bluuebunny/crossref_metadata_2025 huggingface dataset:
Prophylactic Inferior Vena Cava Filter Insertion for Trauma: Intensive Care Unit versus Operating Room
Authors: Gonzalez Richard P. , Cohen Mabelle , Bosarge Patrick , Ryan Jeffrey , Rodning Charles
Published: June 2020

The frequency of insertion of prophylactic inferior vena cava filters (IVCF) among traumatized patients has increased nationally. That has placed a substantial operational and economic burden upon trauma centers. The purpose of this study was to compare and contrast successful implantation, morbidity, and cost-effectiveness of prophylactic IVCF insertion in a surgical-trauma intensive care unit (STICU) versus an operating room (OR). A retrospective chart review was conducted of all trauma patients who received a prophylactic IVCF at an urban Level I trauma center between January 1999 and December 2003. Data were collected to identify patient demographics, indications, anatomical site of insertion, hospital location of insertion, hospital days before insertion, and complications associated with insertion. One hundred thirty-four patients underwent prophylactic IVCF during the study period: seventy-eight (58%) in the OR and fifty-six (42%) in the STICU. The average age of patients for the OR and STICU groups were 38.6 years and 39.6 years, respectively. The average number of days to IVCF insertion was 6.5 days and 7.0 days in the OR and STICU groups, respectively. Indications for IVCF among patients who had placement in the OR were orthopedic injury (60%), spinal cord injury (25%), and head injury (15%). Indications for IVCF among patients who had placement in the STICU were head injury (38%), orthopedic injuries (34%), and spinal cord injury (25%). Three (3.8%) patients in the OR group and two (3.6%) patients in the STICU group required a change of anatomic insertion site from the femoral to the internal jugular vein. There were two (2.6%) complications associated with IVCF insertion in the OR and two (3.5%) complications associated with IVCF insertion in the STICU (P > 0.05). Insertion of IVCF in the STICU decreased patient-cost by an average of $1636 per patient. Prophylactic IVCF insertion in an STICU is cost-effective and can be performed with similar success and complication rates to IVCF insertion in an OR.
Trauma Nurse Specialists’ Performance of Advanced Skills Positively Impacts Surgical Residency Time Constraints
Authors: Kendrick Aaron S. , Ciraulo David L. , Radeker Theresa S. , Lewis Patricia L. , Richart Charles M. , Maxwell Robert A. , Barker Donald E. , Smith Philip W.
Published: June 2020

The Accreditation Council for Graduate Medical Education imposed 80-hour work week constraints on residency programs in July 2003. Certain programs were granted an additional 10 per cent for specific educational purposes, bringing restrictions to 88 hours per week. The increased demand for residents to leave the hospital has placed teaching institutions in exhaustive situations to provide comprehensive patient care. In response to the work hour constraints among residents and emergency room staff, a unique group of registered nurses, trauma nurse specialists (TNSs), were credentialed with advanced practice skill sets. Governed by practice guidelines and overseen by a medical director, TNSs perform invasive procedures that are normally the responsibility of the surgical resident. The purpose of this study was to evaluate work hours saved for surgery residents using credentialed nurses (TNSs). Procedure logs were maintained by the TNSs over a 6-month period, and surgical house staff (postgraduate year 1–3) over a 4-month period. A total of 423 procedures were recorded, reflecting time taken for attempted/completed procedures and complications. Resident procedures numbered 98; TNS procedures numbered 325. TNSs spent an average of 42 hours per month (10.6 hours per week) completing advanced procedures with no statistical difference in time or complications compared with surgical residents. By using the TNSs, work hours for surgery residents were saved while maintaining a safe and reliable work atmosphere for patients.
Dynamic Self-Regulating Prosthesis (Protesi Autoregolantesi Dinamica): The Long-Term Results in the Treatment of Primary Inguinal Hernias
Authors: Valenti Gabriele , Baldassarre Emanuele , Testa Alessandro , Arturi Alessandro , Torino Giovanni , Campisi Costantino , Capuano Giorgio
Published: June 2020

The dynamic self-regulating prosthesis (protesi autoregolantesi dinamica, PAD) is a double-layered prosthesi, in use since 1992 in inguinal hernia repair. In 1999, we published the short-term results on 500 patients and herein we report the long-term follow-up. Five hundred eighty-five PAD procedures were performed on 500 adult male, unselected patients. Hernias were unilateral in 415 patients, were bilateral in 85 patients, were direct in 197 patients (33.7%), were indirect in 269 patients (46.0%), and were combined in 119 patients (20.3%). Four hundred sixty-four patients were alive at the follow-up period of minimum 5 years, whereas 36 died (7.2%) of causes unrelated to the hernia. No information was available on 73 patients (14.6%). Therefore, the follow-up was consisted of 391 patients (78.2%) with 469 hernias. The recurrence and testicular atrophy rates were nil. Three patients (0.77%) presented chronic pain and 18 (4.6%) suffered persistent discomfort or paresthesia. A hydrocoele was observed in one patient (0.2%). The long-term data confirm the efficacy of the dynamic self-regulating posthesis hernioplasty. We propose it as a standard of care in all cases of primary inguinal hernia in adult males, retaining it as a definitive and comfortable solution.
Total Pancreatectomy for the Treatment of Chronic Pancreatitis: Indications, Outcomes, and Recommendations
Authors: Behrman Stephen W. , Mulloy Matthew
Published: June 2020

Total pancreatectomy (TP) for chronic pancreatitis (CP) has not gained widespread acceptance because of concerns regarding technical complexity, diabetic complications, and uncertainty with respect to long-term pain relief. Records of patients having TP from 1997 to 2005 were reviewed. Patient presentation, etiology of disease, and the indication for TP were examined. Operative results were analyzed. Long-term results were critically assessed, including narcotic usage and the need for re-admission. Postoperative quality of life (QOL) was assessed by the SF-36 health survey. During the study period, 7 patients with CP had TP, and 28 had other operations. The etiology of CP was alcohol in four and hereditary pancreatitis in three. The indication for surgery was pain and weight loss. Preoperatively, all patients used narcotics chronically and two had insulin-dependent diabetes. Four had TP after failed previous surgical procedures. Endoscopic retrograde cholangiopancreatography and computed tomography demonstrated small ducts and atrophic calcified glands. The mean length of the operation was 468 minutes, and only two patients required transfusion. There were no biliary anastomotic complications. The mean length of stay was 14 days. Major morbidity was limited to a single patient with a leak from the gastrojejunal anastomosis. Thirty-day mortality was zero, with one late death unrelated to the surgical procedure or diabetes. The mean length of follow-up was 46 months. All patients remained alcohol and narcotic free. No patient was readmitted with a diabetic complication. When compared with the general population, QOL scores were diminished but reasonable. We conclude that TP is indicated in hereditary pancreatitis and in those with an atrophic, calcified pancreas with small duct disease; that TP is technically arduous but can be completed with very low morbidity and mortality; and that on long-term follow-up, pain relief and abstinence from alcohol and narcotics was excellent with an acceptable QOL.
Rib Fracture Stabilization in Patients Sustaining Blunt Chest Injury
Authors: Nirula Ram , Allen Brian , Layman Ralph , Falimirski Mark E. , Somberg Lewis B.
Published: June 2020

Conservative management for the majority of patients with severe chest injuries has produced a reduction in mortality, complications, and hospital length of stay. More recently, operative stabilization of rib fractures has been used with the implication of improved outcome. We assessed the impact of operative rib fracture stabilization on outcome among trauma patients. A matched case-control study of patients undergoing operative rib fracture stabilization was performed. Thirty patients undergoing rib stabilization were matched with 30 controls. Length of intensive care unit (controls, 14.1 ± 2.7 vs cases, 12.1 ± 1.2, P = 0.51) and total hospital (controls, 21.1 ± 3.9 vs cases, 18.8 ± 1.8, P = 0.59) stay were similar for both groups. There was a trend toward fewer total ventilator days for operative patients (6.5 ± 1.3 days vs 11.2 ± 2.6 days, P = 0.12). Ventilator days for operative patients from the time of stabilization was 2.9 ± 0.6 days compared with 9.4 ± 2.7 days in controls (P = 0.02). Rib fracture fixation may reduce ventilator requirements in trauma patients with severe thoracic injuries. Long-term functional outcomes need to be assessed to ascertain the impact of this procedure.
Increased Use of Computed Tomography Does Not Harm Patients with Acute Appendicitis
Authors: Menes Tehillah S. , Aufses Arthur H. , Rojas Mary , Bickell Nina A.
Published: June 2020

The increased use of computed tomography (CT) in patients with appendicitis may cause a delay in surgery and, therefore, higher perforation rates. We examined the use of CT, delay in time to surgery, and perforation rates in appendicitis patients operated on in two periods: Phase 1, 1996 through 1998 and Phase 2, 2001 through 2002. CT was performed in 18 per cent of the Phase 1 group compared with 62 per cent in the Phase 2 group. In the Phase 1 group, patients undergoing CT had a delay to surgery compared with those without CT (18.6 hours vs 7 hours; P < 0.0001). In the Phase 2 group, time to surgery was reduced (median time = 12 hours with CT vs 6 hours without CT; P < 0.001). CT was more accurate in the later group; there were less false-negative and equivocal studies. There was no difference in perforation rates between the Phase 1 and 2 groups. Over time, the increased use, efficiency, and accuracy of CT in patients with acute appendicitis were associated with reduced delays to surgery. The use of CT did not harm patients, but did not translate to better overall outcomes in this group of patients.
Reversible Gastroparesis: Functional Documentation of Celiac Axis Compression Syndrome and Postoperative Improvement
Authors: Trinidad-Hernandez Magdiel , Keith Phillip , Habib Ibrahim , White John V.
Published: June 2020

Celiac axis compression syndrome has generated much controversy since its original description in 1963. The main symptoms are postprandial epigastric abdominal pain, regurgitation of undigested food, and weight loss, all of which are caused by gastric ischemia from impingement of the celiac axis by the median arcuate ligament of the diaphragm. These symptoms are seen in other common disorders such as chronic mesenteric ischemia and gastroparesis. This makes the diagnosis of celiac axis compression syndrome a true challenge for the clinician. We present data on three patients successfully treated. The pre- and postoperative studies clearly demonstrate a resolution of the condition. The duplex ultrasound images clearly show variable compression on the celiac axis. The angiogram presented shows a classic image of the disease. A review of the data has enabled us to develop an algorithm for the diagnosis of this disease.
Carcinosarcoma of the Pancreas Arising in a Mucinous Cystic Neoplasm
Authors: Bloomston Mark , Chanona-Vilchis Jose , Ellison E. Christopher , Ramirez Nilsa C. , Frankel Wendy L.
Published: June 2020

We report a carcinosarcoma of the pancreas in a 67-year-old woman who presented with nausea, vomiting, and painless jaundice. A work-up demonstrated a well-circumscribed mass in the head of the pancreas. After pylorus-preserving pancreaticoduodenectomy, the tumor was found to be grossly yellow, and it compressed the common bile duct and pancreatic duct. Histological examination of the neoplasm showed a 4.0 x 4.0 x 3.0-cm mucinous cystadenocarcinoma with invasive poorly differentiated carcinoma, well-differentiated squamous cell carcinoma, and sarcomatous stroma invading into the duodenum. There was no evidence of nodal metastasis (pT3N0M0). Immunohistochemical studies showed that the epithelial cells stained positive for cytokeratin 7, cytokeratin AE1/3, cytokeratin monoclonal antibody 5.2, epithelial membrane antigen, M-carcinoembryonic antigen, and low-molecular-weight kininogen, and the sarcomatous component was immunoreactive with vimentin. The patient had an uneventful recovery, but died 4 months later of rapidly progressive metastatic disease to the liver and peritoneum. To the best of our knowledge, this is the second case of carcinosarcoma with invasive epithelial and sarcomatous areas in the background of a mucinous cystic neoplasm of the pancreas.
Cecal Volvulus in a Child with CHARGE Syndrome
Authors: Lai Hong-Shiee , Feng Chi-Yen
Published: June 2020

Cecal volvulus occurring in a child with CHARGE syndrome is presented. This boy was known to have CHARGE syndrome with multiple congenital anomalies, including coloboma, ventricular septal defect, choanal atresia, growth and mental retardation, bilateral cryptorchidism, dysplasia of the right ear, cleft lip, and hydrocephalus. Nissen's fundoplication had been previously performed for severe hiatal hernia and gastroesophageal regurgitation at the age of 1 year. Cecal volvulus occurred with a 540-degree clockwise rotation of terminal ileum to the right transverse colon and a displacement of the rotated loop to the right upper quadrant of the abdomen when he was 10 years old. Right hemicolectomy with divided ileo- and colostomy was performed. A second staged ileocolostomy was performed uneventfully 3 months later. The midline structural defects with nonfixation of the cecum and ascending colon, chronic constipation, and previous abdominal surgery might have been the predisposing factors.
Nonoperative Management of Spontaneous Splenic Rupture in Infectious Mononucleosis: The Role for Emerging Diagnostic and Treatment Modalities
Authors: Brichkov I. , Cummings L. , Fazylov R. , Horovitz J.H.
Published: June 2020

Infectious mononucleosis (IM) is a self-limiting lymphoproliferative disorder affecting teenagers and young adults. Splenomegaly is a common manifestation of IM and results in a compromised organ that may rarely rupture spontaneously, with significant morbidity and mortality. The IM spleen should be protected from even minor trauma. Although traditional management of spontaneous splenic rupture in IM has been splenectomy, the role of nonoperative management is evolving. The advent of endovascular interventional modalities has augmented the physician's armamentarium in managing these patients nonoperatively. We report a case of spontaneous splenic rupture in a patient with IM managed conservatively with the aid of splenic angiography. The option of arteriography, with or without embolization, should be considered in the management of all patients with spontaneous splenic rupture in the setting of IM.
Correlation between Clinical and Histological Findings in Parathyroid Tumors Suspicious for Carcinoma
Authors: Chang Yeon-Jeen , Mittal Vijay , Remine Stephen , Manyam Harish , Sabir Mubashir , Richardson Todd , Young Shun
Published: June 2020

Carcinoma of the parathyroid is a rare malignancy that can be cured surgically if the proper diagnosis and treatment is given initially. Arriving to the clinical suspicion of a malignancy preoperatively is by far the most important step for a good prognosis. Our goal is to review the correlation between clinical and final histopathological findings that can arouse the suspicion of such malignancy and their true predictive value in the diagnosis. All patients that underwent surgical removal of the parathyroid mass between March of 1992 and March of 2003 were reviewed retrospectively at Providence Hospital and Medical Centers. Among 168 patients who underwent parathyroid excision, 14 (8.3%) had hyperplasia of the parathyroid, 121 (72%) had benign adenoma, 25 (14.8%) had other benign lesions, and 8 (4.7%) patients had primary carcinoma of the parathyroid confirmed by pathology. Our mean serum calcium level was 11.57 mg/dL, which was lower than the mean level (12 mg/dL) for benign hyperparathyroidism. The mean tumor size was 2.18 cm, smaller than the proposed for malignant criteria, and none of the eight patients (0%) had any symptoms of hypercalcemia at the time of diagnosis. Seven of eight patients (87.5%) had frank signs of invasion together with other histological features, and two patients had associated papillary carcinoma of the thyroid. Five patients from our series did not meet clinical criteria for malignancy (tumor size > 3 cm, palpable mass, and serum calcium > 14 mg/dL), but had undisputable histological findings (high mitotic pattern, fibrous trabeculae, capsular invasion, vascular invasion, and nodular involvement). On the other hand, 17 patients with benign histology had tumors greater than 3 cm, and an additional 18 had palpable masses on physical examination. We believe that these patients need to be followed closely. The patients with diagnosis of parathyroid carcinoma, their kindred, and those with large adenomas may benefit from genetic screening for HRTP2 gene mutations in search of early detection of tumors suspicious for malignancy. This is based on the fact that we did not find correlation between the clinical presentation and the histological features in our patients with proven malignancy.
Pancreaticoduodenectomy after Neoadjuvant Therapy in a Jehovah's Witness with Locally Advanced Pancreatic Cancer: Case Report and Approach to Avoid Transfusion
Authors: Magner David , Ouellette James R. , Lee Joseph R. , Colquhoun Steven , Lo Simon , Nissen Nicholas N.
Published: June 2020

Although the morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, perioperative transfusions are often needed. Here, we review the preoperative planning and overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion. Management of this case is reviewed, along with the relevant literature regarding major surgery in the Jehovah's Witness population. The use of neoadjuvant chemoradiation was used successfully in locally advanced disease, allowing surgical resection. In addition, we outline a cogent strategy using pre-, intra-, and postoperative techniques to minimize blood loss and maintain hemoglobin at acceptable levels thereby preventing the need for transfusion. These strategies, once in place, may be able to reduce transfusions in all patients having major resections for malignancy.
Prognostic Importance of Sclerosing Variant in Papillary Thyroid Carcinoma
Authors: Falvo Laura , Giacomelli Laura , D'Andrea Vito , Marzullo Antonella , Guerriero Gabriella , De Antoni Enrico
Published: June 2020

The diffuse sclerosing variant (DSV) of papillary thyroid carcinoma is known for its high aggressiveness, high incidence of lymph node metastases, and high incidence of pulmonary metastases, and thus its consequently poorer prognosis. In this study, we undertook a retrospective analysis of papillary thyroid carcinomas to assess whether DSV can be considered a predictive factor for prognosis. We performed a retrospective evaluation of the Department's database of patients with papillary thyroid carcinoma who had undergone total thyroidectomy from January 1992 to December 2000. Group I consisted of 83 DSV patients and Group II was 168 pure papillary carcinoma (PC) patients. A significant prevalence of multinodular thyroid disorder on diagnosis was found for PC (P < 0.05), whereas with DSV, there was a significantly higher prevalence of post-thyroiditis nodular thyroid disorder than with PC (P < 0.001). The incidence of laterocervical lymph node pathology on diagnosis was significantly higher for DSV (P < 0.05). In 3.6 per cent of PC patients and 15.7 per cent of DSV patients, we observed recurrences in the regional lymph nodes (P < 0.001). We found 1.2 per cent distant metastases in PC patients and 7.2 per cent in DSV patients (P < 0.05). One PC patient (0.6%) and three DSV patients (3.6%) died of tumor-related causes (P < 0.05). Our study demonstrated that diffuse sclerosing carcinoma leads to a poorer prognosis to the extent that its classification as an autonomous clinical pathological entity is justified. In conclusion, we can state that DSV is a form of papillary thyroid tumor characterized by its higher aggressiveness, diffuse intrathyroid growth, and high incidence of lymph node and pulmonary metastasis. Ultimately, this means a poorer prognosis. In the presence of risk factors indicating a possible increase in biological aggressiveness, adequate postoperative treatment and close follow-up become essential.
Gastric Metastasis 14 Years after Mastectomy for Breast Lobular Carcinoma: Case Report and Literature Review
Authors: Aurello Paolo , D'Angelo Francesco , Cosenza Giulia , Petrocca Sergio , Stoppacciaro Antonella , Ramacciato Giovanni , Ziparo Vincenzo
Published: June 2020

In planning treatment of a gastric neoplasm in a patient previously treated for lobular breast carcinoma, it is important to differentiate a primary gastrointestinal tract tumor from a metastatic form. We report a case of a breast lobular carcinoma metastatic to the stomach. The patient underwent a subtotal gastrectomy for symptomatic disease. Although gastric symptoms appeared 14 years after the breast carcinoma, immunohistochemical analysis of the surgical specimen helped to establish that the gastric lesion, thought to be primary, was effectively a metastatic repetition of the breast neoplasm. To better define treatment in a gastric neoplasm patient previously treated for breast carcinoma, the preoperative diagnosis should rule out a metastatic disease. The patient described received an adjuvant chemotherapy according to breast cancer protocol after gastric resection for symptomatic disease. The patient is still alive and undergoing chemotherapy for peritoneal carcinosis.
Pediatric Pelvic Fractures: A Marker for Injury Severity
Authors: Spiguel Lisa , Glynn Loretto , Liu Donald , Statter Mindy
Published: June 2020

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.
Treatment of Pilonidal Disease with Laser Epilation
Authors: Schulze S.M. , Patel N. , Hertzog D. , Fares L.G.
Published: June 2020

Pilonidal disease is a debilitating, chronic disease of the natal cleft. It mainly involves the sacrococcygeal region and the presentation varies from asymptomatic pits to painful draining abscesses. Treatment options vary from observation to wide excision. Unfortunately, surgical treatment often results in recurrence. The etiologic agent remains in question, as does the optimal treatment. Our objective was to assess the efficacy of laser epilation as an adjunctive therapy to surgical excision of the pilonidal sinus. Eighteen men and five women were treated with laser epilation in our office from 2001 to 2004. All patients had experienced recurrent folliculitis and had undergone some form of drainage procedure or prior excision. After surgical excision of the affected area, a Vasculite™ Plus laser was used for the epilation treatments. Each session involved 9 to 12 treatments and the patients underwent an average of two sessions. All 19 of the patients that remain in follow-up report no recurrence of their folliculitis or need for further surgical procedures. During treatment, six of the men and one of the women experienced a superficial wound dehiscence. All healed with local wound care and continued laser treatments. Laser epilation is an effective adjunctive therapy for the treatment of pilonidal disease. Although not curative in and of itself, the removal of hair allows better healing and decreases the chance of recurrence by removal of a significant etiology of pilonidal disease.
Adrenal Insufficiency in Hemorrhagic Shock
Authors: Rushing G.D. , Britt R.C. , Collins J.N. , Cole F.J. , Weireter L.J. , Britt L.D.
Published: June 2020

Adrenal insufficiency during sepsis is well documented. The association between hemorrhagic shock and adrenal insufficiency is unclear and may be related to ischemia, necrosis, or resuscitation. This study was designed to determine the incidence of relative adrenal insufficiency in hemorrhagic shock. A retrospective review of a prospectively gathered database for patients admitted to the trauma intensive care unit with hemorrhagic shock was undertaken. A random serum cortisol of <25 mcg/dL defined relative adrenal insufficiency. All of the cortisol levels were drawn within the first 24 hours of admission. Data analyzed included demographics, length of stay, injury mechanism, infections, and mortality. Fifteen patients presented with hemorrhagic shock, with 14 of 15 meeting the criteria for relative adrenal insufficiency. The average serum cortisol level was 15.8 (9–26.8). The average APACHE II score was 18.3 (4–33), and the average Injury Severity Score was 22.5 (8–41). The mechanism was blunt trauma in 10 patients and penetrating trauma in 5. The average intensive care unit and hospital length of stay were 13.2 and 27.4 days, respectively. There were five urinary tract infections, four blood stream infections, and two wound infections. Two of the 15 patients died. Relative adrenal insufficiency appears to be common in hemorrhagic shock. Future research is warranted to elucidate the pathophysiology, as well as to prospectively determine which patients may benefit from steroid replacement.
Intraperitoneal Hemorrhage in a Patient with Hepatic Focal Nodular Hyperplasia
Authors: Demarco Mario P. , Shen Perry , Bradley Robert F. , Levine Edward A.
Published: June 2020

Focal nodular hyperplasia (FNH) is a common benign liver tumor that is often confused with hepatic adenoma. Despite the benign course of both lesions, hepatic adenomas are associated with rupture and bleeding, and suggested management often includes prophylactic surgical resection. FNH lesions are thought to not rupture or bleed, and traditional management does not include resection. We report the case of a woman with FNH who presented with intraperitoneal hemorrhage after the rupture of a FNH lesion. Only six previous documented cases of hemoperitoneum associated with FNH have ever been reported. This report reviews all previously recorded cases of FNH lesions that have resulted in intraperitoneal hemorrhage. We suggest that although FNH is a benign lesion and intervention is typically unnecessary, the potential for rupture requiring surgical resection should always be considered.
Mentorship in a Community-Based Residency Program
Authors: Zusan Erin , Vaughan Aislinn , Welling Richard E.
Published: June 2020

The concept of mentorship has become a timely issue in surgical residency education. Traditionally, surgical training programs contained resident teams consisting of chiefs, seniors, juniors, and interns on 4- to 8-week blocks. With the new hour regulations, many programs have had to make changes in the format of their teaching programs to accommodate the new hour restrictions and yet still strive to maintain excellence in residency education. We examined a rotation with a mentor or a small group of surgeons in an apprenticeship model. This consists of one resident following one to three surgeons in a practice, in essence being their apprentice. One of the strongest advantages of this is the exposure the resident has to the true lifestyle of a practicing general surgeon. There is also strong continuity of care, because that one resident goes to office with their mentor, scrubs all their cases, rounds with them, and sees the patients in follow up. This continuity concept ultimately results in better outcomes for the patients.
Internal Hernia: Postoperative Complication of Roux-en-Y Gastric Bypass Surgery
Authors: Eckhauser Aaron , Torquati Alfonso , Youssef Yassar , Kaiser Joan L. , Richards William O.
Published: June 2020

Obesity surgery is becoming one of the most common general surgery procedures done in the United States. Internal hernias are a known and increasingly more common occurrence after laparoscopic roux-en-Y gastric bypass (LRYGB). Increased clinical awareness of this complication will lead to decreased surgical morbidity and mortality. We retrospectively reviewed our database of 529 patients who had undergone LRYGB from 2000 to 2005 and identified those presenting with intestinal obstruction from an internal hernia. The type of internal hernia (jejunojejunostomy, transverse mesocolon, roux limb mesentery [Peterson's hernia]), length of time from presentation to operative intervention, and length of stay were obtained for all patients. Of 529 laparoscopic retrocolic retrogastric LRYGBs, 13 internal hernias (2.5%) were identified in 13 different patients. Eight of the hernias were at the mesenteric defect created by the jejunojejunostomy (62%), 3 originated from the transverse mesocolon defect (23%), and 2 were a Peterson's hernia (15%). The median time from initial operation to repair was 150 days. The average time from presentation to operative repair was 29.2 hours (range, 5–67.5 hours). The median length of stay was 3 days (range, 1.5–45 days). Eleven hernias were repaired laparoscopically (85%). There were no mortalities associated with obstruction from the internal hernia. Intestinal obstruction from an internal hernia after LRYGB is becoming increasingly more common. General awareness of this condition and high clinical suspicion allow for prompt surgical intervention with decreased morbidity and mortality.
Bedside Modified Clagett Procedure for Empyema after Pulmonary Resection
Authors: Keeling W. Brent , Garrett Joseph R. , Vohra Nasreen , Maxey Thomas S. , Blazick Elizabeth , Sommers K. Eric
Published: June 2020

The objective of this study is to demonstrate the effectiveness and feasibility in treating empyema after pulmonary resection with a modified Clagett procedure performed at the bedside (BMCP). A retrospective review of a single surgeon's experience at a single institution was undertaken. All operative, postoperative, and outcome data were analyzed. Follow-up data were obtained from subsequent clinic charts. Five patients, including four males, were identified who underwent BMCP after pulmonary resection. The original operative procedures included two lobectomies, one pneumonectomy, one bilobectomy, and one bilateral metastastectomy. Patients were diagnosed with an empyema (positive thoracostomy tube culture, fever, and radiographic abnormality) at a mean time of 31 days from their initial procedure. Culture results disclosed Gram-positive empyemas in all patients. Three patients underwent BMCP as an outpatient, whereas the other two had BMCP during their hospitalizations. All patients are free from complications or recurrence at a mean follow up of 11.2 months. No patient required a further procedure after BMCP. The bedside modified Clagett procedure is both safe and effective. It is a valuable option in the management of postoperative empyema because it avoids additional operative procedures. This procedure is cost-effective when compared with operative management of perioperative empyema.
Recurrent Rectal Diverticulitis
Authors: Lundy Jonathan B. , Edwards Kurt D. , Parker David M. , Rivera David E.
Published: June 2020

Diverticular involvement of the colon is very common in the United States. Patients present with asymptomatic diverticuli and may have complications of these, spanning the spectrum of uncomplicated diverticulitis to an acute surgical abdominal as a result of feculent peritonitis. We discuss a patient requiring low anterior resection for intractable symptoms resulting from recurrent rectal diverticulitis as well as a review of the limited literature on the subject of diverticular disease of the rectum.
Evaluation of the Effect of Endovascular Options on Infrarenal Abdominal Aortic Aneurysm Repair
Authors: Sandridge Layne C. , Baglioni A.J. , Kongable Gail L. , Harthun Nancy L.
Published: June 2020

Endovascular devices designed to exclude flow to infrarenal abdominal aortic aneurysms (AAA) were approved by the Food and Drug Administration in the United States in 1999. This action allowed widespread use of this technology for AAA exclusion. The purpose of this report is to examine trends for use of these modalities, rates of rupture of AAA, and to compare results of open AAA repair with endovascular repair. Results were collected for all hospitals, except for Veterans Administration hospitals, by a state-wide repository. Data for the years 1996 through 1998 and 2001 through 2002 were evaluated, and data from 1999 through 2000 were excluded because no separate codes were available to distinguish between open and endovascular repair. The information gathered is based on the All Patient Refined Diagnostic Related Group (APR-DRG®; 3M, St. Paul, MN). An average of 718 open, elective AAA was performed between 1996 and 1998. This dropped to 503 open repairs from 2001 to 2002 ( P < 0.005). During that same interval, 308 endovascular elective AAA repairs were performed, therefore the total rate of elective repair increased by 100. The average rate of ruptured AAA repairs from 1996 to 1998 was 121 per year, and this dropped to 89 from 2001 to 2002 ( P < 0.005). The mortality of open AAA repair during the 1996 to 1998 and 2001 to 2002 intervals was unchanged (4.7%). Mortality from endovascular AAA repair between 2001 and 2002 was 1.9 per cent ( P = 0.003). Major morbidity was 14.5 per cent for open, elective AAA repair and 6.3 per cent for endovascular elective repair from 2001 to 2002 ( P < 0.001). These data suggest that the advent of endovascular AAA repair has contributed to a reduction in the rate of ruptured AAA repairs, an increase in total procedures performed, and a significant decrease in perioperative deaths and major complications when compared with open AAA repair.
Electronic Submission of Resident Work Hours: A Convenient Way of Exchange of Information
Authors: Asad Muhammad , Shah Ajay K. , Ehrlich Frank
Published: June 2020

The purpose of this protocol is to assess how residents can document their work hours in a convenient and objective way; to find an efficient, secure, quick, and reproducible way of communication between house staff and residency administrators regarding work hours data; and to fulfill the requirements of the Accreditation Council for Graduate Medical Education and other monitoring bodies regarding work hours documentation. This electronic work hours submission protocol is based on the Microsoft Excel system. The data is submitted via e-mail to the residency coordinators. The work hours sheet recognizes the time spent by the residents in various categories such as patient care, off hours, off days, vacations, outpatient clinic time, on-site rest time, and education time. Calculations are done automatically in the work sheet and results are shown graphically. We found electronic submission of work hours as a more convenient, secure, objective, efficient, and reproducible way of communication than the paper submission forms. Each resident can now easily be tracked for the time he/she spends in various categories. The data will be used to assess how more efficiently residents can spend their time. It also fulfills the documentation requirements of different monitoring bodies
Hospital Characteristics Affect Outcomes for Common Pediatric Surgical Conditions
Authors: Cosper Graham H. , Hamann Mary Sue , Stiles Anquonette , Nakayama Don K.
Published: June 2020

Appendicitis, hypertrophic pyloric stenosis (HPS), and intussusception are common conditions treated in most hospitals. In which hospital settings are children with these conditions treated? Are there differences in outcomes based on hospital characteristics? Our purpose was to use a nationwide database to address these questions. Data were extracted from Kids’ Inpatient Database 2000. Data were queried by International Classification of Diseases procedure code for appendectomy and pyloromyotomy and by diagnosis code for intussusception. Length of stay (LOS) and hospital charges were analyzed based on hospital size, location, teaching status, and specialty designation. There were 73,618 appendectomies, with 5,910 (8%) in children's hospitals. Overall LOS was 3.1 days, and was the longest in children's hospitals (3.9). Overall charges were $10,562, with the highest in children's hospitals ($14,124). There were 11,070 pyloromyotomies, with 2,960 (27%) in children's hospitals. Overall LOS was 2.7 days, the shortest being in children's hospitals (2.5). Overall charges were $7,938, with the highest in children's hospitals ($8,676). There were 2,677 intussusceptions, with 921 (34%) in children's hospitals. Overall LOS was 3.0 days, the shortest being in children's hospitals (2.8). Overall charges were $9,558, with the highest in children's hospitals ($10,844). Most children with appendicitis, HPS, and intussusception are treated in nonspecialty hospitals. HPS (27%) and intussusception (34%) are more likely than appendicitis (8%) to be treated in children's hospitals. Children's hospitals have higher charges for all three conditions despite shorter LOS for HPS and intussusception.
Pancreaticoduodenectomy in a Community General Surgery Residency Program
Authors: Smith Chadwick P. , Cheatham Michael L. , Lube Matthew W. , Safcsak Karen
Published: June 2020

The morbidity and mortality of pancreaticoduodenectomy (PD) has been well documented. A retrospective review was performed to determine the morbidity and mortality of PD performed within the general surgery residency program of a tertiary community hospital. Patients undergoing PD for benign or malignant disease over a 6-year period were analyzed to determine overall mortality, major complication rate, and length of stay (LOS). Of 50 consecutive patients undergoing PD, overall mortality was 6 per cent, with a major complication rate of 52 per cent. Mean operative time was 333 ± 68 minutes with an estimated blood loss of 459 ± 301 mL. Mean hospital LOS was 21 ± 13 days. Eighty-four per cent of patients with malignant disease had negative margins of resection. General surgery residents within a community residency program, with attending faculty supervision, can perform PD with mortality, morbidity, and LOS comparable with that reported in the university setting.
Obesity Alters Rat Abdominal Flap Survival
Authors: Reyna Ronald E. , Feldmann Mark E. , Evans Zachary P. , Seung-Jun O. , Chavin Kenneth D.
Published: June 2020

Obesity presents a risk factor for flap-related complications in autologous tissue breast reconstruction. In this study, an animal model was developed to examine this phenomenon. Abdominal flaps based on a superficial inferior epigastric pedicle were elevated in an experimental group of obese Zucker (fa/fa) rats (n = 8; mean weight, 413 g) and in their lean littermates (n = 9; mean weight, 276 g). Flap tissue was harvested from a subset of both groups for baseline characterization, including histology, and assays for ATP and oxidative phosphorylation uncoupler, UCP-2. Flaps were then evaluated for survival by planimetry at 4 and 7 days postprocedure. Flap survival 7 days postoperatively was reduced in obese (42.0% ± 8.6%) versus lean (70.3% ± 6.7%) rats ( P < 0.05). At baseline, flap tissue of obese animals had decreased ATP content relative to lean counterparts (0.12 ± 0.12 nM/μg vs 0.36 ± 0.23 nM/μg protein, P < 0.05), whereas UCP2 mRNA was higher in obese flap tissue versus lean. Reduced viability of obese flaps may be attributable to decreased baseline energy stores due to oxidative phosphorylation uncoupling by UCP-2. This study is the first to introduce a promising animal model for examining the effect of obesity on increased flap-related complications in breast reconstruction using autologous tissue.
Prospective Evaluation of Adhesion Formation and Shrinkage of Intra-Abdominal Prosthetics in a Rabbit Model
Authors: Harrell Andrew G. , Novitsky Yuri W. , Peindl Richard D. , Cobb William S. , Austin Catherine E. , Cristiano Joseph A. , Norton James H. , Kercher Kent W. , Heniford B. Todd
Published: June 2020

Laparoscopic ventral hernia repair requires an intraperitoneal prosthetic; however, these materials are not without consequences. We evaluated host reaction to intraperitoneal placement of various prosthetics and the functional outcomes in an animal model. Mesh (n = 15 per mesh type) was implanted on intact peritoneum in New Zealand white rabbits. The mesh types included ePTFE (DualMesh®), ePTFE and polypropylene (Composix®), polypropylene and oxidized regenerated cellulose (Proceed®), and polypropylene (Marlex®). Adhesion formation was evaluated at 1, 4, 8, and 16 weeks using 2-mm mini-laparoscopy. Adhesion area, adhesion tenacity, prosthetic shrinkage, and compliance were evaluated after mesh explantation at 16 weeks. DualMesh® had significantly less adhesions than Proceed®, Composix®, or Marlex® at 1, 4, 8, and 16 weeks ( P < 0.0001). Marlex® had significantly more adhesions than other meshes at each time point ( P < 0.0001). There were no statistically significant differences in adhesions between Proceed® and Composix® meshes. After mesh explantation, the mean area of adhesions for Proceed® (4.6%) was less than for Marlex® (21.7%; P = 0.001). The adhesions to Marlex® were statistically more tenacious than the DualMesh® and Composix® groups. Overall prosthetic shrinkage was statistically greater for DualMesh® (34.7%) than for the remaining mesh types ( P < 0.01). Mesh compliance was similar between the groups. Prosthetic materials demonstrate a wide variety of characteristics when placed inside the abdomen. Marlex® formed more adhesions with greater tenacity than the other mesh types. DualMesh® resulted in minimal adhesions, but it shrank more than the other mesh types. Each prosthetic generates a varied host reaction. Better understanding of these reactions can allow a suitable prosthetic to be chosen for a given patient in clinical practice.
Discharging to a Nursing Home: Not a Terminal Event–A Follow-Up Study of Senior Motor Vehicle Crash Patients
Authors: Aaland Mary O. , Leffers Kevin , Hlaing Thein
Published: June 2020

Discharge to a nursing home (NH) because of chronic debilitating diseases or old age is generally a terminal event. The purpose of this study was to evaluate the NH outcome of senior citizens injured in motor vehicle crashes (MVC) discharged to a NH. From 2000 through 2004, 157 patients 75 years and older were admitted to the hospital for MVC. Of these, 32 patients were discharged to a NH, and these patients or their proxies were interviewed by telephone in June 2005 to request information as to driving status before and after the MVC, feeding, expression, and locomotion status, and/or date of death. After discharged from the NH, 72 per cent (23/32) of the patients lived at home, 52.2 per cent (12/23) among the drivers returned to drive, and those with functional impairments (excluding the five NH deaths and four still remaining in a NH) at the time of hospital discharge had 100 per cent or partial improvement in three functional independent measures at the time of the interview: 5 cases in feeding, 2 in expression, and 20 in locomotion. Eleven of the 20 individuals dependent or partially dependent in locomotion status were fully independent. The majority of the senior patients discharged to a NH after a MVC returned to a normal life by going back home, driving again, and regaining functional activities after NH discharge. Discharge to a NH for elderly MVC trauma patients may be regarded as a stepping-stone to independent living rather than a final resting place.
Aggressive D2 Lymphadenectomy is Required for Accurate Pathologic Staging of Gastric Adenocarcinoma
Authors: Smith Brian R. , Stabile Bruce E.
Published: June 2020

The therapeutic efficacy of aggressive regional D2 lymphadenectomy as an adjunct to gastrectomy for adenocarcinoma of the stomach remains controversial. It is hypothesized that D2 lymphadenectomy compared with limited D1 lymphadenectomy increases nodal yield without adding to operative morbidity or mortality, and is necessary to allow accurate pathologic staging according to current American Joint Committee on Cancer (AJCC) criteria. A 10-year retrospective review of a consecutive series of 105 gastrectomies for adenocarcinoma at an urban public teaching hospital was performed. Of 69 intended curative gastrectomies, 55 (80%) included D2 lymphadenectomies, whereas of 36 palliative gastrectomies, only 9 (25%) included D2 lymphadenectomies (P = 0.0041). Only D2 and not D1 lymphadenectomy achieved the AJCC minimum guideline of the 15 lymph nodes required for accurate pathologic staging (mean 25.2 vs 12.4 nodes, respectively; P = 0.0001). For D2 cases, 86 per cent had greater than 15 nodes excised compared with only 20 per cent for D1 cases (P = 0.0002). The morbidity and mortality rates for D2 and D1 operations were 22 per cent and 2 per cent, and 41 per cent and 2 per cent, respectively. We conclude that there was no increased morbidity or mortality associated with D2 lymphadenectomy; that reliable harvesting of an adequate number of lymph nodes for accurate AJCC pathologic tumor staging requires D2 lymphadenectomy; and that D2 lymphadenectomy should be performed as part of virtually all gastrectomies for invasive adenocarcinoma having curative intent.