Abstract: Background: Major vascular surgery with aortic cross-clamping is associated with temporary ischaemia of the lower limb due to lack of tissue blood flow. The present study was designed to determine if the short-term changes in cellular metabolism occurring during this situation can be detected by subcutaneous microdialysis. It was also hoped to ascertain if this new technique is useful in the continuous bedside monitoring of metabolism during aortic surgery. Methods: In a controlled clinical study 20 patients undergoing elective aortic surgery were monitored using microdialysis probes that were inserted in the subcutaneous tissue of the left lower limb and a non-ischaemic region (shoulder). Interstitial fluid was obtained and the concentrations of glucose and lactate during lower limb ischaemia and during reperfusion were measured and compared with concentrations observed in fluid obtained from the non-ischaemic control tissue. Results: Circulatory occlusion caused an immediate and significant decrease in the glucose/lactate ratio from 3·1±1·3 to 0·48±0·5 (P 〈 0·05) that returned to preocclusion values within 2 h of commencing reperfusion. Conclusion: We suggest that microdialysis may be used both to assess acute changes in tissue metabolism during ischaemic periods and also to act as an additional tool for the detection of peri-operative acute variations in limb blood flow.

Abstract: The aim of this study was to determine characteristics of the most cited publications in the history of the American Surgical Association (ASA). Summary Background Data: The Annals of Surgery has served as the journal of record for the ASA since 1928, with a special issue each year dedicated to papers presented before the ASA Annual Meeting. Methods: The top 100 most cited ASA publications in the Annals of Surgery were identified from the Scopus database and evaluated for key characteristics. Results: The 100 most cited papers from the ASA were published between 1955 and 2010 with an average of 609 citations (range: 333–2304) and are included among the 322 most cited papers in the Annals of Surgery . The most common subjects of study included clinical cancer (n = 43), gastrointestinal (n = 13), cardiothoracic/vascular (n = 9), and transplant (n = 9). Ninety-three institutions were included lead by Johns Hopkins University (n = 9), University of Pittsburgh (n = 8), Memorial Sloan-Kettering (n = 7), John Wayne Cancer Institute (n = 7), University of Texas (n = 7), and 5 each from Brigham and Women's Hospital, Mayo Clinic, and University of Chicago. The majority of manuscripts came from the United States (n = 85), followed by Canada (n = 7), Germany (n = 5), and Italy (n = 5). Study design included randomized controlled trials (n = 19), retrospective matched cohort studies (n = 11), retrospective nonmatched studies (n = 46), and other (n = 24). Conclusions: The top 100 most cited publications from the ASA are highly impactful, landmark studies representing a diverse array of subject matter, investigators, study design, institutions, and countries. These influential publications have immensely advanced surgical science over the decades and should serve as inspiration for all surgeons and surgical investigators.

Abstract: This paper assesses the rate of lymph node metastasis and the correlation between lymph node metastasis and some pathological characteristics in special types of invasive breast cancer. In the paper, a descriptive cross‐sectional study was conducted on 200 patients with special types of invasive breast cancer at the Institute of Molecular Biology and Pathology - National Cancer Hospital from August 2020 to April 2021. The study results show that 32% of the 200 cases had nodal metastases. The factors associated with the increased risk of lymph node metastasis were of histological types (invasive lobular, invasive micropapillary carcinomas) (p = 0.000), high tumour grade (p = 0.000), the presence of lymphovascular invasion (p = 0.000), tumor-infiltrating lymphocytes (TILs) 〈 10% (p = 0.000), the presence of tumor necrosis (p = 0.001), Her-2/neu overexpression (p = 0.01), Ki-67 ≥ 20% (p = 0.036), HER2-positive breast cancer (p = 0.015).  Overall, the rate of lymph node metastasis was 32%. Histological type, tumour grade, the presence of lymphovascular invasion, TILs, tumor necrosis, Her-2/neu and Ki-67 expression, and molecular subtype were factors related to lymph node metastasis in special types of invasive breast cancer. Keywords: Lymph node metastasis, invasive breast cancer, special types. References [1] World Health Organization, Breast Tumors (5th ed), International Agency for Research on Cancer, Lyon, France, 2019.[2] K. M. Masters, S. L.Wong, R. C. 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Demaria et al., The Evaluation of Tumor-Infiltrating Lymphocytes (TILs) in Breast Cancer: Recommendations by An International TILs Working Group 2014, Annals of Oncology, Vol. 26, No. 2, 2015, pp. 259-271, https://doi.org/10.1093/annonc/mdu450. [6] K. H. Young, Statistical Notes for Clinical Researchers: Chi-Squared Test and Fisher's Exact Test, Restorative Dentistry & Endodontics, Vol. 42, No. 2, 2017, pp. 152-155, https://doi.org/10.5395/rde.2017.42.2.152.[7] L. G. L. Tan, Y. Y. Tan, D. Heng, M. Y. Chan, Predictors of Axillary Lymph Node Metastases in Women with Early Breast Cancer in Singapore, Singapore Med J, Vol. 46, No. 12, 2005, pp. 693, https://doi.org/10.1016/s0959-8049(98)80134-2. [8] A. Barth, P. H. Craig, M. J. Silverstein, Predictors of Axillary Lymph Node Metastases in Patients with T1 Breast Carcinoma, Cancer, Vol. 79, No. 10, 1997, pp. 1918-1922, https://doi.org/10.1002/(SICI)10970142(19970515) 79:10 〈 1918::AID-CNCR12 〉 3.0.CO;2-Y. [9] Y. 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Abstract: With advances in operative technique and perioperative care, traditional endpoints such as morbidity and mortality provide an incomplete description of surgical outcomes. There is increasing emphasis on the need for patient-reported outcomes (PROs) to evaluate fully the effectiveness and quality of surgical interventions. The objective of this study was to identify the outcomes reported in clinical studies published in high-impact surgical journals and the frequency with which PROs are used. Methods Electronic versions of material published between 2008 and 2012 in the four highest-impact non-subspecialty surgical journals (Annals of Surgery, British Journal of Surgery (BJS), Journal of the American College of Surgeons (JACS), Journal of the American Medical Association (JAMA) Surgery) were hand-searched. Clinical studies of adult patients undergoing planned abdominal, thoracic or vascular surgery were included. Reported outcomes were classified into five categories using Wilson and Cleary's conceptual model. Results A total of 893 articles were assessed, of which 770 were included in the analysis. Some 91·6 per cent of studies reported biological and physiological outcomes, 36·0 per cent symptoms, 13·4 per cent direct indicators of functional status, 10·6 per cent general health perception and 14·8 per cent overall quality of life (QoL). The proportion of studies with at least one PRO was 38·7 per cent overall and 73·4 per cent in BJS (P & lt; 0·001). The proportion of studies using a formal measure of health-related QoL ranged from 8·9 per cent (JAMA Surgery) to 33·8 per cent (BJS). Conclusion The predominant reporting of clinical endpoints and the inconsistent use of PROs underscore the need for further research and education to enhance the applicability of these measures in specific surgical settings.

Abstract:  The aim of the study was to investigate the proportion of publications arising from work presented at a regional surgical meeting. Design  A list of all presentations to the Welsh Surgical Society 1983–95 was compiled and a detailed search made of the Medline Database. The surgical topic of each presentation, the date of presentation, the date of publication and the journal of publication were recorded. Setting  University Hospital of Wales. Results  Four hundred and ninety‐six papers were presented to the society, of which 402 (81%) were by trainees. The most frequent topics of presentation were colorectal (15%), vascular (15%) and hepato–pancreatico–biliary (11%). Two hundred and thirty‐three papers (47%) have been published in peer‐reviewed journals. The most popular journals for publication were Annals of the Royal College of Surgeons of England (19%), British Journal of Surgery (16%) and Journal of the Royal College of Surgeons of Edinburgh (8%). The median time from presentation to publication was 17·0 months (interquartile range 10·0–27·5 months). Conclusions  Regional surgical meetings have an important role in the annual surgical calendar and they are the ideal initial setting for presentation by trainees.

Abstract: Major surgery predisposes to endothelial glycocalyx injury. Endothelial glycocalyx injury associates with cardiac morbidity, including spontaneous myocardial infarction. However, the relation between endothelial glycocalyx injury and the development of perioperative myocardial infarction remains unknown. Methods Fifteen perioperative myocardial infarction patients and 60 propensity-matched controls were investigated in this prospective study. The diagnosis of perioperative myocardial infarction was based on repeated cardiac troponin T measurements, electrocardiographs and recordings of ischaemic signs and symptoms. We measured endothelial glycocalyx markers – soluble thrombomodulin, syndecan-1 and vascular adhesion protein 1 – and an inflammatory marker, namely interleukin-6, preoperatively and 6 h and 24 h postoperatively. We calculated the areas under the receiver operating characteristics curves (AUCs) to compare the performances of the different markers in predicting perioperative myocardial infarction. The highest value of each marker was used in the analysis. Results The interleukin-6 concentrations of perioperative myocardial infarction patients were significantly higher preoperatively and 6 and 24 h postoperatively ( P =  0.002, P =  0.002 and P =  0.001, respectively). The AUCs (95% confidence intervals) for the detection of perioperative myocardial infarction were 0.51 (0.34–0.69) for soluble thrombomodulin, 0.63 (0.47–0.79) for syndecan-1, 0.54 (0.37–0.70) for vascular adhesion protein 1 and 0.69 (0.54–0.85) for interleukin-6. Conclusions Systemic inflammation, reflected by interleukin-6, associates with cardiac troponin T release and perioperative myocardial infarction. Circulating interleukin-6 demonstrated some potential to predict perioperative myocardial infarction, whereas endothelial glycocalyx markers did not.