IntroductionPancreatic and periampullary adenocarcinomas are associated with abnormal body composition visible on CT scans, including low muscle mass (sarcopenia) and low muscle radiodensity due to fat infiltration in muscle (myosteatosis). The biological and clinical correlates to these features are poorly understood.MethodsClinical characteristics and outcomes were studied in 123 patients who underwent pancreaticoduodenectomy for pancreatic or non-pancreatic periampullary adenocarcinoma and who had available preoperative CT scans. In a subgroup of patients with pancreatic cancer (n = 29), rectus abdominus muscle mRNA expression was determined by cDNA microarray and in another subgroup (n = 29) 1H-NMR spectroscopy and gas chromatography-mass spectrometry were used to characterize the serum metabolome.ResultsMuscle mass and radiodensity were not significantly correlated. Distinct groups were identified: sarcopenia (40.7%), myosteatosis (25.2%), both (11.4%). Fat distribution differed in these groups; sarcopenia associated with lower subcutaneous adipose tissue (P<0.0001) and myosteatosis associated with greater visceral adipose tissue (P<0.0001). Sarcopenia, myosteatosis and their combined presence associated with shorter survival, Log Rank P = 0.005, P = 0.06, and P = 0.002, respectively. In muscle, transcriptomic analysis suggested increased inflammation and decreased growth in sarcopenia and disrupted oxidative phosphorylation and lipid accumulation in myosteatosis. In the circulating metabolome, metabolites consistent with muscle catabolism associated with sarcopenia. Metabolites consistent with disordered carbohydrate metabolism were identified in both sarcopenia and myosteatosis.DiscussionMuscle phenotypes differ clinically and biologically. Because these muscle phenotypes are linked to poor survival, it will be imperative to delineate their pathophysiologic mechanisms, including whether they are driven by variable tumor biology or host response.

There has been considerable literature on breast conservation therapy over the past few years, with an emphasis on cosmesis and less emphasis on the possible disadvantages of excision with inadequate margins at initial surgery.Recent literature 1 suggests that 1 in 4 women who have had breast conservation therapy require a second operation to remove residual tumours, an improvement over the last few years, but still substantial. Recent literature 1,2 suggests that inadequate margins at in itial surgery are disadvantageous for patients from a psychological and economic standpoint. There does not ap pear to be emphasis that having a positive margin at initial surgery negatively influences the likelihood of remaining disease free, although studies 3,4 have demonstrated that local recurrence after breast conservation surgery increases systemic disease, which can lead to increased mortality. It has been stated 5 that cancer cells have growth factor re ceptors that are compatible with growth factors in the wound environment and that cancer cells that shed intraoperatively can contribute to both local re currence and distant metastases.It is suggested that the cosmetic advantages of removing a specimen 1-2 cm smaller does not warrant the disadvantage of removing a specimen with inadequate margins, particularly since a second procedure negates the cosmetic advantage of removing a smaller specimen. Silverstein and colleagues 6 in discussing ductal carcin oma in situ made a comment that should also apply to lumpectomy for neoplasm: "the first excision is the best opportunity to achieve both goals, complete excision and good cosmetic result." Competing interests: None declared. References 1. McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. JAMA 2012; 307: 467-75. 2. Lovrics PJ, Cornacchi SD, Farrokhyar F, et al. Technical factors, surgeon case volume and positive margin rates after breast conservation surgery for early-stage breast cancer. Can J Surg 2010;53:305-12. 3. Punglia RS, Morrow M, Winer EP, et al. Local therapy and survival in breast cancer. N Engl J Med 2007;356:2399-405. 4. Kingsmore D, Hole D, Gillis C. Why does specialist treatment of breast cancer improve survival? The role of surgical management. Br J Cancer 2004;90:1920-5. 5. Reid SE, Kaufman MW, Murthy S, et al. Perioperative stimulation of residual cancer cells promotes local and distant recurrence of breast cancer. J Am Coll Surg 1997; 185:290-306. 6. Silverstein MJ, Parker R, Grotting JC, et al. Ductal carcinoma in situ of the breast.

Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during PD significantly reduces the risk of incisional SSI.

Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results.

Assessment of resectability varied significantly between specialties, and resectability was often underestimated by nonhepatobiliary surgeons. Hepatobiliary referral was not considered in a substantial proportion of cases erroneously deemed unresectable. These disparities result largely from an imprecise understanding of modern surgical indications for resection of CRLMs.

Non-invasive hepatobiliary cystadenomas present as large central/left-sided cysts in young or middle-aged women. Associated malignancy was relatively uncommon and found within mural nodules. Intra-operative frozen section analysis was ineffective at ruling out cystadenomas. Complete excision is recommended, but close follow-up might be considered in patients with a prohibitive technical or medical risk, in the absence of nodularity on high-quality imaging.

Background: Breast cancer is treated in its early stages with breast-conserving surgery. Current strategies still lead to a reexcision rate for positive margins as high as 47%. We proposed using NaviKnife, a real-time electromagnetic (EM) navigation system connected to a wire-localization needle and an ultrasound to define the desired tumour resection margins and allow the surgeon to follow its movement during surgery. The goal of this prospective phase 1 study was to assess the feasibility of using an EM navigation system in the operating room. Methods: Female patients with a single palpable tumour were recruited to undergo a partial mastectomy. Intraoperatively, an ultrasound was used to define the tumour contour, which was displayed on a computer screen using NaviKnife navigation. Feasibility was assessed via 3 components: confirmation of safety and sterility, measurement of the duration of the operation and tumour contouring, and completion of surgeon questionnaire. Results: Eleven patients (mean age 57.8 yr) with breast cancer (n = 9) or a benign breast lesion (n = 2) were recruited. The mean operative duration was 74.3 (range 48-94) minutes for cases of partial mastectomy with sentinel node biopsy (n = 9) and 35.5 (range 29-42) minutes for the partial mastectomy alone (n = 2). Mean tumour contouring time was 8.44 (range 5-12) minutes. There were no EM-specific complications or breaches in sterility during surgery. Feedback questionnaires stated that NaviKnife navigation was easy to use and did not interfere with the surgical procedure. Conclusion:This study demonstrates the NaviKnife system is feasible and safe to use intraoperatively in breast-conserving surgery.Intraoperative margin assessment in wire-localized breastconserving surgery: a population-level comparison of techniques.

Bariatric patients are difficult to assess clinically for signs of postoperative complication. Diagnostic laparoscopy (DL) is used to investigate patients suspicious for complications such as anastomotic leak (AL) and intra-abdominal hemorrhage (IH). Most bariatric surgeons use DL in the presence of sustained tachycardia; however, the rate of this procedure and its clinical value have not been sufficiently investigated.A retrospective review of patients undergoing bariatric surgery from January 2010 to December 2011 was performed. Data from 4 collaborative bariatric centres of excellence were included in this analysis. From among all elective bariatric procedures, cases that required early reoperation were selected for further evaluation.A total of 1001 elective bariatric procedures were identified. Of these, 952 (95%) were primary bariatric procedures, including 866 (91%) Roux-en-Y gastric bypasses and 86 (9%) sleeve gastrectomies. The remaining 48 cases represented revisional proced ures. Of these, 11 patients (1.1%) returned to the operating room within 72 hours for DL: 64% were primary cases (n = 7) and 36% revisional cases (n = 4). Intraoperative findings included AL (45%, n = 5), IH (27%, n = 3), no pathology identified (18%, n = 2) and small bowel obstruction (9%, n = 1). Of the 9 patients with complications, all were tachycardic (heart rate > 100 beats/min), and 4 of the 5 patients with AL were febrile (t > 37.5). There were no reported adverse events directly related to the use of DL.Diagnostic laparoscopy is a useful and safe option for both the diagnosis and treatment of suspected complications after bariatric surgery. The majority of patients returning to operating room had significant findings, and all were treated laparoscopically. Persistent postoperative tachycardia or fever were highly predictive of positive findings during DL. An emphasis on early decisionmaking and expeditious return to the operating room for laparoscopy should be the standard for bariatric patients on clinical suspicion of a postoperative complication. 4Changes of active and total ghrelin, GLP-1 and PYY following restrictive bariatric surgery and their impact on satiety: comparison of sleeve gastrectomy and adjustable gastric banding. A