy patients by minimizing the postoperative systemic response and accelerating recovery.
[Show abstract][Hide abstract] ABSTRACT: Uptake of docosahexaenoic acid (DHA)/eicosapentaenoic acid (EPA) improves the treatment of cancer and reduces tumor-associated macrophage count. However, the mechanism of this relationship is still unclear. In this study, macrophages enhanced gastric cancer cell migration ability and induced the differentially expressed matrix metalloproteinase genes (MMP1, MMP3 and MMP10) of N87 as identified by polymerase chain reaction array. Furthermore, DHA and EPA inhibited macrophage-enhanced cancer cell migration and attenuated MMP10 at both the RNA and protein level. The suppression of MMP10 expression was further verified by zymography and antibody blocking experiments. Additionally, DHA and EPA attenuated expression of macrophage-activated extracellular-signal-regulated kinase (ERK) and signal transducers and activators of transcription 3 (STAT3) in cancer cells. Attenuation was verified by demonstrating blockade with specific inhibitors and thereby increased MMP10 expression. Accordingly, we hypothesized that macrophage enhances cancer cell migration through ERK and STAT3 phosphorylation and subsequent increased MMP10 expression and that DHA and EPA could attenuate these signals. These findings not only explain the beneficial effects of DHA/EPA, but also point to ERK/STAT3/MMP10 as the potential targets for gastric cancer treatment.
The Journal of nutritional biochemistry 01/2012; 23(11):1434-9. DOI:10.1016/j.jnutbio.2011.09.004 · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To improve the ultrasonographic detection rates of thyroid cancers with microcalcifications, we propose to enhance the sensitivity of sonographic calcifications detection and to avoid interobserver variation by a computerized quantification method in a prospective setting. A total of 227 participants with 258 nodules were evaluated. Among them, two nodules were excluded for suspicious aspiration cytology results without pathologic proof. Among the remaining 256 nodules, the diagnosis of 181 nodules was verified by surgical pathology and the diagnosis of 75 was based on fine needle aspiration (FNA) biopsy results. There were 173 benign thyroid nodules and 83 malignant thyroid nodules, which included 74 papillary carcinomas. Patient clinical data were collected and the presence of calcifications on conventional gray-scale ultrasound images was retrospectively reviewed by a thyroid specialist. Quantification of cystic components and calcifications was automatically performed by a proprietary program (AmCAD-UT) implemented with methods proposed in this article. The calcification index (CI) was calculated after the cystic component was excluded. The CI between benign and malignant nodules diagnosed by combined FNA biopsy and surgical pathology results (total number, 256) showed a significant difference (p < 0.0001, AUC = 0.746). Furthermore, we excluded patients without surgical pathology results for further validation and the CI between benign and malignant nodules confirmed by pathology results (total number, 181) showed a significant difference (p < 0.0001, AUC = 0.763). To learn whether our computer program increased our diagnostic capabilities, we analyzed human investigators and their abilities to detect and evaluate. In this study, calcifications were noted in 48.19% (40 of 83) of malignant thyroid nodules and in 10.98% (19 of 173) of benign nodules. This new computer-aided diagnosis method to evaluate the sonographic calcifications of thyroid nodules is a more sensitive and more objective method. It can provide better sensitivity than conventional methods in the diagnosis of thyroid malignancies containing microcalcifications.
Ultrasound in medicine & biology 06/2011; 37(6):870-8. DOI:10.1016/j.ultrasmedbio.2011.03.002 · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this multicenter study was to evaluate the clinical relevance of serum vascular endothelial growth factor-D (VEGF-D) in papillary thyroid carcinoma (PTC). This prospective study consisted of 74 patients with primary PTC and 15 patients with benign thyroid nodules treated from 2008 to 2009. VEGF-D concentration was compared with patient clinicopathologic features and lymph node metastases. There was no significant difference in mean serum VEGF-D levels between the PTC and benign thyroid nodule groups. Within the PTC group, serum VEGF-D levels were significantly higher in patients with lymph node metastases than in patients without metastases (241.92 vs. 213.89 pg/ml, respectively; P = 0.035). Receiver operating characteristic curve analysis revealed that preoperative serum VEGF-D levels were predictive of lymph node metastases in the patients >45 years. Serum VEGF-D level that was correlated with the presence of cervical lymph node metastases in PTC patients might be a useful prognostic indicator.
[Show abstract][Hide abstract] ABSTRACT: Gasless laparoscopy-assisted surgery has been utilized in many abdominal diseases, and it has been proved to be effective and efficient compared with conventional open surgery. The study was conducted to evaluate the efficacy of gasless laparoscopy-assisted surgery in management of intraabdominal/retroperitoneal tumor of unknown origin.
From June 2004 to April 2009, nine patients who underwent gasless laparoscopy-assisted surgery for intraabdominal/retroperitoneal tumor of unknown origin were recruited. Intraabdominal/retroperitoneal tumor of unknown origin was defined as (1) diagnosis of enlarged retroperitoneal lymph node; (2) evaluation of peritoneal or mesenteric lesion, or tumor of nondigestive systems; and (3) staging of intraabdominal malignancy.
Four patients underwent gasless laparoscopy-assisted surgery for retroperitoneal enlarged lymph nodes, four for evaluation of intraabdominal lesion, and two for staging of the malignancy. Sufficient tissue was obtained from all patients, and the diagnosis was as follows: three lymphomas, three peritoneal carcinomatoses, two chronic imflammations, and one benign tumor.
Three purposes can be achieved: a familiar method for the surgeon compared with total laparoscopic surgery, easy accessibility for further oncological management, and intraoperative miniconversion for peritoneal examination. It is a safe and effective way to obtain tissue for pathology and feasible in case of necessary sequential tumor resection.
[Show abstract][Hide abstract] ABSTRACT: We had developed an innovative method of minimally invasive surgery using gasless laparoscopy in resection of the small bowel lesion. This study aimed at evaluating the feasibility and efficacy of this procedure by comparison with traditional open small bowel surgery.
A wedge or segmental resection of the small bowel for removal of the lesion was performed in 25 patients at National Taiwan University Hospital from September 2006 to January 2009. Thirteen patients underwent gasless laparoscopy-assisted surgery (GLAS), and 12 patients underwent open surgery. The perioperative characteristics and clinical results between the two groups were compared.
The demographics, clinical data, lesion size, and operative time were comparable between the GLAS and open surgery groups, but the wound length and blood loss were significantly less in the GLAS group (P < 0.001 and P = 0.021, respectively). The time to first postoperative flatus and first oral intake were significantly less in the GLAS group (P = 0.007 and 0.036, respectively). No major complication occurred in either group. No tumor recurrence was found after a median follow-up period of 14 months (range = 1-30) in the GLAS group.
GLAS for resection of the small bowel may be a feasible and safe procedure for the small bowel lesions. It has the advantages of better cosmetic outcome, less blood loss, and earlier recovery of bowel movement.
[Show abstract][Hide abstract] ABSTRACT: Gastrointestinal stromal tumors (GISTs) are rare neoplasms with malignant potential. Surgery is the definitive management for resectable nonmetastatic lesions. Although minimally invasive resection has been established for GISTs, it is still considered unfeasible when tumors are near the esophagogastric junction. This study aimed to compare the relative efficacy of gasless laparoscopy-assisted (GLA) and open approaches for resection of GISTs.
Between January 2006 and December 2008, 28 consecutive patients undergoing surgery for upper GIST were reviewed retrospectively. Among these patients, 15 underwent GLA procedures and 13 underwent open surgeries.
Patient demographics, comorbidities, and tumor characteristics (mean tumor size and prognosis) were similar for both groups. All patients underwent wedge resection. The mean operating time (129.6 versus 110.8 minutes), mean estimated blood loss (35.5 versus 40.3 mL), mean day of first flatus (2.7 versus 3.2 days), mean tumor size (2.5 versus 2.6 cm), and tumor prognosis or complication rate (13.3% versus 7.7%) between the GLA and open surgery groups were not significantly different. The length of maximal wound (P < 0.001), visual analog scale on postoperative days 1 (P = 0.001), 2 (P = 0.001), and 3 (P = 0.001), the mean time for resuming oral intake (P = 0.028), and the length of hospital stay (P = 0.005) in the GLA group were significantly lesser than the corresponding values in the open surgery group. None of the patients had dysphagia or died.
GLA method is a safe and feasible procedure for resecting GISTs of the upper stomach. In addition, it offers better cosmetic results, less pain, and faster recovery.
[Show abstract][Hide abstract] ABSTRACT: In this article, we describe a new technique for performing a laparoscopic-assisted hepatectomy, using a self-designed abdominal wall-lifting systems. We used this system for 5 patients; 2 were left lateral segmentectomy, 1 was S6 segmentectomy, and 1 was S8 wedge resection, and the other was an extended left hepatectomy. This procedure can minimize the length of the wound, while avoiding the lethal complications associated with the pneumoperitonium. This device and technique can also provide a bridge for young or less-experienced surgeons to be familiar with advanced laparoscopic surgery from open surgery. Also, the patients under such an operation were found to have fast postoperation recovery and short hospital stay.
[Show abstract][Hide abstract] ABSTRACT: The present study investigated the effect of parenteral glutamine (Gln) supplementation on cellular adhesion molecule expression and release of chemokines responsible for inflammatory cell recruitment in rats undergoing a total gastrectomy. Normal rats with internal jugular catheters were assigned to one control group and two experimental groups and received total parenteral nutrition (TPN). A total gastrectomy was performed in the experimental groups, whereas the control group received a sham operation (Sham). The TPN solutions were isonitrogenous and identical in nutrient composition except that the Sham group and one of the experimental group received conventional (Conv) TPN solution, whereas the other experimental group received 25% of the amino acid nitrogen as Gln. Half of the rats in each group were killed 1 or 3 d after surgery or the Sham to examine their immune response. The results showed that the surgery produced higher polymorphonuclear leucocyte CD11b/CD18 expressions, and Gln supplementation lowered CD11b/CD18 expressions compared with the Conv group post-operatively. The levels of monocyte chemotactic protein-1 and macrophage inflammatory protein-2 in peritoneal lavage fluid were higher in the Gln group than those in the Conv group 1 d post-operatively; these chemotactic proteins had returned to the levels comparable with those in the Sham group on post-operative day 3. These results suggest that Gln supplementation attenuated polymorphonuclear leucocyte integrin expression. In addition, Gln-enriched parenteral nutrition induced an earlier more intensive and rapid immune response to injury than the Conv parenteral nutrition after a total gastrectomy.
The British journal of nutrition 03/2009; 102(4):520-5. DOI:10.1017/S0007114508207257 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The optimal timing of laparoscopic cholecystectomy (LC) in the treatment of acute cholecystitis remains controversial. This retrospective study was undertaken to assess the clinical outcomes, possible advantages and disadvantages of early versus delayed LC for acute cholecystitis.
Records of all patients admitted for acute cholecystitis in whom laparoscopic cholecystectomy was attempted between January 2004 and January 2006, at National Taiwan University Hospital were reviewed.
A total of 89 patients were recruited to the study. Of these, 56 patients received early laparoscopic cholecystectomy (ELC), and 33 patients received delayed laparoscopic cholecystectomy (DLC) following conservative therapy. There were no intergroup differences in age, gender, or days of symptoms prior to presentation. Patients undergoing ELC experienced a significantly longer operation time (109 +/- 37.59 minutes versus 77 +/- 25.65 minutes, p < 0.001), more blood loss (76ml versus 28ml, p = 0.006) and a longer post-operation hospital stay (4.5 days versus 2.6 days, p < 0.001). The conversion rate to open cholecystectomy was not significantly different (4/56 versus 2/33, p = 0.84), and there were no biliary tract injury or other major complications in either group. However, patients with ELC had a shorter total hospital stay (4.53 days versus 7.79 days, p < 0.001) and fewer admission times (1 time in ELC versus 2.4 times in DLC, p < 0.001).
Both early and delayed LC appears to be effective and safe in the treatment of acute cholecystitis. Early LC may be more technically demanding and time-consuming, and may be associated with a higher rate of wound infections; however, it also tends to shorten the total length of hospital stay and reduce the risk of repeat cholecystitis. We recommend early LC for acute cholecystitis comparison with delayed LC.
[Show abstract][Hide abstract] ABSTRACT: Intussusceptions of the small bowel, along with multiple intraluminal metastatic tumors, were noted during surgery. A segmental resection of the small bowel was performed, and the histologic diagnosis of metastatic melanoma was made. Long-term survival remains poor; therefore, complete surgical resection of macroscopic tumors remains the best treatment of choice.
American journal of surgery 06/2008; 196(3):e1-2. DOI:10.1016/j.amjsurg.2007.05.062 · 2.29 Impact Factor