bluuebunny/crossref_metadata_2025 huggingface dataset:
Left-Side Preference in Carotid Endarterectomies
Authors: Maxwell Bryan G. , Maxwell J. Gary , Brinker Carla C.
Published: November 2022

Although the incidence of carotid atheromatous disease is presumably equal between the right and left carotid arteries, right and left carotid endarterectomies (CEs) may not be performed with equal frequency on the two sides. This study sought to examine whether right and left CEs are performed with equal frequency and whether there are any differences in outcome between these groups. Detailed chart review was performed on all CEs performed from 1979 through 1998 at our institution, and those lacking side data were excluded. Data were collected on the side of the procedure, demographics, comorbid conditions, details of the procedure, hospital stay, and major complications. The surgeons performing CE were surveyed about their practice of considering side factors. CE was performed on the left in 1190 (52%) of 2305 procedures; 1115 (48%) of the procedures were right CEs. This difference is statistically significant ( P = 0.014). No significant differences in demographics, comorbidity, presence of symptoms before surgery, length of stay, or postoperative morbidity or mortality between the left and right groups were found. A majority of the surgeons surveyed indicated they do consider the relationship of side of the carotid disease to the patient's dominant side. The significant difference in the performance of left CE more often than right has not been previously reported. This may reflect willingness by surgeons to intervene more frequently in carotid disease on the side supplying the dominant hemisphere. A prospective CE outcome study that identifies the side of CE and the patient's dominant side is needed for further exploration of this issue.
Angiographic Embolization of Bilateral Internal Iliac Arteries to Control Life-Threatening Hemorrhage after Blunt Trauma to the Pelvis
Authors: Velmahos George C. , Chahwan Santiago , Hanks Sue E. , Murray James A. , Berne Thomas V. , Asensio Juan , Demetriades Demetrios
Published: November 2022

Angiographic embolization of bleeding pelvic vessels is increasingly used in patients with pelvic injuries. Temporary angiographic embolization of bilateral internal iliac arteries (TAEBIIA) is occasionally necessary. From November 1991 to March 1998, 30 consecutive patients (mean age of 43 years, mean Injury Severity Score of 25) with complex pelvic fractures underwent TAEBIIA to control severe hemorrhage not responding to subselective embolization. Angiography revealed multiple sources of pelvic bleeding in 28 (93%) patients. In the two remaining patients, no bleeding was identified but TAEBIIA was done empirically. Thirteen patients had laparotomies before TAEBIIA with unsuccessful bleeding control, and the remaining 17 had TAEBIIA as the primary treatment. After TAEBIIA 90 per cent of patients had successful clinical (27 of 30) and radiographic (25 of 28) control of bleeding. Of the three patients who continued to bleed after TAEBIIA two were successfully re-embolized and one died of acute cardiac failure before any further intervention was attempted. TAEBIIA had a success rate of 97 per cent (29 of 30) in controlling pelvic hemorrhage without significant complications related to it. TAEBIIA is a safe and effective alternative to subselective embolization in controlling retroperitoneal bleeding in selected patients with blunt pelvic trauma.
Pediatric Falls: Is Height a Predictor of Injury and Outcome?
Authors: Murray James A. , Chen David , Velmahos George C. , Alo Kathy , Belzberg Howard , Asensio Juan A. , Demetriades Demetrios , Berne Thomas V.
Published: November 2022

Falls account for a significant proportion of pediatric injuries and deaths. A retrospective review of pediatric patients (age 0–14 years) was performed to determine whether patterns of injuries and outcomes could be predicted on the basis of the height of the fall. In addition we evaluated the triage criterion “fall greater than 15 feet” for transport of patients to a trauma center. Patients were stratified by the height of the fall: greater than or less than 15 feet. The end points for analysis were the associated injuries and survival. Patients who fell less than 15 feet had a higher incidence of intracranial injuries (and fewer extremity fractures than patients who fell more than 15 feet). Skull fractures were the most frequent injury and were associated with an increase in intracranial injuries in both subgroups. In conclusion low-level falls are associated with significant intracranial injuries. The evaluation of patients sustaining low-level falls should not be limited on the basis of the height of the fall. Using falls of greater than 15 feet as a triage criterion for transport to a trauma center needs to be prospectively evaluated to ensure that critically injured patients are triaged appropriately.
Complicated Appendicitis: Is There a Minimum Intravenous Antibiotic Requirement? A Prospective Randomized Trial
Authors: Taylor Edward , Dev Vip , Shah Darshan , Festekjian Jaco , Gaw Felix
Published: November 2022

The proper duration of postoperative intravenous (IV) antibiotics in patients suffering complicated (perforated or gangrenous) appendicitis is debatable. Some advocate a set minimum number of IV antibiotic days whereas others discontinue IV antibiotics depending on the patient's clinical course regardless of the length of therapy. Our objective was to determine whether there are differences in morbidity and resource utilization between the two treatment methodologies. Ninety-four patients with intraoperative findings of complicated appendicitis were included. In all patients IV antibiotics were discontinued on the basis of clinical factors. However, Group 1 patients were given a minimum 5-day IV antibiotic course whereas Group 2 patients had no minimum IV antibiotic requirement. Group 1 patients received more IV antibiotics than Group 2 patients did (5.9 vs 4.3 days; P = 0.014). Infectious complications were not statistically different between the two groups (13.0% in Group 1 and 12.5% in Group 2). Average hospital stay was also not statistically different between the two groups. The data suggest that a protocol with no minimum IV antibiotic requirement in patients with complicated appendicitis does not increase morbidity. Furthermore, the protocol arm with no minimum IV antibiotic requirement led to less IV antibiotic use but did not significantly decrease hospital stay.
Scintigraphic Determination of Equivocal Appendicitis
Authors: Rypins Eric B. , Kipper Samuel L.
Published: November 2022

We evaluated Tc-99m-labeled anti-CD15 immunoglobulin M monoclonal antibody (LeuTech)™ for scintigraphic detection of acute appendicitis in patients with an equivocal clinical presentation. LeuTech™ avidly binds to circulating and sequestered human polymorphonuclear neutrophils in vivo eliminating the need for in vitro cell labeling and the risks of blood handling. We studied 99 patients to evaluate the safety and efficacy of LeuTech™ imaging. Serial dynamic and static planar images were acquired for up to 3 hours after the intravenous administration of 10 to 20 mCi of Tc-99m LeuTech™. Scans were read as positive or negative for acute appendicitis or other intra-abdominal infection. The institutional diagnosis was established by surgery and histopathology of the appendix, results of other diagnostic studies, or 2-week clinical follow-up. Scans were positive for appendicitis in 39 of 40 patients with appendicitis at surgery (sensitivity 98%) and negative for appendicitis in 49 of 58 patients without appendicitis (specificity 84%). One was lost to follow-up. Accuracy, positive predictive value, and negative predictive value were 90, 81, and 98 per cent respectively. In patients with appendicitis and positive scans more than 50 per cent of the images were positive at 4 minutes, and all were positive by 1 hour. Mean time of first positive image was 15 minutes. There were no serious adverse reactions. We conclude that LeuTech™ imaging is a highly sensitive test for detection of appendicitis in equivocal cases. There are advantages of this agent over the other currently used radiotracers in terms of convenience and time to diagnosis particularly the rapidity with which acute appendicitis will be seen on the images.
Acute Lung Injury after Hemorrhagic Shock is Dependent on Gut Injury and Sex
Authors: Adams Charles A. , Louis J. Magnotti , Xu Da-Zhong , Qi Lu , Edwin A. Deitch
Published: November 2022

Recent studies have established gut-derived lymph rather than portal blood as the major source of toxic mediators after hemorrhagic shock that causes distant organ injury. Similarly, emerging data have identified sex as a major modifier of the response to injury and illness. Thus we tested the hypothesis that female rats would be more resistant to shock-induced lung injury than male rats because females are more resistant to shock-induced gut injury and produce mesenteric lymph that is less toxic to endothelial cells. Male and female rats were subjected to sham or hemorrhagic shock and lung permeability was quantitated by Evans blue dye and protein extravasation into the alveolar space. Next, mesenteric lymph collected from shocked and sham-shocked rats of both sexes was incubated with human umbilical vein endothelial cells (HUVECs) and assayed for toxicity. Trypan blue dye exclusion and the release of lactate dehydrogenase assessed HUVEC viability and injury respectively. Lastly, sections of the terminal ileum were histologically examined for evidence of shock-induced mucosal injury. Male rats but not female rats subjected to hemorrhagic shock had evidence of increased lung permeability and produced mesenteric lymph that was cytotoxic to HUVECs. Shock caused gut injury in the male rats whereas histological evidence of gut injury was not observed in the female rats. Hemorrhagic shock-induced lung injury depends on gut injury and mesenteric lymph appears to be the route by which gut-derived toxic factors exit the gut to cause lung injury. The resistance of female rats to shock-induced lung injury appears to be secondary to their resistance to shock-induced gut injury.
A Successful Multitnodality Strategy for Management of Liver Injuries
Authors: Jeffrey A. Claridge , Jeffrey S. Young
Published: November 2022

The treatment of liver injuries involves many strategies ranging from observation to operative intervention and includes numerous options such as angiography, packing, and damage-control procedures. In July 1994 we instituted a protocol for the management of traumatic liver injuries. The main objective of this study was to evaluate the management of liver injuries occurring since the institution of the protocol. Two hundred three consecutive adult patients with liver injuries were evaluated at our Level I trauma center between July 1994 and May 1999. Eighty-eight per cent of the injuries were blunt with a mean Injury Severity Score (ISS) of 24.3 ± 0.8 and a survival probability (Ps) of 90.0 ± 1.5 per cent. The overall mortality was 6.4 per cent. A comparison between patients with minor liver injuries and patients with more severe injuries [Abbreviated Injury Score (AIS) <3 vs >3] demonstrated no difference in mortality between the two groups despite a Ps of 93.8 ± 1.3 per cent in patients with an AIS <3 versus 84.1 ± 3.3 per cent in patients with an AIS >3. The most common complication in our patient population was posthemorrhagic anemia, which was seen in 10.8 per cent of cases. Severity of injury did not result in a significant difference in the complication rate. Patients who underwent laparotomy had a statistically higher ISS, a lower Ps, and a mortality rate of 11.5 per cent compared with 3.7 per cent ( P = 0.03) in patients managed nonoperatively. However, a comparison of patients undergoing laparotomy with those who did not and who had equivalent ISS demonstrated no difference in mortality. Our results demonstrated that a preplanned management strategy was a successful way in which to treat patients with traumatic liver injuries. Although nonoperative management of liver injuries has been common practice a management plan that involves a multimodal surgical strategy is essential.
Laparoscopic Adrenalectomy is Superior to an Open Approach to Treat Primary Hyperaldosteronism
Authors: Duncan James L. , George M. Fuhrman , John S. Bolton , John D. Bowen , William S. Richardson
Published: November 2022

We reviewed our institutional experience with primary hyperaldosteronism to compare clinical outcomes after laparoscopic versus open adrenalectomy. All patients surgically treated for primary hyperaldosteronism from 1988 through 1999 are included in this study. Patients were assigned to either the LA (laparoscopic) or OA (open) group depending on the initial surgical approach selected for treatment. Records were reviewed to determine demographics, operative results, and complications. Twenty-four patients were surgically treated for primary hyperaldosteronism. There were no significant differences between groups with respect to age, weight, number of preoperative antihypertensive medications, or preoperative potassium level. The results of adrenalectomy with respect to number of postoperative antihypertensive medications or serum potassium level were also similar. Operative times were not significantly different (191 ± 53 minutes for OA and 205 ± 88 minutes for LA) between groups, but four LA patients were converted to OA. Estimated blood loss was 401 ± 513 cm3 for OA and 127 ± 131 cm3 for LA ( P = 0.07). Hospital length of stay was 6.7 ± 3.7 days for OA and 3.3 ± 2.7 days for LA ( P = 0.02). Complications were nine for OA and three for LA ( P = 0.001 by Pearson's Chi square). LA is similar to OA in the treatment of primary hyperaldosteronism. The significantly fewer complications and shorter length of hospital stay associated with LA makes the laparoscopic approach the preferred method for treating primary hyperaldosteronism.
A Simple Approach to Nipple Discharge
Authors: Tari A. King , Kristine M. Carter , John S. Bolton , George M. Fuhrman
Published: November 2022

Evaluation and management of patients with nipple discharge (ND) aims to identify carcinoma when present, and in benign cases, stop the discharge when bothersome. We reviewed our recent experience with ND to develop a simple and effective algorithm to manage these patients. Records of all patients with ND evaluated from December 1996 through June 1999 were reviewed. Patients were liberally offered duct excision for a clinical suspicion of malignancy (persistent clear or bloody fluid) or to stop bothersome discharge. Patients with breast imaging abnormalities (mammography or ultrasound) related to their ND underwent biopsy and were considered separately. Of 104 patients with ND, 11 underwent biopsy as a result of mammographic findings; three of these cases proved malignant. The remaining 93 patients were evaluated with 55 tests that did not demonstrate malignancy, including ductography, discharge fluid cytology, serum prolactin and thyroid-stimulating hormone levels, and image-guided breast or nipple biopsy. Thirty-nine patients underwent duct excision with only a single patient demonstrating malignancy. Clinical follow-up has not identified malignancy in any patient managed nonoperatively. When diagnostic breast imaging is negative, malignancy related to ND is uncommon. Patients with ND should have diagnostic breast imaging and, if it is negative, should be offered duct excision. There is little role for ductography, cytology, or laboratory studies in evaluating these patients.
Necrotizing Soft Tissue Infections: A Surgical Disease
Authors: Brandt Mary-Margaret , Cynthia A. Corpron , Wahl Wendy L.
Published: November 2022

Despite advances in antibiotics and infection control practices necrotizing fasciitis is still a potentially lethal disease. We reviewed 37 patients with necrotizing fasciitis to identify prognostic factors indicating outcome. Overall mortality was 24 per cent. Mortality was significantly increased for elderly patients. Solid-organ transplant recipients also represented a subset of patients with increased mortality. Most infections were polymicrobial. There was no Clostridium perfringens cultured. Rapid diagnosis and treatment with surgical debridement remains the cornerstone of therapy.
Duplex Examination of the Inferior Vena Cava
Authors: Kazmers Andris , Groehn Harvey , Meeker Chris
Published: November 2022

Duplex examination of the inferior vena cava (IVC) was performed in 270 patients from 1/1/96 to 1/1/00 to define suitability of the IVC for caval interruption using noninvasive means. The IVC was interrogated using a 3-mHz curved linear array probe and an ATL Ultramark 9 ultrasound machine (Bothell, WA). Duplex measured IVC dimensions and defined presence of thrombus or anomalies. Of the 270 IVC duplex examinations 10.7 per cent (n = 29) could not be completed because of overlying bowel gas or for other technical reasons. Of the 241 completed studies 4.1 per cent (n = 10) revealed acute or chronic thrombosis of the IVC. The lateral diameter of the IVC was 20.3 ± 4.4 mm (95% confidence interval 19.8–20.9 mm), whereas the anteroposterior diameter was 12.6 ± 4.0 mm (95% confidence interval 12.1–13.1 mm). Excluding those with vena cava thrombosis maximum vena cava diameters exceeded 28 mm in only 2.2 per cent (n = 5) of those with technically adequate studies. Apart from the latter megacavas there were no major IVC anomalies detected. For those with incomplete studies body weight was 192 ± 59 lb versus 169 ± 38 lb for those with technically adequate studies ( P = 0.008). Technically adequate vena cava duplex examinations can be performed in 89 per cent of patients. On the basis of this and one prior study done at this center IVC duplex can define vena cava dimensions and presence of thrombus. Using the standard criteria for IVC filter insertion that require presence of a maximum cava diameter ≤ 28 mm and absence of caval thrombus or anomalies, 94 per cent (226 of 241) of those with complete duplex examinations would have been anatomically suitable for standard Greenfield filter insertion based on noninvasive testing.
Factors Affecting Axillary Lymph Node Metastases in Patients with T1 Breast Carcinoma
Authors: Markopoulos Christos , Kouskos Efstratios , Gogas Helen , Mandas Dimitrios , Kakisis John , Gogas John
Published: November 2022

The purpose of this study was to determine factors associated with the incidence of axillary lymph node metastases (ALNM) in T1 tumors and cases in which axillary dissection could be omitted. Data from 195 patients with T1 primary invasive breast cancer (size ≤2 cm) who underwent either mastectomy or wide local excision of the tumor and axillary dissection were reviewed. ALNM was found in 59 of 195 patients with T1 tumors (30.3%). Tumor size was found to be the only independent predictor of ALNM, having a directly analogous relationship with the probability of invaded nodes: T1a (≤5 mm) tumors had 0 per cent ALNM, whereas T1b (5 mm < T1b ≤ 10 mm) and T1c (10 mm < T1c ≤ 20 mm) tumors had 25.7 per cent and 33.8 per cent ALNM respectively. Among the other factors studied (patient age, tumor site, hormone receptor status, histologic type, and grade of the tumor) only the histologic grade of the tumor cells appeared to correlate with the incidence of lymph node involvement, but this was not statistically significant. In conclusion only tumor size has statistically significant correlation with the incidence of ALNM. Routine axillary dissection could be omitted only in patients at minimal risk of ALNM (ductal carcinoma in situ and T1a) and when treatment decisions were not influenced by lymph node status (e.g., elderly patients with clinically negative axilla). Axillary dissection (at least levels I and II) should be performed in all cases with primary invasive breast cancer with tumor size >5 mm.
Comparison of Videothoracoscopy and Axillary Thoracotomy for the Treatment of Spontaneous Pneumothorax
Authors: Miller John D. , Simone Carmine , Kahnamoui Kam , Thomas Jackie , Bennett William F. , Young James E.M. , Urschel John D.
Published: November 2022

Surgical treatment of spontaneous pneumothorax can be done through a thoracotomy or a videothoracoscopic approach. Although the videothoracoscopic technique is currently popular it is not obviously superior to a more traditional axillary thoracotomy approach. We compared our recent experience with both techniques to determine the optimal surgical treatment for spontaneous pneumothoraces. A retrospective review of 79 patients treated surgically (34 thoracotomy and 45 thoracoscopy) for spontaneous pneumothoraces was done. Patients were treated between 1991 and 1997. Patients older than 60 years of age and those with spontaneous pneumothoraces secondary to generalized pulmonary emphysema were excluded. There were no operative deaths. Recurrence rate [thoracotomy, two of 34; thoracoscopy, three of 45 ( P < 0.89)], air leak exceeding 7 days [thoracotomy, three of 34; thoracoscopy, three of 45 ( P < 0.73)], operating room times [thoracotomy, 54 ± 26 minutes; thoracoscopy, 53 ± 16 minutes ( P < 0.59)], and postoperative length of stay [thoracotomy, 5.7 ± 4.3 days; thoracoscopy, 4.7 ± 4.4 days ( P < 0.26)] were not significantly different for the two techniques. We conclude that axillary thoracotomy and videothoracoscopy are equally effective surgical treatments for spontaneous pneumothoraces. A large randomized trial would be needed to determine whether one approach is truly superior to the other.
Combined Carotid Artery Injury and Laryngeal Fracture Secondary to Dog Bite: Case Report
Authors: Varela J. Esteban , Dolich Matthew O. , Fernandez Luis A. , Kane Atara , Henry Robert , Livingston Jeffrey , Arnold David , Namias Nicholas
Published: November 2022

Approximately 914 new dog bite injuries requiring emergency department visits occur daily in the United States. Attacks by dogs with training and strength to attack should be triaged cautiously because of the possibility of serious internal injury. A high index of suspicion is needed when treating patients with neck injuries secondary to dog bites. We report a case of successfully treated combined carotid artery and laryngeal injury produced by a dog bite.
Left Hepatic Lobectomy for Type IV-A Choledochal Cyst
Authors: Nakayama Hisashi , Masuda Hideki , Ugajin Wakato , Koshinaga Tsugumichi , Fukuzawa Masahiro
Published: November 2022

We report a case of a 37-year-old woman who was diagnosed with a type IV-A choledochal cyst with intrahepatic bile duct strictures. Because the stricture in the medial segment was located too far from the hilum for a hepaticojejunostomy we performed a left hepatic lobectomy. In this report we evaluate the therapeutic benefit of hepatectomy in a patient with a type IV-A choledochal cyst involving the intrahepatic bile ducts.
The Role of the Ultrasonically Activated Shears and Vascular Cutting Stapler in Hepatic Resection
Authors: Wrightson William R. , Edwards Michael J. , McMasters Kelly M.
Published: November 2022

Hemorrhage and liver failure are the two greatest concerns for patients undergoing major liver resection. Inflow occlusion (Pringle maneuver) is often used to minimize blood loss, but hepatic ischemia results in an increased risk of postoperative hepatic dysfunction. We report our experience with the Harmonic Scalpel ultrasonically activated shears (UAS; Ethicon Endo-Surgery, Cincinnati, OH) and a vascular stapler for hepatic resection as technological advances that aid in minimizing blood loss and thereby reduce the need for inflow occlusion. We retrospectively reviewed liver resections performed from September 1997 through July 1998, in which the UAS and articulating vascular endoscopic linear cutting stapler were used. The vascular stapler was used to divide the appropriate portal vein branch and hepatic vein(s) before parenchymal transection. Parenchymal dissection was performed with UAS to a depth of approximately 2 to 3 cm, and the remainder of the liver parenchyma was divided by a clamp crush and clip and suture ligate technique. Patients underwent segmental resection (n = 12), lobectomy (n = 13), or extended lobectomy (n = 11). Resection was performed for metastatic disease, primary liver tumors, or benign disease in 21, 8, and 7 patients, respectively. A Pringle maneuver was performed in 7 of 36 patients (mean clamp time, 8 minutes). The median required intraoperative blood transfusion was 0 units of packed red blood cells. Major and minor complications occurred in 12 and 3 patients, respectively. Two deaths were related to pneumonia and abdominal infection. The vascular stapler safely and securely divides portal vein branches and hepatic veins. The UAS initiates parenchymal transection with minimal blood loss. These two technologies facilitate the surgeon's aim of liver resection without blood transfusion or Pringle maneuver.
Spontaneous Perforation of the Bile Duct
Authors: Niedbala Angela , Lankford Ashley , Boswell William C. , Rittmeyer Chris
Published: November 2022

We present a classic but rare case of spontaneous perforation of the bile duct in infancy and a previously undescribed treatment technique. The patient, a male age 5 weeks, was admitted with abdominal distention, ascites, and conjugated hyperbilirubinemia. Ultrasound revealed ascites but did not provide visualization of the gallbladder. Although hepatobiliary scintigraphy with technetium [dimethyl iminodiacetic acid (HIDA scan)] showed normal uptake peritoneal excretion suggested perforation of the common bile duct (CBD). Exploratory laparotomy revealed 200 cm3dark amber ascitic fluid in the peritoneal cavity and cholestasis of the liver. Intraoperative cholangiogram performed via the gallbladder showed a large perforation at the cystic duct/CBD junction. The perforation was large and leakage of contrast prevented demonstration of the distal CBD despite our attempt to primarily repair the perforation. The CBD was explored; a T-tube was placed. T-tube cholangiogram demonstrated flow of contrast into the duodenum. A large leak remained at the cystic CBD junction. A cholecystectomy was performed and a vascularized flap of the gallbladder wall was used to repair the CBD over the T-tube. The T-tube was clamped intermittently beginning 3 weeks postoperatively. T-tube cholangiogram performed 6 weeks postoperatively revealed no extravasation and normal intra- and extrahepatic biliary tree. The T-tube was subsequently discontinued and liver function tests remained normal at 6 months follow-up.
Nontropical Pyomyositis: Analysis of Eight Patients in an Urban Center
Authors: Hossain Azhar , Reis Ernane D. , Soundararajan Krish , Kerstein Morris D. , Hollier Larry H.
Published: November 2022

Nontropical pyomyositis is rare and usually associated with immunodeficiency virus (HIV) infection. This study assessed manifestations and response to treatment of nontropical pyomyositis in an area with a high prevalence of HIV seropositivity. We undertook a chart review of eight consecutive patients treated for pyomyositis—primary infection of skeletal muscles—from 1988 through 1998. All patients complained of myalgia; four (50%) had fever and six (75%) had leukocytosis. Muscles involved were deltoid, quadriceps, gluteus, and psoas. Six (75%) patients had identifiable risk factors for pyomyositis: HIV seropositivity (two), history of intravenous drug abuse (one), chronic paraplegia and malnutrition (one), diabetes and chronic renal failure (one), and leukemia (one). One patient had had streptococcal pharyngitis previously but was otherwise healthy; another, a 2-year-old, had no evidence of underlying disease. Staphylococcus aureus was the most common organism isolated (50%). Four patients were treated with incision and drainage plus antibiotics; the remaining four patients were treated with intravenous antibiotics only; all recovered. Nontropical pyomyositis, which is often associated with HIV seropositivity or chronic illness, has a favorable outcome. Treatment can be effective even without surgical intervention.
Results of Liver Transplantation for Nodular Regenerative Hyperplasia
Authors: Radomski John S. , Chojnacki Karen A. , Moritz Michael J. , Rubin Raphael , Armenti Vincent T. , Wilson Gary A. , Herrine Steven , Conn Mitchell
Published: November 2022

Liver transplantation has been performed in individuals with a pretransplant clinical diagnosis of cirrhosis but with nodular regenerative hyperplasia histologically. The purpose of this report is to investigate the results of liver transplantation in patients proven to have nodular regenerative hyperplasia post-transplant. A retrospective review was undertaken of four patients who underwent liver transplantation with a histologic diagnosis of nodular regenerative hyperplasia. All were felt to be cirrhotic on clinical grounds. Final histology of the explanted liver was confirmed by a single pathologist. Their ages ranged from 39 to 54 years, and three of the four were male. Three had pretransplant needle liver biopsies, two percutaneous and one transjugular. All revealed nonspecific reactive changes. Ultrasound and MRI were interpreted as consistent with cirrhosis in four of four and three of four cases, respectively. Portal vein flow was hepatopedal in three and absent in one. Pretransplant clinical characteristics and frequency were as follows: bleeding varices two, clinical ascites three, encephalopathy three, and impaired hepatic synthetic function two. All four patients underwent successful liver transplantation. There were no episodes of acute rejection. All are alive and well with normal graft function 2 to 4 years post-transplant. We conclude the following. 1) Patients with clinical end-stage liver disease due to underlying nodular regenerative hyperplasia can successfully undergo transplantation. 2) Nodular regenerative hyperplasia can present with signs and symptoms of liver failure, is difficult to diagnose by needle biopsy, and can be difficult to discriminate clinically from cirrhosis. 3) Although each case must be individually evaluated transplantation may be the optimal therapy in patients presenting with complications of liver failure.
Revisiting Breast Masses with the Plastic Surgeon: Suggestions for Biopsy and Resection
Authors: Shawa Tania , Cohen Robert , Jansen David , Mckinnon William
Published: November 2022

Between 250,000 and 500,000 breast mass biopsies are performed each year. This is a common procedure of the breast that should be planned such that maximum treatment is achieved with minimal disfigurement and scarring. Plastic surgery techniques must be used in the choice of biopsy site and planned excision and can result in an improved cosmetic result for the patient. Subareolar masses are resected using a radial elliptical incision. Lateral and medial masses are resected using the Wise pattern reduction mammaplasty whereas the vertical mammaplasty is used for lesions of the central inferior breast and inframammary fold. Awareness of these basic reconstructive principles by the general surgeon can minimize disfigurement and facilitate future reconstruction by the plastic surgeon so that both cure and cosmesis can be achieved.
Chest Wall Resection and Reconstruction via a Muscle-Sparing Minithoracotomy for Lung Cancer
Authors: Campo Carlos Del , Roethe Robert A. , Lee Victor W.
Published: November 2022

Five per cent of lung cancers involve the parietal pleura and chest wall. En bloc resections improve survival. Lung resections via muscle-sparing chest incisions have minimized complications and hospital stay. We present a case in which we performed an en bloc lobectomy with chest wall resection and reconstruction through a muscle sparing minithoracotomy in a 48-year-old woman. She was discharged in the fourth postoperative day and remains tumor free and asymptomatic after 4 years.
Persantine Attenuates Hemorrhagic Shock-Induced P-Selectin Expression
Authors: Olinde John G. , Zibari Gazi B. , Brown Mark F. , Howell James G. , Akgur Feza M. , Granger D. Neil , McDonald John C.
Published: November 2022

Ischemia/reperfusion (I/R), a phenomenon that is associated with conditions such as organ transplantation, trauma, vascular disease, and stroke, involves the recruitment of activated and adherent leukocytes that subsequently mediate tissue injury. Endothelial cell adhesion molecules such as P-selectin mediate I/R-induced leukocyte recruitment and allow the adherent leukocytes to damage the vascular wall and parenchymal cells. This study examines the influence of dypiridamole (persantine) on hemorrhagic shock (H/S)-induced P-selectin expression. H/S was induced in C57BL/6 mice by withdrawing blood to drop the mean arterial blood pressure to 30 to 35 mm Hg for 45 minutes. The mice were resuscitated by infusing the shed blood and Ringer's lactate (50% shed blood volume). In vivo P-selectin expression was determined using a dual monoclonal antibody technique in the heart, lung, liver, kidneys, stomach, small bowel, and colon of a control group, a hemorrhagic shock group, and a hemorrhagic shock group that was pretreated with Persantine (Boehringer, Ingelheim, Ingelheim, Germany). H/S significantly ( P < 0.01) increased P-selectin expression in all regional vascular beds of untreated mice. Persantine treatment largely prevented the H/S-induced P-selectin expression in the same vascular beds. Persantine significantly attenuates the upregulation of P-selectin in the hemorrhagic shock model.
Results of Local Excision of Benign and Malignant Rectal Lesions
Authors: Hoth J. Jason , Waters Gregory S. , Pennell Timothy C.
Published: November 2022

Local excision of selected rectal cancers is an acceptable alternative to radical surgery. The results of local excision of various rectal lesions using either the transanal or trans-sacral approach were reviewed over a 10-year period at this institution. A total of 56 procedures were performed on 47 patients (50 transanal/six trans-sacral). The trans-sacral approach was used six times on five patients for lesions averaging a distance of 8 cm from the anal verge. The transanal approach was used 50 times on two patients for lesions occurring at an average distance of 5 cm from the anal verge. Twenty-six malignant lesions were excised (25 transanal/one trans-sacral) with pathologies ranging from poorly to well-differentiated adenocarcinoma. Staging included 12 T1lesions (46%), 10 T2lesions (38%), and four T3lesions (16%). Eighteen malignancies were completely excised and recurrence occurred in four of 18 (22%) with an average follow-up of 2.3 years (range 0–10 years). Local recurrence occurred in two patients (T1and T2lesions) and recurrence was in the form of distant metastasis in two patients (two T3lesions). Three of the recurrences occurred in patients with T3lesions (three of four; 75%), two occurred in a patient with a T2lesion (two of 10; 20%), and one occurred in a patient with a T1lesion (one of 12; 8%). There were no cancer-related deaths during the study period. Twenty-six premalignant lesions (adenomatous polyps) and four benign lesions were excised (25 transanal/five trans-sacral). Local recurrence occurred 10 times with an average follow-up of 1.8 years. In conclusion local excision of certain rectal cancers is an acceptable alternative in the treatment of these malignancies.
Sarcoidosis of the Breast: Implications for the General Surgeon
Authors: Ojeda Herminio , Sardi Armando , Totoonchie Adil
Published: November 2022

Sarcoidosis is a multisystemic disease that may involve the breast parenchyma and can be confused with benign or malignant tumors. A recent case of sarcoidosis of the breast treated in our institution prompted us to review the world literature on the topic. From 1921 to 1997, 45 cases relating to sarcoidosis of the breast were reported; 10 of these cases were excluded from our review because of the lack of histological proof of sarcoidosis. The data were organized according to clinical presentation, diagnostic studies, treatment plan, and follow-up care. The mean age at presentation was 47 years (range 20–72 years) and all patients were female. Seven patients (20%) had a breast mass as primary presentation of sarcoidosis without any clinical evidence of systemic sarcoidosis. Thirty-one patients (89%) presented with a self-detected mass and three patients (8%) demonstrated skin dimpling and peau d'orange appearance mimicking cancer. The size of the breast lesions ranged from 0.25 to 5 cm in diameter. One patient presented with bilateral breast lesions and one with more than one lesion in the same affected breast. A single breast mass was found in the rest of the patients. Of the seven patients evaluated by mammography, only one revealed changes suspicious for malignancy. Fine-needle aspiration was used only in four cases; the results of two were compatible with sarcoidosis and two required an excisional biopsy as a result of inconclusive results. Seventeen cases reported excisional biopsy as the diagnostic procedure. In 11 patients the type of biopsy was not stated. In two cases of radical mastectomies for breast adenocarcinoma, sarcoidosis was an incidental finding, either in the remaining breast tissue or in the axillary nodes. One patient underwent a partial mastectomy revealing sarcoidosis as the definitive diagnosis. Ultrasound was used in two cases; one revealed a suspicious lesion and one was inconclusive. Although sarcoidosis of the breast constitutes a rare entity it should be considered in the differential diagnosis of breast cancer even in patients without clinical evidence of systemic sarcoidosis. These patients should undergo a biopsy to rule out malignancy because clinical findings, mammography, and ultrasound results can be misleading or inconclusive.
Mammary Endocrine Ductal Carcinoma in Situ: A Case Report
Authors: Danikas Dimitrios , Matthews William E. , Averbach David J.
Published: November 2022

Endocrine differentiation represents a pathway of neoplastic development available to a range of breast cancers. This pattern occurs in tumors with different morphological appearances as ductal carcinoma in situ (DOS), mucinous carcinoma, a variant of lobular carcinoma, and low-grade invasive ductal carcinoma. Endocrine ductal carcinoma in situ is an uncommon entity. It occurs in older women with a mean age of 70 years. Histologically it shows expansile intraductal growth forming solid sheets and festoons transversed by delicate fibrovascular septa. Conventional microscopy permits the diagnosis in most cases. Specialized techniques such as immunohistochemistry and electron microscopy can serve as the basis of diagnosis in the absence of the appropriate morphological features. We present a 68-year-old female with a 1.5-cm firm mobile nodule of the left breast. Mammography and ultrasounds showed a 15 x 15-mm circumscribed solid lobulated nodule. The mass was excised and pathology was positive for endocrine DCIS. Although endocrine DCIS has a biologic marker profile similar to that of well-differentiated or noncomedo DCIS it may constitute a different histogenetic pathway of carcinogenesis in the breast. The tumor may exhibit the invasive characteristics of a neuroendocrine neoplasm. Larger studies and longer follow-up are needed for the determination of the clinical behavior.
Octreotide in the Treatment of Thoracic Duct Injuries
Authors: Markham Kevin M. , Glover John L. , Welsh Robert J. , Lucas Robert J. , Bendick Phillip J.
Published: November 2022

Anecdotal reports support the use of octreotide in the treatment of traumatic thoracic duct injuries and chylothorax, but no prospective studies have proved its efficacy. We evaluated the effects of octreotide in treating thoracic duct transection in a canine model. Eight mongrel dogs (27.8 ± 5.1 kg) were fed one pint of 10.5 per cent milkfat 2 hours before operation. Through a left supraclavicular neck incision, the thoracic duct was identified and transected, producing free flow of chyle. A quarter-inch drain was tunneled subcutaneously from the wound and attached to closed suction. After wound closure dogs were randomized to a control group (n = 4) receiving sham injections of saline subcutaneously three times per day, or a treatment group (n = 4) given 3 μg/kg octreotide three times per day. Postoperatively all dogs were fed a standard low-fat (5–7%) crude fat diet. Drain output was measured each day, and on odd-numbered postoperative days the drainage was analyzed for cholesterol, triglycerides, albumin, and total protein. Fistula closure was defined as drainage <10 m1/24-hour period. Treated dogs achieved fistula closure significantly faster than controls: 3.5 ± 1.3 days versus 7.8 ± 1.0 days ( P = 0.0037). Whereas equivalent amounts of drainage occurred on the day of surgery and on postoperative day one in both groups, by postoperative day 2 the treatment group had significantly less drainage over 24 hours: 63 ± 69 ml versus 195 ± 79 ml ( P = 0.046); this significant difference persisted through postoperative day 5 when drainage began to decrease in the control group. No significant differences between groups were seen in levels of cholesterol, triglycerides, albumin, or protein in the drainage at any time point. We conclude that octreotide is effective in treating thoracic duct injury, leading to an early decrease in drainage and early fistula closure. The mechanism for this effect remains to be clarified.
Primary Gastrointestinal Sarcomas
Authors: Medina-Franco Heriberto , Eltoum Isam E. , Urist Marshall M. , Heslin Martin J.
Published: November 2022

Gastrointestinal (GI) sarcomas are uncommon tumors with the majority of previous studies performed over long time intervals. The purpose of this review is to analyze our single-institution experience with primary GI sarcomas. Between January 1990 and June 1998,27 adult patients with primary GI sarcomas were identified in the tumor registry at the University Hospital, School of Medicine of University of Alabama at Birmingham and retrospectively reviewed. Patient, tumor, and treatment factors as well as expression of p53 and Ki-67 were analyzed with overall survival as the main outcome variable. Statistical analysis was performed by log rank test and Cox regression. Significance was defined as P < 0.05. Median age was 55 years (range 36–80 years). The stomach was the most common site of presentation (59%) followed by small bowel (29%). The average tumor size was 15 cm (range 2–46 cm). A complete resection was performed in 22 patients (81.5%). Fifteen tumors were classified as low grade (55.5%). Actuarial 3-year survival was 43 per cent with a median follow-up of 16 months. Overexpression of p53 and Ki-67 correlated with a trend to decreased survival but it did not reach statistical significance. Multivariate analysis found incomplete resection ( P = 0.00001) and high grade ( P = 0.003) to be significant negative prognostic factors. We conclude that GI sarcomas tend to be large tumors with most arising in the stomach and proximal GI tract. Complete surgical resection is associated with prolonged survival and despite the large size of these tumors should be attempted whenever possible.
Routine Chest X-Rays after Insertion of Implantable Long-Term Venous Catheters: Necessary or Not?
Authors: Guth Amber A.
Published: November 2022

Can long-term subcutaneous venous (Mediport) catheters be safely inserted without routine chest X-ray (CXR) verification? An estimated 500,000 Mediport catheters are inserted yearly in the United States, and elimination of unnecessary radiographs would result in substantial savings of increasingly limited health care resources. A total of 513 consecutive Mediport catheters were inserted by a single surgeon over a 5-year period using a standardized protocol and selective indications for follow-up CXR that included unilateral chest pain, aspiration of air, decreased breath sounds, and difficult catheter insertion. The 513 catheters were inserted in 498 patients with 271 patients (53%) undergoing postprocedure CXR. Of the 513 catheters 461 (90%) were placed by percutaneous approach to the subclavian vein. Six pneumothoraces (1.2% incidence) occurred, all in patients who met criteria for immediate CXR. The overall complication rate was 3.1 per cent and included eight instances of catheter-tip malposition (seven of the eight were successfully repositioned by vascular radiology), one mediastinal hematoma, and one chest-wall hematoma. This largest single-surgeon-reported series demonstrates that Mediport insertion can be safely accomplished with minimal complications following a standardized protocol using selective radiologic evaluation.
Impact of Presenting Physiology and Associated Injuries on Outcome following Traumatic Rupture of the Thoracic Aorta
Authors: Karmy-Jones Riyad , Carter Yvonne M. , Nathens Avery , Brundage Susan , Meissner Mark H. , Borsa John , Demirer Seher , Jurkovich Gregory
Published: November 2022

We hypothesized that the predominant factor influencing outcome of traumatic rupture of the thoracic aorta (TRA) was the degree of shock on presentation and associated injuries. We reviewed our experience with TRA over a 15-year period. Patients were classified as “unstable” if presenting systolic blood pressure was <90 mm Hg or if it decreased to <90 mm Hg after admission. We determined the presence of closed head injury, cardiac risk factors, a preoperative acute lung injury (ALI). The influence of these factors on mortality, postoperative adult respiratory distress syndrome (ARDS), and paralysis was analyzed. One hundred thirty-six patients were admitted with TRA. One hundred twenty underwent operative repair with a mortality of 31 per cent. Operative mortality was significantly higher in unstable patients (62%) versus stable patients (17%, P = 0.001), in patients with cardiac risk factors (71%) versus those without (24%, P = 0.001), and in patients with preoperative free rupture (83%) with versus those without (19%, P = 0.001). Free rupture was the cause of hypotension in only 10 of 42 unstable patients, with the remainder being due to other causes. Preoperative ALI was associated with a marked increase in postoperative ARDS (47% with vs 9% without, P = 0.001) but not operative mortality. Mechanical circulatory support (MCS) was used in 59 cases, none of whom experienced paralysis, whereas eight of 61 operated on without MCS developed paralysis ( P = 0.001). When logistic regression was applied the use of MCS was not determined to be statistically significant. However, preoperative instability was found to be a significant predictor of postoperative paralysis with the risk being increased 5.5 times (confidence interval 3.3–10). The predominant factor influencing mortality, postoperative ARDS, and paralysis was preoperative instability and associated injuries. In patients who are hypotensive, other injuries should take precedence over repair of TRA. Patients who are stable but who have cardiac or pulmonary risk factors may be better managed by a period of nonoperative management until their condition improves.