bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Total Pancreatectomy with Islet Cell Transplant on Chronic Pancreatitis Management at a Disease-Based Center
Authors: Dixon Jennifer , Delegge Mark , Morgan Katherine A. , Adams David B.
Published: June 2020

Because of poor outcomes with traditional surgical management, total pancreatectomy with autologous islet transplantation (TPAIT) has been heralded as a breakthrough in the management of severe chronic pancreatitis intractable to medical management. To assess the impact of TPAIT on a pancreatobiliary disease-based center, a retrospective review and analysis of patients who underwent TPAIT after failing traditional surgical management was undertaken. Seven patients who underwent TPAIT were identified. Patient hospitalizations, emergency department visits, and clinic visits in the year pre- and post-TPAIT were tabulated. Average body weights and serum prealbumin were recorded during the year pre- and post-TPAIT. Based on the number of hospitalizations, clinic visits, and emergency department visits as an indicator of overall symptom severity, patients experienced an improvement in symptoms during the 12 months after TPAIT. Prealbumin values remained stable during the postoperative year. An observed decrease in weight suggests that other factors may be impacting the overall state of nutrition. The impact of TPAIT on the surgical management of chronic pancreatitis is limited in scope and benefit and continues to require careful analysis to identify appropriate candidates.
Necrotizing Fasciitis with No Mortality or Limb Loss
Authors: Martin Deborah A. , Nanci Gabriella N. , Marlowe Steven I. , Larsen Alan N.
Published: June 2020

Necrotizing fasciitis is a potentially lethal invasive soft tissue infection. Early aggressive antibiotic therapy and surgical debridement have been the hallmark of successful therapy. It is commonly held that delays in surgical debridement significantly increase the mortality rate and rate of limb loss. A mortality rate of 20 per cent or greater has been reported throughout the last 80 years. We recently reviewed the cases of 20 consecutive patients admitted to our hospital in various stages of necrotizing fasciitis progression. Treatment of all 20 patients consisted of antibiotic therapy and surgical debridement, with frequent follow-up serial debridement. Topical negative pressure was achieved with the use of the Vacuum Assisted Closure system. An aggressive surgical approach, (including the frequency of debridement, appropriate antibiotic utilization, and use of the Vacuum Assisted Closure system), significantly impacted our results, despite delays in treatment and progression of the infection.
A Comparison of Flexion and Extension Radiographs with Computed Tomography of the Cervical Spine in Blunt Trauma
Authors: Goodnight Travis J. , Helmer Stephen D. , Dort Jonathan M. , Nold R. Joseph , Smith R. Stephen
Published: June 2020

The purpose of this study was to compare flexion and extension (F/E) cervical radiographs with CT of the cervical spine in patients sustaining blunt trauma for the evaluation of ligamentous injury. A retrospective chart review of 2 years duration at an American College of Surgeons-verified Level I trauma center was performed. All patients sustaining blunt trauma who were evaluated with both a CT as well as F/E radiographs were identified. Exclusion criteria included penetrating injuries, neurologic symptoms, and age younger than 18 years. Follow-up MRI of each positive F/E radiograph after a negative CT scan was performed. Flexion and extension cervical radiographs were obtained in 379 patients after CT. Eight positive F/E radiographs were obtained after a negative CT scan. Follow-up MRI was negative for ligamentous injury in all cases. No cases of a clinically relevant positive F/E radiograph after a negative CT scan were identified. Follow-up F/E radiographs are not efficacious when a negative CT has been performed in blunt trauma without neurologic findings.
Impact on Patient Outcomes after Closure of an Adjacent Trauma Center
Authors: Yaghoubian Arezou , Lewis Roger J. , Putnam Brant A. , De Virgilio Christian
Published: June 2020

In 2005, a major Level I trauma center closed in Los Angeles County, leading to media speculation that the sudden expansion of our catchment area would adversely affect outcome. We sought to determine whether the closure led to longer transport times and increased trauma morbidity and mortality at our Level I trauma center. Annual patient volume, paramedic transport times, injury severity score (ISS), mechanism of injury, complication rate, and mortality were retrospectively compared between two time periods, Period 1 (1997–2005, before closure) and Period 2 (March 1, 2005 to March 1, 2006, after closure), using multivariable logistic regression models. Median monthly patient volume rose from 123 patients to 190 patients in Period 2 (P < 0.01). Median transport time increased from 12 to 13 minutes (P = 0.004) and median ISS increased from four to five (P < 0.01) in Period 2. The proportion of patients with ISS > 15 increased from 17 to 24 per cent as well (P < 0.01). After accounting injury severity, the adjusted mortality rate decreased in Period 2 (odds ratio 0.69, P = 0.03) and the adjusted complication rate was unchanged (odds ratio 1.16, P = 0.2). In conclusion, the closure of a Level I trauma center resulted in a significant increase in trauma patient volume and injury severity, as well as a slight increase in paramedic transport times. However, the adjusted complication rate was unchanged, and the adjusted mortality rate actually improved.
Effectiveness of Decentralized Community-Based Screening, Detection, and Treatment of Breast Cancer in Low-Income, Uninsured Women
Authors: Bhaskara Achala , Altamirano Maria , Trisal Vijay , Paz I. Benjamin , Lai Lily L.
Published: June 2020

Different systems exist currently in the provision of breast care to low-income, uninsured women. We assessed the efficacy of screening, diagnosis, and treatment of breast cancer in this patient population through a decentralized network of providers. We retrospectively reviewed charts of all patients referred for evaluation and treatment under the Cancer Detection Program: Every Woman Counts (CDP:EWC), the California equivalent of the National Breast and Cervical Cancer Detection and Prevention Program, in a suburban area of Los Angeles County. A total of 972 CDP:EWC screening mammograms was performed in the Antelope Valley during a 7-year study period (2000 to 2007). Sixty-two screened women aged 40 to 64 years were referred for further evaluation. Breast cancer detection rate per screening mammogram was 0.8 per cent; 80 per cent were early-stage breast cancer. The majority of the women (nine of 15) underwent breast conservation surgery. The axilla was staged using sentinel lymph node dissection and/or axillary lymph node dissection. Adjuvant chemotherapy and radiation were administered to all eligible patients. Compliance with published practice guidelines was high. This suggests that a decentralized community-based network of providers may be an effective model to deliver breast care to a low-income, uninsured patient population.
The Value of Endoscopic Ultrasonography in Predicting Resectability and Margins of Resection for Periampullary Tumors
Authors: Ho Joyce M. , Eysselein Viktor E. , Stabile Bruce E.
Published: June 2020

Cure of pancreatic head and other periampullary neoplasms continues to be infrequent and is unattainable unless clear surgical margins are achieved during Whipple pancreaticoduodenectomy. Endoscopic ultrasonography (EUS) is a relatively recent gastrointestinal tumor imaging modality and may be superior to other techniques used in locoregional staging. We hypothesized that EUS can accurately predict not only tumor resectability, but also negative resection margins with Whipple resection. A retrospective review was undertaken of 81 consecutive patients with periampullary tumors who underwent preoperative CT and EUS followed by surgical exploration for intended Whipple resection. Correlations among preoperative EUS results, successful resection, and surgical margins on final histopathology were investigated. Of the 81 patients, 61 (75%) underwent successful Whipple resection, and 20 (25%) were found to be unresectable at laparotomy. Resection was achieved in 57 (86%) of 66 patients predicted to be resectable by EUS. Of the 61 resected patients, 52 (85%) had negative margins and nine (15%) had positive margins on final pathology. Margins were determined to be negative in 50 (88%) of 57 resected patients predicted to have negative margins by EUS. We conclude that EUS is a powerful and desirable imaging modality in the preoperative assessment of periampullary neoplasms.
Gastric Injury Increases Infections in Trauma Patients
Authors: Edelman David A. , Donoghue Lydia , White Michael T. , Tyburski James G. , Wilson Robert F.
Published: June 2020

Some physicians feel gastric injury is not a significant contributing factor to the adverse outcome of trauma patients, but rather a marker of epigastric injury. We hypothesized the addition of a gastric injury to multiple injured trauma patients would increase infection rate. We conducted a retrospective study comparing 450 consecutive patients with full-thickness gastric injury with 983 patients without gastric injury during the same time period. Infection rate in patients with gastric injury was 44 per cent (200 of 455) and significantly higher than 36 per cent (357 of 983) seen without gastric injury (P = 0.006). Logistic regression revealed gastric injury was an independent risk factor for infection controlling for age, Injury Severity Scale, gender, mechanism of injury, shock, and associated injuries (P = 0.047). Requiring a transfusion, Injury Severity Scale, colon injury, age, pancreas injury, and emergency department shock were also independent risk factors for developing an infection. The addition of a gastric injury to a trauma patient appears to increase the risk for infection.
Large Gaps of Midline Abdominal Incisions and Their Management
Authors: Kulaylat Mahmoud N. , Karakousis Constantine P.
Published: June 2020

The operative management of midline full-thickness abdominal wall gaps is difficult, often requires several surgical procedures and is associated with significant short- and long-term complications. A rectus abdominis-posterior sheath (RAPS) flap with skin grafting provides a tension-free one-step repair which was used in three patients successfully with midline abdominal wall (including the skin) gaps who had multiple previous operations related to intra-abdominal malignancy. No complications occurred in these patients in relation to this procedure.
Fistulogram after Arteriovenous Dialysis Graft Thrombectomy Should be Mandatory
Authors: Kumar Shakthi D. , Jain Krishna M. , Jain Shikha , Munn John S. , Rummel Mark C.
Published: June 2020

The purpose of this study was to determine if fistulogram after prosthetic arteriovenous dialysis graft thrombectomy would reveal underlying lesions, which need correction, and if revision would improve graft patency. One hundred and ninety-two open thrombectomy procedures in 61 patients from January 1, 2000 to July 31, 2005 were reviewed retrospectively. All of the study patients were divided into two groups: In Group I fistulogram was carried out and in Group II no fistulogram was performed. Based on the fistulogram or clinical findings, appropriate intervention was carried out. In Group I, of 99 thrombectomy procedures, a significant lesion was identified and revision was carried out in 77 cases (78%). In Group II, of 93 thrombectomy procedures, a significant lesion was identified and revised in 53 cases (57%). A significant abnormality was more likely to be encountered by routine fistulogram than surgical exploration alone, 78 per cent versus 57 per cent (P < 0.05). Assisted primary patency is significantly increased in Group I and II when revision was performed (4.84 months) compared with when no fistulogram and no revision was performed (2.9 months), P < 0.05. Routine fistulogram after thrombectomy of an arteriovenous dialysis graft increases the likelihood of identifying a significant stenosis. Revision of the graft increases the longevity. We recommend routine use of fistulogram during thrombectomy.
Surgical Management of Cervical Paragangliomas
Authors: Davidovic Lazar , Ilic Nikola , Dimitrijevic Milovan , Đukic Vojko , Dzodic Radan
Published: June 2020

Carotid body tumors are rare, but represent the most common form of head and neck paraganglioma. We present 17 surgically treated patients. The present study reviews our experience in the diagnosis and treatment of these uncommon lesions. At surgery, 11 tumors were classified as Shamblin Class II and six as Class III. A cerebral angiogram was obtained in all cases before surgery. A cervical approach was the method of choice in 16 cases; in one case with mediastinal extension of the tumor we used a combined cervical and transsternal approach. Complete excision of the tumor was accomplished in all cases. Subadventitial tumor excision was performed in eight cases whereas internal carotid artery reconstruction was obtained in eight cases (three saphenous interposition vein grafts, two polytetrafluoroethylene (PTFE) 6 mm grafts, and end-to-end anastomosis in three cases). Resection of the left common carotid artery and reconstruction with a Dacron 8 mm graft was performed in the case with mediastinal tumor extension. Duplex scan along with angiography is effective in making the diagnosis. Excision is indicated for most tumors, and best results are achieved by an experienced vascular surgeon.
Short-Term Outcomes after Unilateral versus Complete Thyroidectomy for Malignancy: A National Perspective
Authors: Zerey Marc , Prabhu Ajita S. , Newcomb William L. , Lincourt Amy E. , Kercher Kent W. , Heniford B. Todd
Published: June 2020

The extent of thyroidectomy for well-differentiated thyroid cancer (WDTC) remains controversial. We compared outcomes of patients undergoing unilateral thyroid lobectomy (UTL) versus complete thyroidectomy (CT) to determine the best operative management of WDTC. We compared outcomes of patients who underwent UTL or CT for malignancy using the 1999 to 2003 editions of the National Inpatient Sample database. A total of 13,854 patients underwent UTL (n = 4,238) and CT (n = 9,616). The CT group was more likely to have complications than the UTL group (15% vs 6%, P < 0.0001). Mean total charges were higher in the CT group ($11,432) versus the UTL group ($9,739), as was LOS (2 days versus 1 day); P < 0.0001. Complete thyroidectomy is associated with increased morbidity, total charges, and length of stay. The higher risk of short-term complications should be considered when considering performing a complete thyroidectomy for WDTC.
Persistent Hyperglycemia in Severe Traumatic Brain Injury: An Independent Predictor of Outcome
Authors: Salim Ali , Hadjizacharia Pantelis , Dubose Joseph , Brown Carlos , Inaba Kenji , Chan Linda S. , Margulies Daniel
Published: June 2020

In patients with severe traumatic brain injury (TBI), admission hyperglycemia is associated with poor outcome. The effect of persistent hyperglycemia (PH) on outcome in severe TBI, however, remains unknown. We performed a retrospective review of all blunt trauma patients with severe TBI (head Abbreviated Injury Score ≥ 3) admitted to the intensive care unit at a Level I trauma center from January 1998 through December 2005. Admission and daily intensive care unit blood glucose levels up to the end of the first week were measured. PH was defined as an average daily blood glucose ≥ 150 mg/dL on all days for the first week of the hospital stay. TBI patients with and without PH were compared with respect to baseline demographics, injury characteristics, and outcomes. Independent risk factors for mortality were identified using logistic regression analysis. One hundred and five (12.6%) out of 834 severe TBI patients had PH. Patients with PH were older, more severely injured, and had worse head injury compared with patients without PH. After adjusting for significant risk factors, PH was identified as an independent risk factor for mortality (odds ratio (OR): 4.91 [95% confidence interval (CI), 2.88–8.56, P < 0.0001]). PH is associated with significantly higher mortality rates in severe TBI patients.
Computed Tomography Grading Systems Poorly Predict the Need for Intervention after Spleen and Liver Injuries
Authors: Cohn Stephen M. , Arango Jorge I. , Myers John G. , Lopez Peter P. , Jonas Rachelle B. , Waite Lindsay L. , Corneille Michael G. , Stewart Ronald M. , Dent Daniel L.
Published: June 2020

Computed tomography (CT) grading systems are often used clinically to forecast the need for interventions after abdominal trauma with solid organ injuries. We compared spleen and liver CT grading methods to determine their utility in predicting the need for operative intervention or angiographic embolization. Abdominal CT scans of 300 patients with spleen injuries, liver injuries, or both were evaluated by five trauma faculty members blinded to clinical outcomes. Studies were graded by American Association for the Surgery of Trauma criteria, a novel splenic injury CT grading system, and a novel liver injury grading system. The sensitivity and specificity of each methodology in predicting the need for intervention were calculated. The kappa statistic was used to determine interrater variability. Twenty-one per cent (39/189) of patients with splenic injuries visible on CT scans required interventions, whereas 14 per cent (21/154) of patients with liver injuries visible on CT required interventions. The overall sensitivity of all grading systems in predicting the need for surgery or angioembolization of the spleen or liver was poor; the specificity seemed to be fairly good. When evaluators were compared, the strength of agreement for the various scoring systems was only moderate. Anatomic CT grading systems are ineffective screening tools for excluding the need for operation or embolization after splenic or hepatic trauma. Although insensitive, CT is a good predictor (highly specific) of the need for intervention if certain definitive abnormalities are identified. Considerable inconsistency exists in interpretation of abdominal CT scans after trauma, even among experienced clinicians.
Lumbar Hernia: Surgical Anatomy, Embryology, and Technique of Repair
Authors: Stamatiou Dimitrios , Skandalakis John E. , Skandalakis Lee J. , Mirilas Petros
Published: June 2020

Lumbar hernia is the protrusion of intraperitoneal or extraperitoneal contents through a defect of the posterolateral abdominal wall. Barbette was the first, in 1672, to suggest the existence of lumbar hernias. The first case was reported by Garangeot in 1731. Petit and Grynfeltt delineated the boundaries of the inferior and superior lumbar triangles in 1783 and 1866, respectively. These two anatomical sites account for about 95 per cent of lumbar hernias. Approximately 20 per cent of lumbar hernias are congenital. The rest are either primarily or secondarily acquired. The most common cause of primarily acquired lumbar hernias is increased intra-abdominal pressure. Secondarily acquired lumbar hernias are associated with prior surgical incisions, trauma, and abscess formation. During embryologic development, weakening of the area of the aponeuroses of the layered abdominal muscles that derive from somitic mesoderm, which invades the somatopleure, may potentially lead to lumbar hernias. Repair of lumbar hernias should be performed as early as possible to avoid incarceration and strangulation. The classic repair technique uses the open approach, where closure of the defect is performed either directly or using prosthetic mesh. The laparoscopic approach, either transabdominal or extraperitoneal, is an alternative.
Selective Laparoscopic Management of Adhesive Small Bowel Obstruction Using CT Guidance
Authors: Lee In Kyu , Kim Do Hyoung , Gorden D. Lee , Lee Yoon Suk , Jung Seung Eun , Oh Seong Taek , Kim Jun-Gi , Jeon Hae Myung , Kim Eung Kook , Chang Suk Kyun
Published: June 2020

Small bowel obstruction after intra-abdominal surgery is a common cause of morbidity necessitating reoperation. The aim of this study was to determine the feasibility of and indications for laparoscopic surgery for acute adhesive small bowel obstruction (AASBO). We conducted a retrospective review of all patients with AASBO who underwent laparoscopic adhesiolysis at a major university medical center. Laparoscopic treatment was performed successfully in 16 patients, and conventional treatment was performed in 13 patients. The rate of conversion from laparoscopic to open was 16.7 per cent. In 15 of 16 total patients who underwent laparoscopic surgery, laparoscopic bandlysis was performed and one patient underwent laparoscopic adhesiolysis. Laparoscopic surgery was performed successfully in nine who had a single adhesive band demonstrated on an abdominal CT, and conventional surgery was performed in all 10 patients without a single adhesive band identified radiographically. Abdominal CT scans facilitate the selection of operative approach for AASBO based on preoperative identification of the obstruction site. Laparoscopic adhesiolysis is a safe and effective treatment modality for patients with AASBO with a single band or single transition zone identified by preoperative imaging.
Retrorectal Tumors: The Choice of Surgical Approach Based on a New Classification
Authors: Pappalardo Giuseppe , Frattaroli Fabrizio M. , Casciani Emanuele , Moles Nicola , Mascagni Domenico , Spoletini Domenico , Fanello Gianfranco , Gualdi Gianfranco
Published: June 2020

Because retrorectal-presacral tumors differ in histologic origin, symptoms, and prognosis, and often involve various neighboring structures, successful treatment of this heterogeneous group of tumors depends on the surgical approach chosen and the specialist surgeons involved. We investigated whether a new classification of retrorectal tumors based on findings from CT and MRI would simplify presurgical planning. The clinical records of a series of 34 patients who underwent surgery for retrorectal tumors from 1989 to 2003 were reviewed. Two radiologists, who were blind to the patients’ records, separately reviewed the preoperative CT and MRI findings and classified tumors according to whether they arose from the presacral area (Group 1), sacrum or spinal cord growing anteriorly (Group 2), or rectum growing posteriorly (Group 3). The preoperative CT and MRI findings for the retrorectal tumors yielded the information required to allow surgery to be properly planned (surgical approach and need to involve various specialist surgeons) in nearly all cases: 17 of the 18 patients (94.5%) with tumors arising from the retrorectal space, all 12 of those with tumors arising from the sacrum or spinal cord, and all four of those with rectal tumors. With the findings yielded by currently available CT and MRI techniques, retrorectal tumors can be anatomically and topographically classified preoperatively so as to allow surgery to be adequately planned in advance and thus optimize the surgical resection.
The Changing Face of Trauma: New Orleans before and after Hurricane Katrina
Authors: Wahl Georgia M. , Marr Alan B. , Brevard Sidney B. , Weintraub Sharon L. , Hunt John P. , Mcswain Norman E. , Duchesne Juan C. , Baker Christopher C.
Published: June 2020

Charity Hospital (CH) was devastated by Hurricane Katrina and remains closed. Design and staffing of a new, temporary dedicated trauma hospital relied on data from prior experience at CH, updated census information, and a changed trauma demographic. The study objective was to analyze the new trauma program and evaluate changes in demographics, injury patterns, and outcomes between pre- (PK) and post-Katrina (POK) trauma populations. A retrospective review of trauma patients’ demographics, anatomical variables, and physiological variables 6 months PK and POK was performed under an approved Institutional Review Board protocol. Trauma activation triage criteria between study periods were also analyzed. Continuous data comparisons between the two time periods were made with Student's t test. Dichotomous data were analyzed using χ2 test. The demographic of trauma patients is different in the POK interval, reflecting changes in the New Orleans population. Modification of triage criteria by the exclusion of mechanism as an activation criterion resulted in an increase of patients with higher acuity and Injury Severity Score, lower initial Glasgow Coma Score, and a higher proportion of penetrating mechanism. Outcome measures reflect longer length of stay (4.4 vs 6.8 days, P < 0.0001) without a significant difference in mortality (6.0 vs 7.5, P = 0.227). Hospital data demonstrates that the POK trauma system was stressed by the increased acuity, penetrating injury, and number of procedures per patient (1.7 vs 3.4). Resources should be directed toward patients requiring multidisciplinary care by increasing intensive care unit beds and operating room capacity. Future resource planning in the recovery phases of large-scale natural disasters should take into account these observations.
Acute Adrenal Insufficiency May Affect Outcome in the Trauma Patient
Authors: Guillamondegui Oscar D. , Gunter Oliver L. , Patel Shivani , Fleming Sloan , Cotton Bryan A. , Morris John A.
Published: June 2020

Acute adrenal insufficiency in the trauma patient is underrecognized and the impact poorly understood. Our hypothesis was that the identification and treatment of acute adrenal insufficiency reduces mortality in trauma patients. Institutional Review Board approval for the retrospective review of a prospective database from a Level 1 trauma center for 2002 to 2004 was obtained. The study population included patients receiving a cosyntropin stimulation test (250 μg) and/or random Cortisol level based on our practice management guideline and an intensive care unit stay longer than 24 hours. Demographic, acuity, and outcome data were collected. The nonresponders had baseline Cortisol levels less than 20 μg/dL or poststimulation rise less than 9 μg/dL. Independent t tests and χ2 statistics were used. One hundred thirty-seven patients had cosyntropin stimulation tests performed. Eighty-two (60%) patients were nonresponders of which 66 were treated with hydrocortisone and 16 went untreated as a result of the discretion of the attending physician. The 55 (40%) responders showed no statistical differences in outcome variables whether or not they received hydrocortisone. The untreated adrenal-insufficient patients had significantly higher mortality, longer hospital length of stay, intensive care unit days, and ventilator-free days. Conclusions were: 1) treatment of acute adrenal insufficiency reduces mortality by almost 50 per cent in the trauma patient; and 2) acute adrenal insufficiency recognized by low random Cortisol levels or nonresponse to a stimulation tests should be considered for treatment.
Liver Transplantation for Iatrogenic Porta Hepatis Transection
Authors: Zaydfudim Victor , Wright J. Kelly , Pinson C. Wright
Published: June 2020

Iatrogenic porta hepatis transection is a rare but devastating surgical complication. There are no systematic studies examining the best treatment strategy in patients with this injury. We report two cases of transection of all three portal structures, one during an open right adrenalectomy and another during a laparoscopic cholecystectomy, both of which were transferred to our tertiary care center hours postinjury. Diagnostic imaging and exploration revealed nonsalvageable livers, and both patients underwent total hepatectomies and portocaval shunting. Donor livers were available 12 to 20 hours after United Network for Organ Sharing Status 1 listing and both patients survived their postoperative course with 2- and 6-year follow up to date. Two-stage total hepatectomy with portocaval shunting followed by liver transplantation should be considered for patients presenting with porta hepatis transection.
The Lateral Paramedian: Revisiting a Forgotten Incision
Authors: Hughes Kenneth , Selim Niazy M.
Published: June 2020

Incisional hernia is a potential complication of all abdominal incisions and still remains a significant problem financially and medically. Presently, there is a lack of general consensus among surgeons in regard to the optimal treatment. The midline incision is the most common used abdominal incision and it carries a high incidence of incisional hernia (up to 15%). The paramedian incision was known to lead to a small incidence of incisional hernias. This discussion is meant to bring the paramedian incision back to the picture as a hope to decrease the incidence of incisional hernia.
Article Commentary: Symptomatic Splenomegaly in Polycythemia Vera: A Review of the Indications for Splenectomy and Perioperative Considerations
Authors: Logan Melissa S. , Watson Christopher M. , Nottingham James M.
Published: June 2020

Polycythemia vera is a condition that surgeons do not commonly encounter. Advances in medical management have largely led to avoidance of surgical intervention in most patients. Indications and timing of splenectomy have been the subject of debate since the disease was first described in the late 19th century. Though anemia and thrombocytopenia associated with polycythemia vera only transiently respond to splenectomy, painful splenomegaly with infarction or compression of surrounding viscera are presently accepted indications for surgery. Special consideration must be given to polycythemia vera patients both preoperatively and postoperatively due to altered coagulation and anatomy. We present a review of the pathophysiology, medical treatment, indications for surgical intervention, and perioperative considerations for polycythemia vera.
Pneumomediastinum in the Injured Patient: Inconsequential or Predictive?
Authors: Macleod Jana B. A. , Tibbs Brian M. , Freiberger Doug J. , Rozycki Grace S. , Lewis Fran , Feliciano David V.
Published: June 2020

Free air in the peritoneum is a portent of significant pathology in the patient with abdominal trauma. The finding of a pneumomediastinum (PM) on a thoracic computed tomography scan (CT) of a trauma patient is, however, not clinically well-defined. The objectives of this study were to evaluate the incidence, pattern, and outcome of CT-diagnosed PM in a cohort of injured patients. The trauma registry and radiology reports were reviewed retrospectively for all injured patients admitted over an 8-year period to determine the incidence of PM. Medical and radiological records of patients with a PM on thoracic CT were then reviewed to determine the pattern and outcome of the injuries. There were 1364 thoracic CTs performed in the study-period. The prevalence of PM was 5.2 per cent (71/1364). For the cohort of patients with a PM, the mean age was 34.8 years, and 14.7 per cent (10/68) had penetrating injuries. Of these 68 patients, 10.3 per cent (7/68) presented with nine clinically significant injuries to the esophagus, trachea, larynx, or bronchus. These injuries were suspected clinically by an associated open wound or significant symptoms, and only 5.8 per cent of (4/68) patients required surgical repair. The remaining 89.7 per cent (61/68) of patients with a PM did not develop any sequelae nor require further directed treatment. A finding of a pneumomediastinum on a thoracic CT in injured patients is rare and clinically nonspecific. Pneumomediastinum alone does not seem to be predictive of severe injury and warrants detailed investigation only when clinical symptoms are present.
Epidemiology of Sternal Fractures
Authors: Recinos Gustavo , Inaba Kenji , Dubose Joseph , Barmparas Galinos , Teixeira Pedro G. R. , Talving Peep , Plurad David , Green Donald , Demetriades Demetrios
Published: June 2020

The epidemiology of sternal fractures has been poorly described. The objective of this study was to examine the demographics, outcomes and injuries associated with sternal fractures. The trauma registry at a level I trauma center was retrospectively reviewed to identify all patients with sternal fractures over a 10 year period. Demographic data collected included age, gender, mechanism of injury and injury severity score. Patients were analyzed according to age ≤ 55 or > 55 years. During the 10-year study period, a total of 37,087 patients were admitted to the emergency department. Of these, 125 (0.33%) had a sternal fracture. The average age was 44 ± 17 years, with 76.0 per cent being male. The most common mechanism of injury was motor vehicle collision (68%) followed by auto vs. pedestrian (18%). Associated rib fractures occurred in 49.6% of the population, cardiac contusions in 8.0%, thoracic aortic injuries in 4.0 per cent and heart lacerations in 2.4 per cent of patients. Associated rib fractures were more likely to occur in patients over the age of 55 (66.7% vs 44.2%, P = 0.032) as well as a traumatic hemothorax (15.8% vs 40.0%, P = 0.005). However, no significant difference in mortality was observed between the two age groups (16.8% vs. 26.7%, OR: 0.56, 95% CI, 0.21 to 1.47; P = 0.234). Sternal fractures are a rare sequela of blunt trauma. Associated injuries are common, including rib fractures and soft tissue contusions. Associated cardiac and aortic injuries are rare but highly lethal and should be screened for on the initial chest CT scan. After appropriate exclusion of associated injuries, the majority of patients diagnosed with a sternal fracture following blunt trauma can be safely discharged to home.
Article Commentary: Surgical Prophylaxis for Inheritable Malignant Diseases: Colorectal and Gastric Cancer
Authors: Benns Matthew V. , Luk Tammy , Scoggins Charles R.
Published: June 2020

Despite advances in modern medicine, cancer remains all too common and deadly. At its core, cancer is a disease of our DNA. As such, many cancers are passed from parents to children, making cancer one of the most commonly inherited diseases. Presently, we have no meaningful methods of “preventing” the malignant transformation that occurs as a result of an inherited gene, but investigators have identified several genetic mutations and subsequently developed risk-reduction strategies that sometimes involve surgery.
Endoscopic Retrograde Cholangiopancreatography Gut Perforations: When to Wait! When to Operate!
Authors: Morgan Katherine A. , Fontenot Bennett B. , Ruddy Jean M. , Mickey Suzanne , Adams David B.
Published: June 2020

Most perforations of the gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) can be managed nonoperatively. Identifying patients who require operative management is problematic. A clinical endoscopy database was queried for patients who sustained ERCP perforation over a 13-year period. Records were reviewed and analyzed with approval of the Institutional Review Board. During the study period, 12,817 patients underwent ERCP; 24 (0.2%) had an endoscopic perforation. Twelve patients had a retroperitoneal perforation during sphincterotomy and all were successfully managed nonoperatively. Nine of these were undergoing treatment for sphincter of Oddi dysfunction. Twelve patients had perforation remote from the papilla. Of these, 10 required surgical intervention. Six patients had surgically altered anatomy (three postpancreaticoduodenectomy, three post-Billroth II gastrectomy) and one had situs inversus. Six of these seven required surgical intervention. Median length of stay of all patients was 7.5 days, morbidity was 25 per cent, and one patient died 16 days after surgery. Gut perforation after ERCP requires prompt surgical evaluation. Patients with sphincterotomy-related retroperitoneal perforation can be managed safely with nonoperative therapy in most instances. Patients with remote perforation usually need surgical intervention. Altered foregut anatomy leads to injuries that usually require operative management.
Patterns of Breast Cancer Presentation in the United States: Does Geography Matter?
Authors: Sariego Jack
Published: June 2020

Distribution of breast cancer varies widely throughout the United States. The factors that influence this geographic variability have not been completely defined. In addition, though a number of studies look at regional and state-to-state variability, few studies have examined this issue with regard to the nation as a whole. State-specific breast cancer data were available from the American College of Surgeons National Cancer Data Base in a series of Benchmark Reports. These data were reviewed and stratified with regard to: age at the time of presentation, race, and stage at the time of presentation. The data were further collected into regional cohorts that corresponded to the United States Census Bureau regions. Statistical analyses were then performed to identify any linked or related variables. A total of 811,652 patients with breast cancer were reported. There was a statistically significant relationship between stage at the time of presentation and census region. The greatest percentage of early-stage disease was recorded in the Northeast and the lowest in the South. There was no significant association between age at presentation and geographic region, but there was a significant relationship between race and stage. The nonwhite subgroup had a greater percentage of patients presenting with advanced-stage disease. Finally, regions with a larger percentage of nonurban population had a higher percentage of later-stage disease at presentation. A relationship exists between the pattern of breast cancer presentation and geographical location within the United States. The Northeast–with the highest percentage of urban areas and white population–reported the highest percentage of early-stage breast cancer at presentation, suggesting a link between these variables. Conversely, the South–with more rural and nonwhite population–had the highest percentage of later-stage disease. The causal relationships are not clear-cut, however, and the relationship between geography and breast cancer presentation is likely multifactorial. Further analysis is indicated to uncover any link between geographic variability and overall breast cancer treatment and survival.
Impact of Sentinel Lymph Node Biopsy on Immediate Breast Reconstruction after Mastectomy
Authors: Wood Benjamin C. , David Lisa R. , Defranzo Anthony J. , Stewart John H. , Shen Perry , Geisinger Kim R. , Marks Malcolm W. , Levine Edward A.
Published: June 2020

Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.
Laparoscopic Rapid Totally Diverting Loop Colostomy: A New Twist on an Old Technique
Authors: Zarour Ahmad , Abdulrahman Husham , Maull Kimball I. , Almusleh Abdulwahab
Published: June 2020

A minimally invasive variation of an established technique of colostomy is described. The method was originally published in 1977. In a setting where traditional celiotomy is not required, three ports are placed with the left lateral port used for the stoma. After initial peritoneal inspection, the colon segment and its mesentery are identified. A suture is passed forming a loop through the end of a soft latex drain, which is passed into the peritoneal cavity. Using the Goldfinger® instrument, the mesentery is breached and the loop end of the drain is snared and brought back through the mesenteric defect. This maneuver enables the colon to be retracted through the port site for completion of the colostomy. Inserting the finger along the loop provides proximal and distal visual confirmation. The colon is stapled but not divided. Maturation of the stoma may be done immediately or delayed depending on the clinical circumstances.
Intraoperative Imprint Cytology for Evaluation of Sentinel Lymph Nodes from Merkel Cell Carcinoma
Authors: Wong S. Lindsey , Young Yorke D. , Geisinger Kim R. , Shen Perry , Stewart John H. , Sangueza Omar , Pichardo-Geisinger Rita , Levine Edward A.
Published: June 2020

Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous malignancy. Intraoperative imprint cytology (IIC) can potentially avoid second operations for completion lymphadenectomy when nodal metastases are found during nodal staging with sentinel lymph node biopsy (SLN). This represents the first series of IIC for MCC we are aware of and our initial experience. Patients with biopsy-proven MCC underwent SLN (at the time of wide excision) using a double indicator technique with “technetium sulfur colloid and isosulfan blue. SLN were identified and bisected and touch imprints of each half were made. One half was air-dried and stained with Diff-Quick and the other was fixed with 95 per cent alcohol and stained with hematoxylin and eosin (H&E). Paraffin-embedded sections were examined by H&E. Eighteen patients underwent successful SLN mapping procedures. IIC was negative in 84.2 per cent (16) cases. Three false-negatives occurred with IIC, but there were no false-positives, making the sensitivity 33 per cent and the specificity 100 per cent. Two of four patients with positive pathology-confirmed SLN also had positive IIC. SLN mapping has usefulness in patients with MCC. IIC is feasible and accurate in evaluating the SLN. IIC is a practical diagnostic tool when intraoperative analysis of SLN biopsy is desired for MCC.
Comparison between Laparoscopic Paraesophageal Hernia Repair with Sleeve Gastrectomy and Paraesophageal Hernia Repair Alone in Morbidly Obese Patients
Authors: Merchant Aziz M. , Cook Michael W. , Srinivasan Jahnavi , Davis S. Scott , Sweeney John F. , Lin Edward
Published: June 2020

Treatment options for morbidly obese patients with complications from large paraesophageal hernias (PEH) are limited. Simple repair of the PEH has a high recurrence rate and may be associated with poor gastric function. We compared a series of patients who underwent repair of large PEH plus gastrostomy tube gastropexy (PEH-GT) with PEH plus sleeve gastrectomy (PEHSG). Retrospective review of patients undergoing PEH-SG and patients with PEH-GT was performed. We assessed symptoms of delayed gastric emptying and reflux postoperatively. In selected patients, gastric-emptying studies and upper gastrointestinal contrast studies were also obtained. All patients with large PEH were repaired laparoscopically with sac resection, primary crural closure using pledgeted sutures, and biologic patch onlay. SG for patients undergoing concomitant weight loss surgery (PEH-SG) was performed with linear endoscopic staplers and staple line reinforcement. Patients undergoing PEH repair alone had a gastrostomy tube gastropexy (PEH-GT). Patients had intraoperative endoscopic evaluation and postoperative contrast swallow studies. In a 12-month period, five patients underwent laparoscopic PEH-SG; two of five had previous antireflux surgery and one of five with a previous diagnosis of delayed gastric emptying. Postoperatively, two patients undergoing PEH-SG had readmission for dehydration and odynophagia. Six-month follow-up body mass index was 32 kg/m2 for the PEH-SG group with no hernia recurrence and complete resolution of gastroesophageal reflux disorder symptoms. Six patients underwent PEH-GT, one for acute incarceration and anemia and four with previous antireflux surgery. Follow up at 8 months demonstrated one recurrence, four of six had severe delayed gastric emptying and reflux, three of six had additional hospitalization for poor oral intake, and three of six underwent reoperation for delayed gastric emptying. There were no perforations, leaks, or deaths in either group. Combined laparoscopic PEH-SG is a clinically reasonable option for patients with morbid obesity with minimal additional risks and decreased incidence of delayed gastric emptying, reflux, and reoperation.
Endoscopic Retrograde Cholangiopancreatography and Histopathology Correlation for Chronic Pancreatitis
Authors: Vitale Gary C. , Davis Brian R. , Zavaleta Carlos , Vitale Michael , Fullerton James K.
Published: June 2020

Endoscopic retrograde cholangiopancreatography (ERCP) is debated as the gold standard for diagnosing and staging chronic pancreatitis (CP). The Cambridge classification grades CP on ECRP findings from normal (Grade I) to marked (Grade V). Comparison is needed with histopathology, which is considered the true gold standard to set the accuracy of any diagnostic test. A retrospective study included patients with CP who underwent ERCP and histopathology examination after surgical resection between 2001 and 2006. ERCP findings were staged according to the Cambridge classification. Thirty-one patients underwent initial diagnostic ERCP and surgical resection for chronic pancreatitis between 2001 and 2006 (61% women, 39% men). Patients with CP were diagnosed based on ERCP findings and the Cambridge classification as having normal (2 of 31 [6.5%]), equivocal (4 of 31 [13%]), mild (3 of 31 [9.7%]), moderate (15 of 31 [48%]), and marked (7 of 31 [23%]) pancreatitis. Patients experienced a mean of 5.5 ERCPs with pancreatic duct stenting before surgery and demonstrated a mean time of 25 months (range, 6 months to 3 years) between initial diagnosis and surgery. Surgeries for chronic pancreatitis included 13 (42%) subtotal pancreatectomies, 10 (32%) Whipples, and 8 (26%) distal pancreatectomies. The ERCP findings and histopathology reports correlated in 23 (74%) patients, whereas in eight (26%), findings did not correlate. The early disease group's (9 of 31 classified as normal, equivocal, or mild) ERCP findings correlated with histopathology in 6 of 9 patients (67%). Patients classified as moderate and marked had a correlation of 17 of 22 (77%). ERCP demonstrates a high correlation with pathology for assessing the severity of CP using the Cambridge classification grading system. Patients with normal, equivocal, or mild disease still represent a difficult patient subset for surgical decisionmaking. ERCP findings accurately predict pathology and thus should be used to help formulate the surgical plan.