bluuebunny/crossref_metadata_2025 huggingface dataset:
Local Injection for the Treatment of Suture Site Pain after Laparoscopic Ventral Hernia Repair
Authors: Carbonell Alfredo M. , Harold Kristi L. , Mahmutovic Aida J. , Hassan Reem , Matthews Brent D. , Kercher Kent W. , Sing Ronald F. , Heniford B. Todd
Published: November 2022

Transabdominal sutures (TAS) used for mesh fixation in laparoscopic ventral hernia repair (LVHR) are an occasional source of prolonged postoperative pain. We sought to analyze the incidence of TAS site pain and the efficacy of local treatment methods. A retrospective review of patients who underwent LVHR from January 1999 to August 2002 was performed to identify patients experiencing suture site pain. Patients were considered candidates for injection therapy if their discomfort lasted 10 days postoperatively. Patient demographics, hernia size, mesh size, and subjective pain intensity were recorded. Treatment consisted of injection circumferentially around the suture site with 0.25 per cent bupivacaine with one to 200,000 epinephrine and 1 per cent lidocaine at the level of the abdominal musculature. Statistical ( P < 0.05) significance was determined by chi-square, logistic regression, and analysis of variance. One hundred three patients (42 men and 61 women) with a mean age of 53 years (range 26–78) and weight of 99.8 kg (range 61–239) underwent LVHR. Mean hernia size was 192 cm2(range 12–450) and mean size of mesh placed measured 534 cm2(range 100–1200). Twenty-four patients (23%) complained of prolonged discomfort at a transabdominal suture site and were injected postoperatively in the office as described. Of these 58 per cent were female and 42 per cent were male. Logistic regression demonstrated increasing mesh size was the only factor ( P < 0.01) that correlated with the need for injection. Twenty-two of 24 patients (92%) undergoing injection therapy had complete relief of their symptoms. Twenty patients required a single injection and two patients required two injections to treat their TAS site pain. After local injection failure two patients were referred to an anesthesia pain service; one underwent intercostal nerve block with complete resolution of pain, while the other is currently in treatment. There were no complications. Suture site pain was present after LVHR in 23 per cent of our patients. Increasing mesh size is associated with a greater chance of suture site pain. It appears to be effectively treated postoperatively with the injection of a local anesthetic at the TAS site. The mechanisms by which short-duration anesthetics relieve chronic pain are not fully understood.
The Predictive Value of Preliminary Bacterial Colony Counts from Bronchoalveolar Lavage in Critically Ill Trauma Patients
Authors: Mueller Eric W. , Wood G. Christopher , Kelley Mark S. , Boucher Bradley A. , Fabian Timothy C. , Croce Martin A.
Published: November 2022

A common strategy for the diagnosis of ventilator-associated pneumonia (VAP) includes quantitative cultures from bronchoalveolar lavage (BAL). Often, empiric antibiotic therapy is initiated and continued until the final culture report. However, approximately 60 per cent of BAL cultures rule out VAP. Preliminary BAL results, obtained earlier, may identify these patients and allow early discontinuation of empiric antibiotics. This is desirable because unnecessary antibiotic therapy results in increased bacterial resistance, adverse drug events, and increased costs. The purpose of this study was to determine the value of preliminary BAL results for predicting final BAL results. A total of 1579 isolates from 868 BAL cultures over a 3-year period were analyzed. Preliminary and final colony counts for each isolate were categorized as either no growth (NG), insignificant (1–99,999 cfu/mL), or significant (≥100,000 cfu/mL). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preliminary results were calculated based on individual isolates and individual BAL samples. The presence of concurrent antibiotic therapy was collected for all false-negative isolates. On preliminary report, there were 367 isolates with NG, 820 isolates with insignificant growth, and 392 isolates with significant growth. Overall preliminary culture results had a sensitivity of ∼90 per cent and specificity of >90 per cent for the presence of VAP. Preliminary culture results accurately predicted the presence or absence of VAP in 838 (96.5%) of the BALs performed. Individual isolates and BAL samples with insignificant preliminary growth had greater reliability in predicting the absence of VAP than those with NG. There was no difference in the number of false-negative isolates that were taken while concurrent antibiotic therapy was present between insignificant and NG groups. Preliminary culture results yielding either insignificant or significant growth are highly predictive for final colony counts of similar magnitude. BALs with preliminary results demonstrating no growth are not as reliable. Isolates with significant preliminary growth should be considered clinically important, and antibiotic therapy should be changed, if necessary, to target such organisms. Isolates with insignificant preliminary growth have a low rate of false negatives; therefore, empiric antibiotic therapy specific for such organisms could be discontinued before obtaining final results. Empiric antibiotics should be continued until the final results are available in those patients with NG BALs.
Skin Implant Metastasis after Percutaneous Radio-Frequency Therapy of Liver Metastasis of a Colorectal Carcinoma
Authors: Bonatti H. , Bodner G. , Obrist P. , Bechter O. , Wetscher G. , Oefner D.
Published: November 2022

Percutaneous radio-frequency ablation (RFA) of liver tumors has been reported to be an effective approach. Skin implant metastases have been described after RFA of hepatocellular carcinoma. A 56-year-old man underwent resection of the transverse colon for an adenocarcinoma (pT3N2M0) following by adjuvant chemotherapy. He developed multiple liver metastases and underwent RFA. Six weeks after RFA, the patient noticed a painful skin lesion at the entrance side of the probe in the right upper abdominal quadrant. Ultrasound examination and computed tomography scan revealed an intracutaneous tumor of 2-cm diameter. The tumor was excised and revealed a metastasis of the previously described adenocarcinoma. CPT-11 monotherapy was started; however, due to tumor progression, the patient died 35 months after colonic resection and 10 months after RFA. This is the first case of an implant skin metastasis after RFA of secondary liver tumors. Although RFA is a promising option in the palliation of such tumors, such rare complications have to be considered.
Laparoscopic Resection of Posterior Duodenal Bulb Carcinoid Tumor
Authors: Bowers Steven P. , Smith C. Daniel
Published: November 2022

Duodenal carcinoid tumors are rare neuroendocrine foregut tumors that, in contrast to midgut carcinoid tumors, have a low metastatic potential. The majority can be resected endoscopically. This case details a 67-year old man presenting with a biopsy-proven carcinoid tumor located at the posterior superior aspect of the duodenal bulb which was not amenable to endoscopic resection. The patient underwent a laparoscopic resection of the tumor after precise localization using simultaneous laparoscopy and duodenoscopy, with reconstruction of the duodenotomy defect using intracorporeal suturing techniques. The authors present a case report and details of an operative technique that may be utilized on other operations of the duodenum.
Solitary Papillary Breast Carcinoma Metastasis to the Large Bowel Presenting as Primary Colon Carcinoma: Case Report and Review of the Literature
Authors: Dhar Sorabh , Kulaylat Mahmoud N. , Gordon Kelly , Lall Purin , Doerr Ralph J.
Published: November 2022

Breast carcinoma has the potential for widespread dissemination. Spread to the lower gastrointestinal tract is infrequent, often multifocal, occurs in association with spread to other sites, and most commonly develops from lobular carcinoma. Solitary colorectal metastasis as the first and sole manifestation of spread is a rare occurrence and can be confused with primary intestinal malignancy. We present a case of metastatic papillary breast carcinoma presenting as a perforated primary colon cancer. Identity of the lesion was confirmed by direct histologic comparison of the resected tumor with prior breast specimen, cytokeratin expression, and the presence of estrogen receptors.
Surgical Management of Adrenal Cysts
Authors: Lal Tanmay G. , Kaulback Kris R. , Bombonati Alessandro , Palazzo Juan P. , Jeffrey R. Brooke , Weigel Ronald J.
Published: November 2022

Adrenal cysts are rare and are often found incidentally during abdominal imaging for another reason. We describe two cases of adrenal cysts, one of which was found to be a cystic pheochromocytoma. Most cystic pheochromocytomas are not diagnosed by urinary screening studies, and the first indication of a pheochromocytoma may be hemodynamic instability during resection. We review the literature on adrenal cysts and make recommendations for the management of cystic adrenal masses.
Laparoscopic Nissen Fundoplication Improves Quality of Life in Patients with Atypical Symptoms of Gastroesophageal Reflux
Authors: Duffy John P. , Maggard Melinda , Hiyama Darryl T. , Atkinson James B. , McFadden David W. , Ko Clifford Y. , Hines Oscar J.
Published: November 2022

Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 ± 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 ± 15.3 preoperatively to 72.0 ± 14.9 postoperatively ( P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 ± 17.6 preoperatively to 71 ± 15.7 postoperatively ( P < 0.0001) and from 55.7 ± 12.6 to 72.8 ± 14.4 ( P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.
Computed Tomography Angiography Validates Duplex Sonographic Evaluation of Carotid Artery Stenosis
Authors: Cinat Marianne E. , Casalme Christine , Wilson Samuel E. , Pham Hahn , Anderson Patrice
Published: November 2022

Controversy regarding the optimal preoperative evaluation for patients with carotid arterial stenosis remains controversial. We hypothesized that carotid artery area reduction measured by computed tomography angiography (CTA) would closely correlate with duplex scanning stenosis. This study was undertaken to evaluate the correlation between duplex, CTA, and conventional arteriography in patients undergoing consideration for carotid endarterectomy. Patients undergoing evaluation for carotid artery stenosis who received at least 2 of the diagnostic tests were included in this study (n = 108); 30 patients underwent all 3 imaging modalities. Linear regression analysis was performed to determine correlation coefficients between the 3 different study modalities. Correlation and P values were as follows: CTA area versus CTA diameter, r = 0.82, P < 0.001; CTA area versus duplex stenosis, r = 0.71, P < 0.001; duplex stenosis versus angio diameter, r = 0.68; P = 0.005; CTA diameter versus angio diameter, r = 0.61, P = 005. CTA was able to identify plaque characteristics more readily than duplex or arteriography. CTA was also able to differentiate critical stenosis from occlusion and to settle discrepancies obtained from duplex scanning. CTA is an acceptable alternative method to validate duplex scanning evaluation of carotid artery stenosis. It can accurately measure lumen stenosis, visualize plaque morphology, and is associated with fewer complications than conventional angiography.
Vascular Injuries to the Extremities in a Suburban Trauma Center
Authors: Diamond Scott , Gaspard Donald , Katz Steven
Published: November 2022

The purpose of this study was to examine the experience with extremity vascular injuries of a level II suburban trauma center. A retrospective chart review was undertaken to include all patients admitted in a 6-year period with vascular injuries to the extremities. The vessels injured were identified along with the mechanism of injury. The method of repair was recorded. All associated neurologic injuries were investigated. Follow-up records, when available, were reviewed. Between January 1, 1996, and November 30, 2002, 48 patients were admitted with 56 vascular injuries to the extremities. Blunt trauma was the mechanism in 24 patients while penetrating trauma was the mechanism in the other 24 patients. The limb salvage rate was 95 per cent. Of the 28 injuries to upper extremity vessels, 24 were associated with neurologic injuries. In contrast, only 3 neurologic injuries were found in patients with lower extremity vascular injuries. In contrast to most urban centers, the distribution of vascular injuries to the extremities in a suburban setting was equally divided between blunt and penetrating injuries. The majority of functional impairment was related to neurologic injury rather than tissue ischemia from vascular injury.
Prevalence of Metastases in Hepatocellular Carcinoma: Risk Factors and Impact on Survival
Authors: Si Ming-Sing , Amersi Farin , Golish S. Raymond , Ortiz Jorge A. , Zaky Joseph , Finklestein Debbie , Busuttil Ronald W. , Imagawa David K.
Published: November 2022

The purpose of this study was to determine the prevalence and risk factors of metastases in hepatocellular carcinoma (HCC) patients and analyze the effects of different locations of metastases on survival. Retrospective analysis was performed on 347 HCC patients who received a metastatic workup including bone scan and computed tomography scans of chest, abdomen, and pelvis. Clinical and tumor characteristics were evaluated as risk factors for metastasis by univariate and multivariate methods. Survival was analyzed by Kaplan-Meier and Cox regression methods. One hundred forty-five patients had metastases: 71 had thoracic, 57 had abdominal, and 34 had bone metastases. Significant differences were noted with weight loss, hepatitis C, tumor grade, tumor multifocality, size, and alkaline phosphatase levels between the metastases group and the nonmetastases group by univariate analysis. Poor differentiation, multilobar spread, and size (≥5 cm) were strongest predictors of metastatic disease by logistic regression. Patients with thoracic metastases had significantly poorer survival. HCC metastasis is prevalent on initial presentation. Evaluation for liver transplantation or curative resection requires a full metastatic workup. Poor differentiation, larger tumors, and those with multilobar spread have increased risk for metastasis. Patients with thoracic spread have poor prognosis as compared to other locations of metastasis.
Liberalization of Donor Criteria in Lung Transplantation
Authors: Whiting David , Banerji Anamika , Ross David , Levine Michael , Shpiner Robert , Lackey Stephanie , Ardehali Abbas
Published: November 2022

Donor shortage remains a major obstacle to widespread application of lung transplantation. In region 5, including California, Nevada, New Mexico, Utah, and Arizona, the United Network of Organ Sharing (UNOS) database median waiting time for lung transplant candidates in 2000–2001 exceeded 17 months. The purpose of this study was to determine the impact of liberalization of donor criteria on median waiting time and short-term outcome of lung transplantation. From September 1999 to October 2002, 42 patients underwent lung transplantation from nonstandard donors. The donors were classified as nonstandard due to (1) infiltrate on chest radiograph (n = 33), (2) PaO2 < 300 on FiO2 1.0 and PEEP 5 (n = 3), (3) PaO2 < 100 on FiO2 0.4 and PEEP 5 (n = 3), (4) purulent sputum on bronchoscopy (n = 22), and (5) smoking history greater than 50 pack-years (n = 1). Perioperative characteristics and short-term outcome of this group was analyzed. The median waiting time for this cohort was 114 days (range, 10–1267), as compared with the national UNOS database median waiting time of 24 months between 1996 and 2001. The incidence of ischemia reperfusion injury was 2.3 per cent. None of the recipients developed pneumonia. The median ventilator support time was 2 days (range, 1–95). The median ICU stay and hospital stay were 4 days (range, 2–103) and 14 days (range, 5–194), respectively. The 3-month survival was 97.6 per cent. Selective liberalization of donor lung criteria can decrease the waiting time and is associated with favorable short-term outcome. Utilization of nonstandard lungs can expand the donor pool.
Differential Expression of Thymidylate Synthase in Colorectal Tumors and Matched Lymph Nodes: Impact on Adjuvant Treatment
Authors: Trocha Steven D. , Saha Sukamal S. , Wiese David , Thompson Jim , Morton Donald L. , Bilchik Anton J.
Published: November 2022

Although the expression of thymidylate synthase (TS) in metastatic colorectal cancer (CRC) may be a better predictor of response to 5-fluorouracil chemotherapy than TS expression in primary CRC, this enzyme has not been well studied in tumor-draining regional lymph nodes. We retrospectively examined TS expression in 12 primary CRC lesions (pT3) and matched sentinel lymph nodes. Of the 8 primary tumors that were TS-positive, 50 per cent (4/8) had tumor-positive lymph nodes and 50 per cent (4/8) had tumor-negative nodes. Of the 4 primary tumors that were TS-negative, 75 per cent (3/4) had tumor-positive nodes and 25 per cent (1/4) had tumor-negative nodes [κ = -0.1386, 95 per cent confidence interval: (-0.4820, 0.2048), P = 0.4284]. Of the 8 TS-positive primaries, 25 per cent (2/8) had TS-positive nodes and 75 per cent (6/8) had TS-negative nodes. Of the 4 TS-negative primaries, 50 per cent (2/4) had TS-positive nodes and 50 per cent (2/4) had TS-negative nodes [κ = -0.0131, 95 per cent confidence interval: (-0.2958, 0.2696), P = 0.9274]. Two of the three TS-negative primaries that had metastasized to regional lymph nodes were associated with TS-positive lymph nodes. Our findings indicate that expression of TS by a primary CRC does not correlate with nodal metastases or nodal TS expression. Nodal expression of TS may be important in predicting response to 5-fluorouracil when a primary CRC is TS-negative.
Validation of an Updated Approach to Preoperative Cardiac Risk Assessment in Vascular Surgery
Authors: Bui Hao , Lee Jason T. , Greenway Scott , Donayre Carlos , Virgilio Christian De
Published: November 2022

To validate a more selective approach to cardiac assessment which consisted of limiting stress testing and coronary revascularization to highly selected patients and limiting coronary revascularization to patients with severe cardiac symptoms, we compared two time periods (1994–1995 and 2000–2001) with respect to cardiac work-up and cardiac morbidity and mortality. Our method involved a retrospective review of patients undergoing vascular procedures from 2000 to 2001 at a single institution. In group 1 (2000–2001), 139 operations were performed on 120 patients. In group 2 (1994–1995), 145 procedures were performed on 109 patients. Preoperative stress testing was reduced from 42 patients (29%) in group 2 to 20 patients (14%) in group 1 ( P < 0.01), and preoperative coronary artery bypass grafting was reduced from six (4.1%) to two (1.4%) ( P < 0.28), respectively. Coronary angiography was unchanged: 8 (5.8%) patients in group 1 versus 11 (7.9%) patients in group 2 ( P = NS). Two (1.4%) patients underwent percutaneous transluminal coronary angioplasty in group 1 and group 2. Cardiac event rates were similar: seven (5%) patients in both groups. Cardiac death was not significantly different: two (1.4%) in group 1 versus one (0.7%) in group 2. Cardiac morbidity and mortality after major vascular surgery remain the same despite using a more selective cardiac stress protocol.
Laparoscopic Roux-en-Y Gastric Bypass: Minimally Invasive Bariatric Surgery for the Superobese in the Community Hospital Setting
Authors: Moose D. , Lourie D. , Powell W. , Pehrsson B. , Martin D. , LaMar T. , Alexander J.
Published: November 2022

Roux-en-Y gastric bypass (RYGB) operation has become a popular choice for weight-reduction surgery. We report an outcome analysis of our early results with laparoscopic Roux-en-Y gastric bypass for superobese (BMI >50) patients. Between January 2000 and October 2001, we operated on 71 superobese patients. The mean body mass index (BMI) of patients at time of surgery was 57 kg/m2. The prospectively collected data included patient demographics, comorbidities, operative times, postoperative weight loss, and complications. Conversion to open gastric bypass was required in one patient. The overall complication rate was 10 per cent. Preoperative comorbidities were resolved or improved in 93 per cent of patients at 1-year postoperative. Average operative time and length of hospital stay were 196 minutes and 2.3 days, respectively. Mean percentage excess weight loss at 3, 6, 9, and 12 months was 27 per cent, 39 per cent, 49 per cent, and 55 per cent, respectively. Mean BMI decreased to 36 kg/m2 over a 12-month period. Laparoscopic Roux-en-Y gastric bypass surgery for superobese patients as performed in the community hospital setting can be both safe and effective with respect to overall postoperative course, early weight loss, and reduction of comorbidity.
Characteristics and Management of Splenic Artery Aneurysm in Liver Transplant Candidates and Recipients
Authors: Heestand Gregory , Sher Linda , Lightfoote Johnson , Palmer Suzanne , Mateo Rod , Singh Gagandeep , Moser Jennifer , Selby Rick , Genyk Yuri , Jabbour Nicolas
Published: November 2022

The incidence of splenic artery aneurysm (SAA) in patients with cirrhosis ranges from 7 per cent to 17 per cent. SAA rupture after liver transplantation (LT) is reported to result in significant morbidity and mortality. We report our experience with SAA in LT candidates. From September 1995 through August 2002, 14 LT candidates were diagnosed with SAA. Twenty SAA occurred in 14 patients with an average diameter of 20 mm. Eleven patients qualified for LT; to date, seven have been transplanted. No intervention for SAA occurred prior to LT. Of the seven patients transplanted, four had SAA identified prior to LT. Three were treated at LT and are alive; the fourth had postoperative splenic artery embolization followed by splenectomy and expired on day 109 from duodenal ulcer complications. Three of seven patients had undiagnosed SAA at LT. One required emergency splenectomy for SAA rupture and is alive at 44 months. The remaining two received no treatment; one suffered a late septic death and one is alive at 15 months. No ruptures occurred in our pre-LT population, suggesting that definitive management can await LT. We recommend that all patients undergo four-phase computed tomography or magnetic resonance angiography (MRA) as part of the LT evaluation and that identified SAA be resected at transplantation.
Portal Vein Thrombosis following Splenectomy: Identification of Risk Factors
Authors: Fujita Fumihiko , Lyass Sergey , Otsuka Koji , Giordano Luca , Rosenbaum David L. , Khalili Theodore M. , Phillips Edward H.
Published: November 2022

Portal vein thrombosis (PVT) following splenectomy is a potentially life-threatening complication, and the true incidence of PVT in splenectomized patients is unknown. The objective of this study was to determine the incidence of symptomatic PVT after splenectomy. The hospital database was searched to identify cases of PVT associated with splenectomy from January 1990 to May 2002. Six hundred eighty-eight patients underwent splenectomy during this period, 321 of them for hematologic diseases. Eleven of the 688 patients had PVT associated with splenectomy, and the charts of these patients were reviewed. Six patients developed PVT after splenectomy. Five had hematologic diseases. Symptoms were abdominal pain (6), ileus (5), fever (3), or diarrhea (2). Diagnosis was confirmed by computed tomography (CT) (4), duplex ultrasonography (1), and magnetic resonance imaging (1). The indications for splenectomy included hemolytic anemia (3), thalassemia (1), and myelofibrosis (1). One patient had an incidental splenectomy during gastrectomy. There were four laparoscopic and two open splenectomies. The median interval between splenectomy and diagnosis of PVT was 40 days (range, 13–741). One patient died of pulmonary embolism. Five of six patients with postsplenectomy PVT had splenomegaly and hemolysis. We conclude that the risk of PVT is higher in patients with hematologic conditions associated with splenomegaly and hemolysis.
Laparoscopic Lysis of Adhesions
Authors: Chopra Ritu , McVay Carie , Phillips Edward , Khalili Theodore M.
Published: November 2022

The surgical treatment of small bowel obstruction is evolving. Laparoscopic exploration and adhesiolysis is increasingly being utilized. We conducted a retrospective chart review of all patients who were operated on and discharged with the diagnosis of adhesiolysis for small bowel obstruction (SBO) from July 1999 to October 2000 at Cedars-Sinai Medical Center. There were a total of 75 patients. Patients were grouped based on the type of operation: laparoscopic (lap), open, and converted. Thirty-four patients were attempted laparoscopically, 11 of those requiring conversion to open. Fifty-two patients were treated with a laparotomy. Complications contributing to morbidity were significantly lower in the lap group ( P < 0.01). There was no difference in morbidity between the converted and open groups. There were fewer pneumonias and wound infections in the lap group when compared to the open group, although it did not reach statistical difference. The reduction of post-op ileus in the lap group was statistically significant ( P < 0.01). Statistically significant differences between the lap and open groups were also found in estimated blood loss (EBL) ( P < 0.004), length of stay (LOS) ( P < 0.01), bowel resection ( P < 0.01) and op-time ( P < 0.003). Laparoscopic release of adhesions is a viable option in the surgical management of small bowel obstruction. A prospective randomized trial comparing both surgical techniques is needed to further validate the laparoscopic approach to small bowel obstruction.
Abdominal Compartment Syndrome as a Consequence of Rectus Sheath Hematoma
Authors: O'Mara Michael S. , Semins Howard , Hathaway Devora , Caushaj Philip F.
Published: November 2022

Abdominal compartment syndrome is a well-documented entity arising from multiple and various causes. The rise of intra-abdominal pressure by the increase in volume of the peritoneal and retroperitoneal contents has been shown in the resuscitation and evaluation of surgical patients. However, the incidence of constriction of the abdomen causing intra-abdominal hypertension is unknown. Previously limited to burn eschar and externally applied devices (such as MAST trousers), external compression leading to abdominal compartment syndrome has been a limited entity. We report the first documented case of an expansive abdominal wall mass, a rectus sheath hematoma, leading to impending abdominal compartment syndrome.
Comparison of Bursting Pressure of Abdominal wall Defects Repaired by Three Conventional Techniques
Authors: Seror Dan , Nissan Aviram , Spira Ram M. , Feigin Elad , Udassin Raphael , Freund Herbert R.
Published: November 2022

Still debated are the appropriate techniques for the repair of abdominal wall defects and the methods used to measure their strength. Although tension has been used in many studies to test wound strength, bursting pressure reflects more accurately the pathophysiology of wound dehiscence. The aim of the current study was to evaluate three different techniques for closure of abdominal wall defects using a new and more accurate device for bursting pressure measurements. Full thickness abdominal wall defects measuring 2 cm2 were created in 43 anesthetized rats randomly assigned to three groups: simple primary closure (n = 15), Mayo repair (n = 14), and primary closure reinforced with a mesh (n = 14). Thirty days after surgery, the rats were sacrificed. The abdominal wall was fully excised and placed over a bursting chamber made of a metal cylinder connected to a carbon dioxide source with a control valve and a manometer. Gas was gradually released while the pressure was recorded until bursting occurred. Disruption of all closures occurred at the point where the suture itself penetrated the tissue. The average bursting pressure was 1383 ± 299 mm Hg for the primary closure group, 1200 ± 409 mm Hg for the mesh reinforcement group, and 1607 ± 337 mm Hg for the imbrication repair (Mayo) group ( P < 0.03). The data suggests an advantage for the Mayo repair over the other two repairs. The bursting chamber tested is a new and more reliable method to study techniques and conditions influencing the strength of abdominal wall closure.
Surgical Management of the Patient with Invasive Carcinoma Discovered at Reduction Mammoplasty
Authors: Rudolph Raymond , Niedbala Angela R.
Published: November 2022

The diagnosis of invasive carcinoma presents a surgical dilemma when discovered incidentally at breast reduction mammoplasty. Subsequent surgical and therapeutic management for such cases have not been established. Although management and treatment may vary according to patient preference, a review of the literature of the past four decades yielded scant discussion of the topic. We describe two cases of occult breast carcinomas that were not evident on preoperative breast screening, but were discovered on the pathology exam of reduction mammoplasty specimen. The purpose of our publication is to recommend a surgical approach for the patient in such a situation.
Bleeding Manifestations after Early Use of Low-Molecular-Weight Heparins in Blunt Splenic Injuries
Authors: Alejandro Kathia V. , Acosta Jose A. , Rodriguez Pablo A.
Published: November 2022

Low-molecular-weight heparins (LMWHs) have emerged as an effective method for deep venous thrombosis (DVT) prophylaxis after major trauma. The early use of LMWH in patients with splenic injuries may result in increased rates of blood transfusions and failure of nonoperative management. A retrospective review of the records of all patients ≥18 years old that sustained blunt splenic injuries from April 2000 to July 2002 was performed. Patients were divided in two groups based on whether they received LMWH during the first 48 hours (early group) or not (late group). A total of 188 patients were evaluated. One hundred fourteen patients had their splenic injuries managed nonoperatively and were included in the study. Fifty patients were assigned to the early group and 64 to the late group. There was no statistical difference between groups regarding basic demographic data, initial laboratory results, and severity of their splenic injuries. In the early group, two (4%) patients failed nonoperative management compared with four (6%) patients in the late group ( P = 0.593). The number of patients requiring blood transfusions within the first 5 days after admission was 25 (50.0%) in the early group and 36 (56.2%) in the late group ( P = 0.507). The average number of blood units given per patient within the first 5 days after admission were 3.2 ± 1.5 in the early group and 3.0 ± 1.8 in the late group ( P = 0.782). This study suggests that the early use of LMWH in trauma patients with splenic injuries is not associated with an increased rate of blood transfusion requirements or an increased rate of failure of non-operative management.
A 40-Year Delayed Locoregional Recurrence of Breast Carcinoma following Mastectomy
Authors: Joseph Kathie-Ann , El-Tamer Mahmoud , Ditkoff Beth Ann , Komenaka Ian , Horowitz Liz , Schnabel Freya
Published: November 2022

A 90-year-old woman who underwent a left modified radical mastectomy 40 years ago with no further adjuvant treatment presented with a left chest wall mass at the suture line. A biopsy of the mass confirmed that it was invasive ductal carcinoma of the breast. After a negative metastatic work-up, the patient underwent a local resection of the chest wall mass with clear margins. We present here the longest documented delayed recurrence after modified radical mastectomy reported in the literature.
Blind Whipple Resections for Periampullary and Pancreatic Lesions
Authors: Camp E. Ramsey , Vogel Stephen B.
Published: November 2022

Many patients with periampullary mass lesions lack a tissue diagnosis at referral despite advances in body imaging and aggressive biopsy techniques. This review evaluates a consecutive cohort of patients who underwent pancreatoduodenectomy (PD) with and without a diagnosis of malignancy. From 1990 to 2001, 121 patients underwent PD on a gastrointestinal surgical service by a single surgeon with a bias toward “blind” Whipple resections (BWR). Sixty-three per cent of the patients had obstructive jaundice with a mass on CT in 51 per cent. Fifty-three patients (44%) had a preoperative diagnosis of malignancy. Sixty-eight patients (56%) underwent a blind PD based on computed tomography (CT), ERCP, and clinical findings. After PD, 113 patients (94%) had a malignancy (46 pancreatic, 30 ampullary, 13 cholangiocarcinoma, 9 neuroendocrine, 4 duodenal, 10 other). Of the 68 patients (56%) who underwent a blind PD, 61 patients (90%) had a malignancy. Ten per cent of the BWR patients had a pathologic diagnosis of chronic inflammation/pancreatitis. Overall mortality was 3.3% (4 patients), with no deaths in the BWR group. In this review, clinical judgment was correct in 90 per cent of patients undergoing a “blind” PD without a prior diagnosis of malignancy. In patients with “potentially resectable” lesions (based on CT exam), biopsy information does not affect the choice of therapy since a negative biopsy still commits the patients to surgery. Combined CT and/or ERCP data with clinical findings leads most often to a correct diagnosis and procedure. These data question the practice of numerous biopsy attempts in patients with periampullary lesions.
Chloride/Phosphate Ratio in Primary Hyperparathyroidism
Authors: Boughey J.C. , Ewart C.J. , Yost M.J. , Nottingham J.M. , Brown J.J.
Published: November 2022

The chloride/phosphate (Cl:PO4) ratio is known to help distinguish between the hypercalcemia of primary hyperparathyroidism (HPT) and hypercalcemia from other causes. The Cl:PO4 ratio of 106 patients with surgically proven primary HPT was compared with that of 126 normocalcemic healthy outpatients to examine its usefulness as a confirmatory test for primary HPT. The Cl:PO4 ratio was significantly higher in patients with HPT (42.5 ± 7.0) compared with healthy controls (28.7 ± 4.6). Patients with HPT and mild renal insufficiency (serum creatinine, 1.5–2.4 mg/dL) also showed a significant increase in the Cl:PO4 ratio (37.3 ± 6.6) as did those with HPT with borderline elevations in serum calcium (calcium <11; ChPO4, 40.3 ± 5.6). A Cl:PO4 ratio ≥ 33 is a reliable diagnostic test for primary HPT when compared with a normal population. The Cl:PO4 ratio is also of value in the evaluation of the patient with suspected HPT and borderline calcium elevation and those with mild renal impairment. These data suggest that an inexpensive Cl:PO4 ratio might replace serum parathormone assay as a confirmatory test in the evaluation of suspected primary HPT, especially for those patients in whom a localizing study (sestamibi scan) is obtained before neck exploration.
Intraductal Oncocytic Papillary Neoplasm of the Extrahepatic Biliary Tree: First Report
Authors: Spector Seth A. , Bejarano Pablo A. , Amortegui Jose D. , Renfrow Michael R. , Livingstone Alan S.
Published: November 2022

Tumors with oncocytic differentiation may occur in a variety of organs, but are extremely rare in the biliary system. Intraductal oncocytic papillary neoplasms (IOPNs) were first described in the pancreas to differentiate a rare subset of pancreatic neoplasm from the intraductal papillary mucinous neoplasms (IPMNs). IOPN of the extrahepatic biliary tree has not been previously described. We describe the first case of an intraductal oncocytic papillary neoplasm at the bifurcation of the common hepatic duct in a 52-year-old white male with a two-year history of intermittent biliary obstruction.
Octreotide Does Not Prevent Postoperative Pancreatic Fistula or Mortality following Pancreaticoduodenectomy
Authors: Barnett Sean P. , Hodul Pamela J. , Creech Steven , Pickleman Jack , Arahna Gerard V.
Published: November 2022

The role of octreotide in preventing pancreatic fistula following pancreaticoduodenectomy (PD) remains controversial. The purpose of our study was to report our experience with octreotide in 266 patients undergoing PD from 1995 to 2002. There were 150 males and 116 females. Patients were divided into two groups. Group 1 did not receive octreotide ( N = 61). Group 2 received octreotide (N = 205). The average patient age was 66.2 years in the control group and 63.6 years in the octreotide group. One hundred fifty patients were male and 116 were female. Thirty-day mortality for both groups was 1.9 per cent. The incidence of pancreatic fistula was 12 per cent. Fistula occurrence in the octreotide group was 13 per cent and in the no-octreotide group 8 per cent ( P = 0.34). Common complications in the no-octreotide group were pancreatic leak (10%), pancreatic fistula (8%), and delayed gastric emptying (8%). Common complications in the octreotide group were pancreatic leak (18%), pancreatic fistula (13%), intra-abdominal abscess (7%), and arrhythmia or myocardial infarction (7%). The only statistically different variable was the incidence of arrhythmia or myocardial infarction ( P = 0.026). Octreotide did not reduce pancreatic fistula, other complications, or mortality. Octreotide may contribute cardiac morbidity. Octreotide cannot be recommended to prevent mortality or postoperative complications after PD.
Characterization of the Human Diaphragm Muscle with Respect to the Phrenic Nerve Motor Points for Diaphragmatic Pacing
Authors: Onders Raymond P. , Aiyar Harish , Mortimer J. Thomas
Published: November 2022

Diaphragm pacing from laparoscopically placed electrodes is an alternative to conventional phrenic pacers that use electrodes placed in direct contact with the nerve in the neck or chest. The challenge with the laparoscopic approach is determining where to implant the electrodes, as the phrenic nerves are not visible from the abdomen. The objective of this study was to locate the phrenic nerve “motor points” in the human diaphragm muscle from an abdominal perspective. Twenty-five cadavers were examined by excising the diaphragm muscle and assessing for the thickness of the muscle, the motor point area, and the accessibility of the motor point from the abdominal approach. The data indicate the average thickness of the muscle in the motor point region was 3.0 mm for the left and 2.9 mm for the right hemidiaphragm. The average motor point area was 73 mm2 for the left and 58.7 mm2 for the right hemidiaphragm. The motor points were accessible from an abdominal approach, but the motor point on the right hemidiaphragm was located on the central tendon in many cases (12 of 25). Thus, although the nerves branch prior to entry into the muscle on the right side, several well-placed electrodes could still activate the entire nerve. In this study, we have characterized the human diaphragm muscle in the motor point region and found that it is feasible to place laparoscopically intramuscular electrodes in the motor point region. This is the foundation for the laparoscopically placed diaphragm pacing device that has been utilized in a small series of patients.
Management of Unsuspected Gallbladder Carcinoma Discovered during or following Laparoscopic Cholecystectomy
Authors: Yeh Chun-Nan , Jan Yi-Yin , Chen Miin-Fu
Published: November 2022

Laparoscopic cholecystectomy (LC) is widely used in the treatment of symptomatic cholelithiasis. Gallbladder carcinoma (GBC) discovered during or after LC presents a management problem because of the difficulty of intraoperative staging. We conducted a retrospective, 8-year review of 10 patients with GBC discovered during or after LC. Of 3050 patients undergoing LC for cholelithiasis, 10 (0.3%) had GBC. The histological diagnoses of the 10 GBC patients included well-differentiated adenocarcinomas ( n = 5), papillary adenocarcinomas (n = 2), moderately differentiated adenocarcinomas ( n = 2), and poorly differentiated adenocarcinoma ( n = 1). Of these patients, four had TNM classified T1 tumors, three had T2 tumors, one had T2N0M0 tumor, one had T2N1M0 tumor, and one had T3N0M0 tumor. In three of them (T2N0M0, T2N1M0, and T3N0M0), the procedure was converted to open cholecystectomy, wedge resection of liver bed tissue in segment 5, and lymph node dissection after frozen-section biopsy of the laparoscopically removed gallbladder revealed GBC. Patients were closely followed at regular intervals until death or May 2000. The median follow-up period was 24.5 months. One patient died of carcinomatosis 6 months after undergoing the open procedure. The remaining nine patients did not have any recurrence during the follow-up period. No patient had a port site recurrence of GBC. Based on our limited experience, early GBC (T1a or T1s) can successfully be managed by simple cholecystectomy, either by LC or the open method.
Comparative Review of Use of Physician Assistants in a Level I Trauma Center
Authors: Oswanski Michael F. , Sharma Om P. , Raj Shekhar S.
Published: November 2022

In view of the new residency guidelines, which restrict resident work hours, the use of physician assistants (PAs) for patient care continuity during off-hours of residents may become a common practice. The purpose of this study was to assess the quality of patient care during transition from resident- to PA-assisted trauma program (without residents) and comparative simultaneous support. A retrospective analysis of patient care during two 6-month segments was carried out: during resident-assisted program at a level II trauma center in 1998 and a PA-dedicated trauma program in 1999. With reinvolvement of senior surgical residents, a focused analysis for the last quarter of 2002 was done. Regression analysis indicated the only statistically significant outcome was decreased length of stay (LOS) when patients were transferred directly from emergency center (EC) to floor in 1999. The mean LOS was 2.54 ± 4.65 compared to 3.4 ± 5.81, and no statistical difference in other assessments was noted. Focused analysis in 2002 showed 100 per cent participation of PAs during the trauma alert compared to 51 per cent by residents. Substitution of residents with PAs had no impact on patient mortality; however, LOS (from EC to floor), was statistically reduced by 1 day. Trauma programs can benefit with collaboration of residents and PAs in patient care.
Migrating Mesh Plug: Complication of a Weil-Established Hernia Repair Technique
Authors: Moorman Matthew L. , Price Phillip D.
Published: November 2022

The mesh plug technique for repair of inguinal hernia has become one of the standard procedures in general surgery. The evolution of the technique of occluding the fascial defect with a foreign body has extensively been described in the surgical literature. The associated complications are also well described. We find only two published reports describing complications related to migration of a mesh plug. We present a case of a 50-year-old man with vague left lower quadrant pain approximately 18 months after left indirect inguinal hernia repair with the PerFix plug (Bard, Murray Hill, NJ) and overlay patch method. Laparoscopic exploration determined that the plug had migrated away from the left internal ring in the preperitoneal space and was involved with significant adhesions. The plug was removed, and his hernia was repaired laparoscopically with GORE-TEX mesh (W.L. Gore, Tempe, AZ). The patient's symptoms were relieved, and he remained pain free through follow-up at 6 months.
Lobular Carcinoma in Ectopic Axillary Breast Tissue
Authors: Giron Gladys L. , Friedman Ira , Feldman Sheldon
Published: November 2022

Accessory mammary tissue is reported to occur in 2 per cent to 6 per cent of women and results from failure of regression of a portion of the galactic band, which runs from the axilla to the groin during embryogenesis. The differential diagnosis of a mass located along the course of the primitive milk line must include accessory breast tissue. This tissue is subject to the same physiologic and pathologic changes as in the breast proper. There are numerous case reports of masses arising in accessory breast tissue ranging from fibroadenomas and phyllodes tumors to invasive mucinous adenocarcinoma. The predominant pathology, as with the pectoral breast, is that of invasive ductal carcinoma. We present the case of a lobular carcinoma arising in axillary ectopic breast tissue. Although this has previously been reported, it is a rare entity.
Mortality in Murine Peritonitis Correlates with Increased Escherichia coli Adherence to the Intestinal Mucosa
Authors: Burch Phillip T. , Scott Melanie J. , Wortz Gary N. , Peyton James C. , Cheadle William G.
Published: November 2022

During peritonitis, bacterial adherence is the initial step in a series of events that include mucosal infection, bacterial translocation, organ dysfunction, and death. Adherent Escherichia coli levels increase in response to stress. This study was designed to assess the adherence of E. coli to the cecal mucosa after cecal ligation and puncture (CLP) of increasing severity and to determine whether a relationship exists between adherence of bacteria and mortality. Sham surgery, sterile peritonitis (thioglycollate administration), lethal CLP (18-gauge double-puncture), and nonlethal CLP (23-gauge single-puncture) were performed on Swiss Webster mice and compared with normal mice or before CLP (time 0). Specimens of bowel tissue were harvested, and serial log dilutions of homogenized specimens or bowel contents were plated and cultured on media selective for determination of individual bacterial species. Low levels of E. coli and Proteus mirabilis adhered to the mucosa of unmanipulated controls; however, adherence of both species increased significantly by 18 hours after both lethal and nonlethal CLP. After 18 hours, adherent E. coli levels increased by greater than 5 x 106-fold compared to unmanipulated controls, whereas P. mirabilis levels decreased. After nonlethal CLP, adherent P. mirabilis increased 3 x 106-fold compared to unmanipulated animals, whereas E. coli levels did not increase after 24 hours. Sterile peritonitis had little effect on bacterial adherence. Higher levels of adherent E. coli in the cecum correlate with the increased mortality observed after lethal CLP. Higher levels of adherent P. mirabilis appear to prevent the overgrowth of adherent E. coli following nonlethal CLP. Our data indicate that E. coli plays a key role in mortality from polymicrobial peritonitis and that Proteus may be antagonistic to E. coli in murine peritonitis.