bluuebunny/crossref_metadata_2025 huggingface dataset:
Stapled Intestinal Anastomosis in Neonates: Validation of Safety and Efficacy
Authors: Simmons Jon D. , Gunter Joseph W. , Manley Justin D. , Sawaya David E. , Blewett Christopher J.
Published: June 2020

The safety and effectiveness of a stapled intestinal anastomosis in adults and children is well documented. However, the role of this technique in neonates is not well validated. We report our experience with stapled intestinal anastomoses in the neonate at the University of Mississippi Medical Center. All patients from the neonatal intensive care unit who had a stapled intestinal anastomosis between February 2007 and May 2008 were identified. A stapled side-to-side functional end-to-end intestinal anastomosis was performed in all patients using a gastrointestinal anastomosis stapler. Demographic, management, and outcome data were collected via chart review. Variables collected included: birth weight, estimated gestational age at birth and surgery, weight at surgery, the use of vasopressors, associated diagnoses, location of the anastomosis, and postoperative clinic visits. A total of 18 patients were identified during the study period. Nine had small bowel to small bowel, eight had ileum to colon, and one had a colon to colon anastomosis. The average weight at time of operation was 2.8 kilograms (Kg) and the average estimated gestational age at surgery was 38.7 weeks. The only complication reported was a partial small bowel obstruction on postoperative day 12, which was successfully treated nonoperatively. Two patients died from problems not associated with the anastomosis. There were no anastomotic leaks or strictures. The literature regarding the use of stapled bowel anastomoses in neonates is scant. Stapled intestinal anastomoses can be performed safely in neonates without a high rate of complication. The long term effects of stapled intestinal anastomoses in the neonate are unknown. Future areas of interest would include effects on postoperative feeding and operative time.
Small Bowel Obstruction: Outcome and Cost Implications of Admitting Service
Authors: Oyasiji Tolutope , Angelo Steve , Kyriakides Tassos C. , Helton Scott W.
Published: June 2020

We compared patients with small bowel obstruction (SBO) admitted through the emergency department to the surgical service (SS) with those admitted to the medical service (MS) with respect to outcomes and healthcare cost. We conducted a retrospective analysis of our SBO database comparing 482 patients admitted to SS and 153 patients admitted to MS at a single institution over a 5-year period (January 2003 to December 2007). Study outcomes included length of hospital stay (LOS), time to surgery (TTS), hospital charges, incidence of bowel resection, and mortality. Both groups were comparable for age, gender, and race. The SS group had a shorter LOS (6.1 vs 7.5 days; P = 0.01), less hospital charges ($29,549 vs $35,789; P = 0.06), shorter TTS (log rank comparison; P = 0.006), and less mortality (eight [1.66%] vs six [3.92]; P = 0.11). The SS group had more bowel resections (13.1 vs 5.2%; P = 0.007). Coronary artery disease (CAD), acute renal failure (ARF), admission to SS, and female gender were significant predictors of bowel resection. CAD and ARF were significant predictors of mortality. Two hundred forty-four patients required operative intervention (surgery operative subgroup [SOS] 210 [43.6%], medicine operative subgroup [MOS] 34 [22.2%]). SOS and MOS were comparable for gender and race. SOS had shorter LOS (9.1 vs 12.3 days; P = 0.02), less hospital charges ($46,258 vs $62,778, P = 0.05), and less mortality (eight [3.81%] vs four [11.76%]; P = 0.07). Bowel resection was comparable (SOS 30% vs MOS 23%; P = 0.44). CAD and congestive heart failure (CHF) were significant predictors of bowel resection, whereas CAD was the only significant predictor of mortality in this subgroup. We recommend that patients with SBO be admitted to SS because this might translate to shorter LOS, earlier operative intervention, and reduced healthcare use direct cost. Bowel resection and death are more likely to occur in patients with comorbidities like CHF, CAD, diabetes mellitus, and ARF.
Day-Case Limberg Flap for Recurrent Pilonidal Sinus: Does Obesity Complicate the Issue?
Authors: Madbouly Khaled M.
Published: June 2020

The purpose of this study was to analyze the long-term outcome of rhomboid excision with Limberg flap reconstruction (LF) as one-day surgery in treatment of recurrent pilonidal sinus (RPS). The effect of obesity on outcome will be addressed. Forty-nine patients with RPS were treated by rhomboid excision and LF as one-day surgery. Data collected included demographics, body mass index, operative time, flap ischemia, wound infection, length of hospital stay, time of complete healing, and recurrence. Patients’ mean age was 33.4 years and mean number of previous operations was 3.4. Operative time ranged from 40 to 70 minutes. Two patients developed sterile seroma (4.1%) and two patients (4.1%) had wound infections. No wound dehiscence or flap ischemia was reported. All patients returned to normal activity within 7 days. No recurrences were reported after a mean follow-up of 32.1 months. Obesity significantly increased the operative time, however, it affected neither the postoperative outcome nor the long-term recurrence. Rhomboid excision and LF as one-day surgery is a safe and reliable method for treatment of RPS. It guarantees low morbidity, short hospital stay, short time off work, and carries low risk of recurrence, even in obese patients.
Functional Status after Injury: A Longitudinal Study of Geriatric Trauma
Authors: Kelley-Quon Lorraine , Min Lillian , Morley Eric , Hiatt Jonathan R. , Cryer Henry , Tillou Areti
Published: June 2020

We evaluated self-rated functional status measured longitudinally in the year after injury in a geriatric trauma population. The longitudinal (L) group included 37 of 60 eligible trauma patients aged 65 years or older admitted December 2006 to November 2007 for greater than 24 hours who completed a Short Functional Status questionnaire (SFS) at 3, 6, and 12 months after injury. The SFS yields scores of 0 to 5 (5 = independent in all five activities of daily living [ADLs]) and has been validated among community-dwelling elders. The control (C) group included 63 trauma patients aged 65 years or older admitted December 2007 to July 2009 for greater than 24 hours who reported their preinjury functional status using the SFS at hospital admission. We used characteristics and scores of the C group to impute preinjury ADL scores for the L group. The groups were similar in baseline characteristics (age, ethnicity, Injury Severity Score, Charlson Comorbidity Index, and living arrangement; P > 0.05). For the C group, the preinjury ADL score was 4.6 (SD = 0.9). For the L group, ADL scores declined at all intervals reaching statistical significance at 12 months. We conclude that in the year after traumatic injury, geriatric patients lost the equivalent of approximately one ADL, increasing their risk of further functional decline, loss of independence, and death.
Variations in Perioperative Steroid Management among Surgical Subspecialists
Authors: Hammond Kerry , Margolin David A. , Beck David E. , Timmcke Alan E. , Hicks Terry C. , Whitlow Charles B.
Published: June 2020

Previously we demonstrated consistency in perioperative steroid dosing among colon and rectal surgeons. To determine whether patterns have changed and if dosing schedules differ across surgical specialties, we evaluated multiple specialties. Questionnaires were mailed to members of the American Society of Colon and Rectal Surgeons (CRS) (n = 1523), American Society of Transplant Surgeons (TS) (n = 988), American Society of General Surgeons (GS) (n = 2750), and American Association of Endocrine Surgeons (ES) (n = 278). Surveys addressed demographic factors and factors in dosing, whether steroids are managed by surgeon alone or in collaboration with colleagues, and the most common taper regimens used. Four hundred fifty surveys were returned. Sixty-four respondents had retired or answered less than 50 per cent; 386 (211CRS, 116GS, 45TS, and 14ES) were available for analysis. The majority managed both perioperative (85.5%) and tapers (77%) themselves; TS and ES were significantly less likely to use other physicians ( P < 0.001). The preoperative dose used most frequently was 100 mg hydrocortisone intravenously (76% CRS, 64% GS, 22% TS, and 93% ES). Most CRS (44.5%) and GS (24.1%) taper intravenous steroids over 3 days, whereas TS (33.3%) and ES (50%) return patients to prednisone within 1 to 2 days. Discharge steroid use was inconsistent with CRS (46.4%) tapering prednisone over greater than 21 days, GS (19%) over less than 21 days, and TS (20%) and ES (21.4%) taper over 21 days to preoperative prednisone doses ( P < 0.001). In the absence of standard guidelines for perioperative corticosteroid administration, significant variations exist in the regimens used by surgeons in multiple specialties.
Inconsistency in the Management of Patients with Hepatocellular Carcinoma: The Need for a Strict Protocol
Authors: Theodoropoulos John , Brooks Ari
Published: June 2020

As more therapies become available for the treatment of hepatocellular carcinoma (HCC), the management of patients with HCC is more complex, and the indications for the various therapeutic modalities are less clear. Although all of the treatment options have shown a certain efficacy in well-selected patient groups, their everyday use, especially in nonspecialized centers, is not always appropriate. We report our experience with 81 individuals who were diagnosed and treated in our institution between 2001 and 2007. Only patients who received transplants had good long-term outcomes, and we noted significant inconsistencies in the management of patients with similar stages of disease and degrees of cirrhosis. Despite recent progress, HCC still carries an overall dismal prognosis, making the optimization of the therapeutic plan mandatory to improve outcomes. We believe that a unified protocol, as well as the early involvement of the hepatology and transplant teams, can help physicians optimize the care of these patients.
MOPEDS: Motorized Objects Propelling Ethanol Drinking Subjects
Authors: Christmas A. Britton , Brintzenhoff Rita A. , Schmelzer Thomas M. , Head Karen E. , Sing Ronald F.
Published: June 2020

Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ2 test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant ( P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant ( P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.
Diagnosis and Management of Choledochoduodenal Fistula
Authors: Zong Kai-Can , You Hai-Bo , Gong Jian-Ping , Tu Bing
Published: June 2020

Recent advances in hepatobiliary imaging techniques have led to the increased detection of choledochoduodenal fistula. However, the diagnosis and treatment of choledochoduodenal fistula is still a challenge. In this study, we summarize how patients were diagnosed and treated for choledochoduodenal fistula at our institution. Sixty-six patients with choledochoduodenal fistula were diagnosed and treated in our department from January 2000 to June 2009. Sixty-one patients were treated operatively, whereas five patients were treated with medicine. Patients with choledochoduodenal fistula were confirmed by endoscopic retrograde cholangiography. Of the 61 patients needing surgical intervention, clinical outcomes were excellent in 57 patients, and five patients underwent successful laparoscopic surgery for repairing the choledochoduodenal fistula. Follow-up of these patients for 6 months to 10 years showed they did not suffer from further cholangitis. A patients’ past history of biliary disease, upper abdominal pain, fever, and jaundice may lead to choledochoduodenal fistula. Operative therapy, including laparoscopic surgery, was the primary treatment for most patients, regardless of the preoperative diagnosis.
Selection Criteria for Complete Cytoreduction after Cytoreductive Surgery for Peritoneal Surface Malignancy: Lessons Learned from Our First Series of Patients
Authors: Mckenzie Shaun , Artinyan Avo , Holt Alicia D. , Garcia-Aguilar Julio , Ellenhorn Joshua , Morgan Robert , Paz Benjamin
Published: June 2020

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months ( P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.
Re-evaluation of the Necessity of Prophylactic Drainage after Liver Resection
Authors: Hirokawa Fumitoshi , Hayashi Michihiro , Miyamoto Yoshiharu , Asakuma Mitsuhiro , Shimizu Tetsunosuke , Komeda Koji , Inoue Yoshihiro , Tanigawa Nobuhiko
Published: June 2020

Abdominal drainage after liver resection is considered unnecessary: however, there still exist a number of cases where drain is effective to prevent serious infectious complications. We reevaluated the necessity of drain placement after liver resection from the retrospective analysis of postoperative complications with special reference to the need for drain insertion of 140 patients undergoing hepatectomy without intraoperative abdominal drainage from 2007 through 2010. Three patients required drain reinsertion in the early postoperative period (before postoperative Day 7); all had undergone extended right hepatectomy for hepatocellular carcinoma with portal vein thrombus followed by postoperative liver failure. Risk factors for postoperative bile leakage included repeated hepatectomy, operative procedure with exposure of the major Glisson's sheath (i.e., central bisegmentectomy and anterior segmentectomy), and intraoperative bile leakage. However, because the onset of this complication was as late as postoperative Day 19.5, prophylactic drainage does not appear useful. Although not required routinely, prophylactic drainage might be useful in patients undergoing extended hepatectomy, a high-risk hepatectomy procedure exposing the major Glisson's sheath, those with positive intraoperative bile leakage, for hepatocellular carcinoma, and especially complicated with portal vein thrombus.
Colonic Pseudo-Obstruction with Distinct Transitional Zone in Adult Constipation Patients: Pathological Analysis and Results of Surgical Treatment
Authors: Choe Eun Kyung , Park Sung-Hye , Park Kyu Joo
Published: June 2020

There are subsets of chronic constipation patients showing features of colonic pseudo-obstruction (CPO) with distinct transitional zone (TZ). We intended to analyze the clinicopathologic characteristics and surgical outcomes of these patients. Twenty-five consecutive patients who underwent surgery for constipation over the 9-year period were analyzed. TZ (+) group was defined as patients showing symptoms or signs of large bowel obstruction with dilated proximal and collapsed distal colon around the TZ at the time of operation, but without any evidence of mechanical causes of obstruction. Nineteen (76%) patients had features of CPO with TZ. All TZs were located in the left colon. Pathologically, segmental hypoganglionosis was identified at the TZ in all TZ (+) patients. On the other hand, pathologic diagnosis was intestinal neuronal dysplasia type B in the remaining six (24%) patients having a uniform colon diameter without demonstrable dilatations (TZ (-) group). Among TZ (+) patients, 17 (90%) underwent total colectomy with ileorectal anastomosis and two (10%) underwent enterostomy. Long-term follow-up (median 56 months) showed no recurrence of constipation in this group of patients. All six TZ (-) patients underwent total colectomy with ileorectal anastomosis and two (33%) of them had persistent symptoms of constipation on long-term follow-up (median 60 months). In a subset of adult constipation patients presenting with features of CPO with TZ, segmental hypoganglionosis was the final pathologic diagnosis. Constipation patients with features of CPO with distinct TZ in the left colon are expected to benefit from surgical intervention.
Utilization of Interventional Radiology in the Postoperative Management of Patients after Surgery for Locally Advanced and Recurrent Rectal Cancer
Authors: Llaguna Omar H. , Calvo Benjamin F. , Stitzenberg Karyn B. , Deal Allison M. , Burke Charles T. , Dixon Robert G. , Stavas Joseph M. , Meyers Michael O.
Published: June 2020

The surgical management of locally advanced primary rectal cancer and locally recurrent rectal cancer requires complex operations frequently resulting in complicated postoperative courses. We sought to evaluate the utilization of interventional radiologic (IR) procedures in the management of postoperative complications. Under Institutional Review Board approval, a prospective database of colorectal cancer patients undergoing resection from July 1999 to January 2010 was analyzed. Data collected included demographics, operative procedure, complications, length of stay, and IR utilization. Fisher's exact tests and logistic regression explored associations with necessitating an IR procedure during the postoperative period. Continuous variables were analyzed using Wilcoxon rank sum tests. One hundred and one patients underwent surgery and 66 received intraoperative electron radiotherapy (IOERT). Primary procedures included pelvic exenteration (n = 35), abdominoperineal resection (n = 25), low anterior resection (n = 23), paraaortic node dissection (n = 7), resection of isolated pelvic/retroperitoneal tumor (n = 7), and colectomy (n = 4). Sixty-two patients required multivisceral resection including partial/total cystectomy (n = 30), small bowel resection (n = 25), oophorectomy (n = 15), vaginectomy (n = 12), hysterectomy (n = 12), hepatectomy (n = 3), and nephrectomy (n = 3). Seventeen partial sacral resections and 47 pelvic sidewall resections were also required. One hundred and thirty-eight complications were identified in 72 patients, 30 of which required a procedural intervention. Twenty-seven IR procedures were performed including drainage of fluid collections (n = 14), nephrostomy tube placement (n = 8), arterial embolization (n = 2), inferior vena cava filter placement (n = 2), and pleural drainage (n = 1). Only three reoperations were required, none related to failure of IR procedures. There were no deaths. Estimated blood loss > 2000 mL ( P = 0.002), IOERT ( P = 0.03), and incomplete resection ( P = 0.02) were found to be associated with postoperative IR utilization. Surgery for locally advanced primary rectal cancer and locally recurrent rectal cancer is associated with significant morbidity but low mortality. IR procedures play a significant role in the postoperative management of these patients and may decrease the need for reoperation.
Utilization of Laparoscopy in Colorectal Surgery for Cancer at Academic Medical Centers: Does Site of Surgery Affect Rate of Laparoscopy?
Authors: Carmichael Joseph C. , Masoomi Hossein , Mills Steven , Stamos Michael J. , Nguyen Ninh T.
Published: June 2020

Use of laparoscopy in colorectal cancer surgery is still limited. The aim of this study was to determine the rate of use of laparoscopic colorectal surgery for cancer at academic medical centers and to evaluate if the site of surgery influences the rate of use. Clinical data of patients who underwent laparoscopic or open colon and rectal resections for cancer from 2007 to 2009 were obtained from the University HealthSystem Consortium database. Data concerning rate of laparoscopy, length of stay, morbidity, and risk-adjusted mortality were obtained. During the 36-month study period, 22,780 operations were performed. The overall rate for use of laparoscopy was 14.8 per cent. Laparoscopy was most often used for total colectomy (22.6%), sigmoid colectomy (17.3%), cecectomy (17.1%), and right hemicolectomy (17.0%). Laparoscopy was most infrequently used for abdominoperineal resection (8.0%), transverse colectomy (10.0%), and left hemicolectomy (13.1%). Length of stay for laparoscopic colon and rectal procedures was 3.2 days shorter than for open surgery. Although the benefits of laparoscopic colorectal surgery for cancer have been demonstrated, the use of laparoscopy for colorectal resection remains under 20 per cent for colon cancer and under 10 per cent for rectal cancer. Further studies are needed to determine the factors limiting the use of laparoscopy in colorectal surgery.
An Intraoperative Localization Technique for a Postexcision Specimen of Nonpalpable Breast Calcifications: A Pilot Study
Authors: Xiaofeng Liu , Lianfang Li , Fei Chen , Yuming Li , Hui Chen , Qing Li , Lu Cheng , Shude Cui
Published: June 2020

The specimens obtained through excisional biopsy (EB) are commonly large in size and it is difficult to remove the tissues containing nonpalpable calcifications accurately from them for pathologic examination. Therefore, the aim of the study is to develop a novel method of subarea localization technique (SLT) for sampling from the postexcisional specimens. A retrospective clinical study of 48 consecutive patients with breast microcalcifications were divided into a study group (n = 24 patients, 25 breasts) and a control group (n = 24 patients, 24 breasts) in time sequence. The specimens of study group were localized by SLT performed by cutting lines and/or metallic markers. The main study end points were the duration of intraoperative pathologic diagnosis (DIPD) and duration of conclusive pathology diagnosis (DCPD). The number of frozen blocks, number of paraffin blocks, number of sections, and other parameters correlated with pathologic diagnosis were compared between the two groups. SLT was succeeded in 48 of 48 (100%) patients, which shortened DIPD (29.3 vs 45.5 minutes, P < 0.01) significantly with less frozen blocks (6.2 vs 12.6, P < 0.01) and less frozen sections (8.5 vs 13.7, P = 0.01) than that of the control group. Moreover, SLT shortened DCPD (4.1 vs 5.1 days, P = 0.02) with less paraffin blocks (12.2 vs 21.7, P < 0.01) and less paraffin sections (20.0 vs 39.9, P < 0.01) than that of the control group. SLT decreased workload of the specimens sampling procedure and SLT may be recommended as a reliable specimens sampling method to guide pathology test for EB specimens containing calcifications.
Article Commentary: Sepsis, Systemic Inflammatory Response, and Multiple Organ Dysfunction: The Mystery Continues
Authors: Fry Donald E.
Published: June 2020

Human sepsis is thought to be systemic inflammatory response syndrome (SIRS) that is activated by invasive infection. The multiple organ dysfunction syndrome (MODS) is the identified failure of critical organ function in patients that have sustained SIRS. Because SIRS and MODS are consequences of the excessive activation of inflammation, extensive research and numerous clinical trials have pursued treatments that would modify the inflammatory response. This presentation reviews the normal local mechanisms of inflammation and provides a theoretical framework for the transition of the inflammatory process to a systemic level. Clinical trials with biomodulators to block or inhibit inflammation have generally failed to improve the outcomes in patients with severe sepsis, septic shock, and MODS. The role of counter-inflammatory signaling and the newer concept of the cholinergic anti-inflammatory pathway are being investigated, and newer hypotheses are focusing upon the balancing of proinflammatory and counter-inflammatory mechanisms as important directions for newer therapies. It is concluded that failure to define novel and effective treatments reflects fundamental gaps in our understanding of inflammation and its regulation.
Living on a Prayer: Religious Affiliation and Trauma Outcomes
Authors: Khoury Amal , Oyetunji Tolulope A. , Bolorunduro Oluwaseyi , Harbour Leia , Cornwell Edward E. , Siram Suryanarayana M. , Mellman Thomas , Greene Wendy R.
Published: June 2020

Research has shown that religious affiliation is associated with reduced all cause mortality. The aim of this study was to determine if religious affiliation predicts trauma-specific mortality and length of stay. Patients admitted to our urban Level I trauma center in 2008 were examined; the main study categorization was based on endorsement of a specific religious affiliation during a standard intake procedure. Bivariate and multivariate analysis was performed with in-hospital mortality and length of stay as the outcomes of interest, adjusting for demographic and injury severity characteristics. A total of 2303 patients were included in the study. Forty-six per cent endorsed a religious affiliation. Patients with a religious affiliation were more likely to be female, Hispanic, and older than those who reported no affiliation ( P < 0.001). There was no difference in length of hospital stay. On bivariate analysis those without religious affiliation were more likely to die ( P = 0.01), but this difference disappeared after adjusting for covariates. Although we could not identify a statistical association between religious affiliation and mortality on multivariate analysis, there was an association with injury severity suggesting religious patients were less severely injured.
Improving the Diagnostic Accuracy of Ultrasonography in Suspected Acute Appendicitis by the Combined Transabdominal and Transvaginal Approach
Authors: Bondi Moshe , Miller Rafael , Zbar Andrew , Hazan Yenon , Appelman Zvi , Caspi Benjamin , Mavor Eli
Published: June 2020

Transabdominal ultrasound has a lower diagnostic yield in acute appendicitis than computed tomography (CT) scanning. The addition of transvaginal sonography in women with suspected appendicitis has shown improvement in the efficacy of diagnosis, potentially providing the option of selective CT use and reducing overall investigative cost and surgical delay. Two hundred ninety-two women who underwent combined transabdominal and transvaginal ultrasound for suspected acute appendicitis were evaluated. Patients were divided into two groups; Group 1 including patients with a positive sonographic diagnosis of appendicitis who underwent operation and Group 2 including patients with a negative sonographic diagnosis. Of the 157 women in Group 1, the diagnosis of appendicitis was histologically confirmed in 144 patients with five cases having a normal appendix in whom eight other pathologies were found. Of the 135 women with negative ultrasound examinations, 14 underwent surgery in which four cases of appendicitis were found. The sensitivity of the combined approach was 97.3 per cent, the specificity 91 per cent, the positive predictive value 91.7 per cent, and the negative predictive value 97 per cent. Combined ultrasound has a high predictive value for the diagnosis of appendicitis and may assist in reduction of the use of CT scanning for diagnosis and in the negative appendectomy rate.
Single-Incision Laparoscopic Surgery for Partial Gastrectomy in Patients with a Gastric Submucosal Tumor
Authors: Takahashi Tsunehiro , Takeuchi Hiroya , Kawakubo Hirofumi , Saikawa Yoshiro , Wada Norihito , Kitagawa Yuko
Published: June 2020

Since 2010, we have used single-incision laparoscopic surgery (SILS) for patients with a gastric submucosal tumor, as a less invasive alternative to conventional laparoscopy. From September 2010 to January 2011, five patients underwent a local resection for a gastric submucosal tumor using a SILS™ port at Keio University Hospital. We performed partial gastrectomy via the SILS™ port using a 5 mm flexible endoscope, a vessel sealing system, and a stapling device. There were no major intraoperative complications, conversion to laparotomy, or cases of tumor rapture. The average operative time was 89 (range, 72–129) minutes with minimal blood loss. Pathological examination revealed four cases of gastrointestinal stromal tumor and one case of inflammatory fibrosis caused by nonspecific inflammation. Although we examined only a small number of cases in this study, the results suggested that SILS gastrectomy can be performed safely and effectively for gastrointestinal stromal tumor.
Thin Chest Wall is an Independent Risk Factor for the Development of Pneumothorax after Chest Tube Removal
Authors: Anand Rahul J. , Whelan James F. , Ferrada Paula , Duane Therese M. , Malhotra Ajai K. , Aboutanos Michel B. , Ivatury Rao R.
Published: June 2020

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the “protective” layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.
Repeat Computed Tomography for Trauma Patients Undergoing Transfer to a Level I Trauma Center
Authors: Young Andrew Joseph , Sadlermeyers Kenneth , Wolfe Luke , Marieduane Therese
Published: June 2020

Our goal was to determine the characteristics of trauma transfer patients with repeat imaging. A retrospective trauma registry review was performed to evaluate trauma patients who were transferred from referring institutions between January 2005 and December 2009. Patients were divided into those who had a duplicate computed tomography (CT) scan versus those who did not. There were 2678 patients included of whom 559 (21%) had at least one repeat CT scan, whereas 2119 (79%) did not have any repeat CT scans. Those with repeat CT scans were older (42.3 ± 27.3 years vs 37.3 ± 25.6 years), had a higher Injury Severity Score (ISS) (13.7 ± 8.7 vs 11.9 ± 8.8), and more likely to have blunt trauma (odds ratio, 4.7; confidence interval, 2.3 to 9.6) (P for all < 0.0007). Those with CT scans done only at the referring facility were younger, had a lower ISS, and shorter lengths of stay (P for all < 0.0003). ISS and age were independent predictors for repeat CT scans. Transfer patients had imaging repeated one-fifth of the time. The younger, less injured patient went without repeat imaging suggesting that they may have been adequately cared for at the outside institution.
Locoregional versus General Anesthesia for Open Inguinal Herniorrhaphy: A National Surgical Quality Improvement Program Analysis
Authors: Bhattacharya Syamal D. , Vaslef Steven N. , Pappas Theodore N. , Scarborough John E.
Published: June 2020

Our objective was to study outcomes associated with open inguinal herniorrhaphy performed under locoregional (LR) versus general anesthesia (GA). National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2009 was queried to capture patients undergoing initial unilateral inguinal herniorrhaphy. We excluded patients with incarcerated/strangulated hernia or those undergoing a concomitant procedure. Outcomes were anesthesia and operative times, postoperative admission, and 30-day morbidity. Using the entire NSQIP sample, forward stepwise multivariate regression analysis was used to compare outcomes between patients receiving LR versus GA after adjustment for patient demographics and comorbid diagnoses. Outcomes were also compared for a smaller subgroup of patients propensity-matched for receiving LR anesthesia. A total of 25,213 patients were analyzed (16,282 GA and 8,931 LR). Patients in the LR group had a higher incidence of comorbid illnesses and were more likely to have an American Society of Anesthesiologists classification ≥ 3. Multivariate analyses demonstrated that LR anesthetic is associated with shorter anesthetic and operative times and a lower hospital admission rate. Comparison using a propensity-matched cohort for undergoing LR anesthesia confirms that these patients had significantly shorter anesthesia (32 vs 38 min, P < 0.0001) and operative times (53.3 vs 57.2 min, P < 0.0001), as well as a significantly reduced rate of postoperative admission (5.9% vs 10.9%, P < 0.0001) and 30-day morbidity (0.9% vs 1.3%, P < 0.05). Our analysis of NSQIP suggests that, compared with general anesthesia, the locoregional technique is associated with shorter anesthesia and operative times, reduced need for postoperative hospital admission, and a small but significant reduction in postoperative morbidity.
Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography: A Novel Approach for the Diagnosis of Cholecystitis for Equivocal Diagnoses after Ultrasound Imaging
Authors: Nasseri Yosef , Ourian Ariel J. , Waxman Alan , D'Angolo Alessandro , Thomson Louise E. , Margulies Daniel R.
Published: June 2020

Although hepatobiliary iminodiacetic acid (HIDA) scan is often used when the diagnosis of cholecystitis remains questionable after ultrasound, it carries a high false-positive rate and has other limitations. Fluorodeoxyglucose positron emission tomography–computed tomography (18FDG PET-CT) has recently gained enthusiasm for its ability to detect infection and inflammation. In this study, we evaluate the accuracy of 18FDG PET-CT in diagnosing cholecystitis. Nineteen patients with suspected cholecystitis (Group S) underwent PET-CT and 10 had positive PET-CT findings. Of these 10, nine underwent cholecystectomies, and pathology confirmed cholecystitis in all nine. One patient was managed nonoperatively as a result of multiple comorbidities. Of the nine patients with negative PET-CT, six were managed nonoperatively, safely discharged, and had no readmissions at 3-month follow-up. The other three patients with negative PET-CT underwent cholecystectomies, and two showed no cholecystitis on pathology. The third had mild to moderate cholecystitis with focal mucosal erosion/ulceration without gallbladder wall thickening on pathology. 18FDG PET-CT detected gallbladder inflammation in all but one patient with pathology-proven cholecystitis with a sensitivity and specificity of 0.90 and 1.00, respectively. 18FDG-PET-CT appears to be a promising, rapid, direct, and accurate test in diagnosing cholecystitis and could replace HIDA scan in cases that remain equivocal after ultrasound.
Effect of Socioeconomic Status on Surgery for Pancreatic Adenocarcinoma
Authors: Seyedin Steven , Luu Carrie , Stabile Bruce E. , Lee Byrne
Published: June 2020

Survival for pancreatic cancer remains poor. Surgical resection remains the only chance for cure. The intent of this study was to investigate the role of socioeconomic status (SES) on resection rates for pancreatic adenocarcinoma. The National Cancer Institute's Surveillance, Epidemiology, and End results database was used to identify patients with pancreatic adenocarcinoma. Disease was deemed resectable or unresectable based on the extent of disease code. Median family income was used as a SES variable to compare patients who underwent resection with those who did not. Median family income was organized into three categories based on definitions from the national census: less than $34,680 (low income), $34,680 to $48,650 (middle), and greater than $48,650 (high income). A total of 5,908 patients with potentially resectable disease were included. A total of 3,331 patients did not have a surgical resection despite having resectable disease. Subgroup analysis of income status revealed that patients with a low or middle income were less likely to have a resection when compared with those with high income (33.0 vs 39.9 vs 45.8%, P = 0.0001). Multivariate analysis revealed that low and middle SES and race were significant predictors of resection. Ongoing study of access to health care may help define the means to eliminate the disparities in the care of patients with pancreatic adenocarcinoma.
Are Community Hospitals Meeting the Same Standards as Academic Hospitals for the Multimodal Management of Rectal Cancer?
Authors: Chiu Connie G. , Hari Danielle M. , Leung Anna M. , Yoon Jeong-Lim , Sim Myung-Shin , Bilchik Anton J.
Published: June 2020

Although multimodal treatment (surgery, chemotherapy ± radiation) has improved survival in patients with rectal cancer, there are inconsistent treatment patterns in hospitals in the United States. The objective of the study was to evaluate whether treatment paradigms have changed for patients with Stage II and III rectal cancer in community hospitals compared with academic research hospitals, i.e., teaching or comprehensive hospitals engaged in research. The National Cancer Database was queried to identify all patients diagnosed with Stage II or III rectal adenocarcinoma between 2000 and 2008. The first course of treatment and patient clinicodemographic factors were evaluated. Of 70,409 patients in the study cohort, 7,235 (62.9%) at community hospitals, 24,465 (66.9%) at comprehensive hospitals, and 14,868 (66.6%) at teaching hospitals received multimodal therapy. Community hospitals were more likely to treat individuals who were older, white, and with lower income compared with the other facility types. Teaching hospitals treated a higher proportion of uninsured patients. Despite differences in patient demographics, community hospitals have increased the use of multimodal treatment for rectal cancer but continue to remain below academic research hospital standards.
Prophylactic Mastectomy: An Appraisal
Authors: Zagouri Flora , Chrysikos Dimosthenis T. , Sergentanis Theodoros N. , Giannakopoulou Georgia , Zografos Constantine G. , Papadimitriou Christos A. , Zografos George C.
Published: June 2020

The main indication of prophylactic mastectomy pertains to BRCA1 or BRCA2 mutation carriers. Prophylactic mastectomy includes the simple method and the subcutaneous method. Both methods can be followed by breast plastic reconstruction either at the same time or later. This review examines key issues regarding prophylactic mastectomy: the selection of patients, its effectiveness, its limitations, convergence/divergence in existing guidelines, and future perspectives.
Endovascular Graft Repair for Blunt Traumatic Disruption of the Thoracic Aorta: Experience at a Nonuniversity Hospital
Authors: Klima David A. , Hanna Erin M. , Christmas A. Britton , Huynh Toan T. , Etson Kristina E. , Fair Brett A. , Green John M. , Madjarov Jeko , Sing Ronald F.
Published: June 2020

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.
Risk Factors for Conversion from Laparoscopic to Open Surgery: Analysis of 2138 Converted Operations in the American College of Surgeons National Surgical Quality Improvement Program
Authors: Papandria Dominic , Lardaro Thomas , Rhee Daniel , Ortega Gezzer , Gorgy Amany , Makary Martin A. , Abdullah Fizan
Published: June 2020

Minimal access procedures have influenced surgical practice and patient expectations. Risk of laparoscopic conversion to open surgery is frequently cited but vaguely quantified. The present study examines three common procedures to identify risk factors for laparoscopic conversion to open (LCO) events. Cross-sectional analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP; 2005 to 2009) identified cases with laparoscopic procedure codes for appendectomy, cholecystectomy, and bariatric procedures. The primary outcome was conversion of a laparoscopic procedure to its open equivalent. Summary statistics for laparoscopic and LCO groups were compared and logistic regression analysis was used to estimate patient and operative risk factors for conversion. Of 176,014 selected laparoscopic operations, 2,138 (1.2%) were converted. Most patients were female (68%) and white (71.2%); mean age was 45.1 years. LCO cholecystectomy was significantly more likely (n = 1526 [1.9%]) and LCO bariatric procedures were less likely (n = 121 [0.3%]); appendectomy was intermediate (n = 491 [1.0%], P < 0.001). Patient factors associated with LCO included male sex ( P < 0.001), age 30 years or older ( P < 0.025), American Society of Anesthesiologists Class 2 to 4 ( P < 0.001), obesity ( P < 0.01), history of bleeding disorder ( P = 0.036), or preoperative systemic inflammatory response syndrome or sepsis ( P < 0.001). LCO was associated with greater incidence of postoperative complications, including death, organ space surgical site infection, sepsis, wound dehiscence, and return to the operating room ( P < 0.001). Overall LCO incidence is low in hospitals participating in ACS-NSQIP. Conversion risk factors include patient age, sex, obesity, and preoperative comorbidity as well as the procedure performed. This information should be valuable to clinicians in discussing conversion risk with patients.
The Efficacy and Morbidity of Different Surgical Treatment Techniques for Chronic Anal Fissure: An Academic Colorectal Experience
Authors: Yurko Yuliya , Crockett Jay A. , Culumovic Patrick J.
Published: June 2020

Up to 40 per cent of chronic fissures will fail to heal with medical treatment alone. Open (OLIS) and closed (CLIS) lateral internal sphincterotomies are considered by many to be the treatment of choice for chronic anal fissures (CAF). The aim of this study was to compare the efficacy and clinical outcomes of different surgical techniques for treatment of CAF. We performed a retrospective chart review of 387 patients with CAF who underwent surgical intervention performed by colorectal surgeons between 2006 and 2012 at Greenville Hospital System. Of 387 patients, 199 underwent OLIS, 124 CLIS, and 64 patients underwent fissurectomy alone (FE). We investigated the effect of the surgical technique on time of healing, rate of flatus incontinence, wound infection, recurrence, and the need for additional intervention. There was no statistically significant difference among patients undergoing OLIS, CLIS, and FE in demographic characteristic, time of healing, rate of wound infections, and fecal continence, or recurrence rate. Comparison of a combined lateral internal sphincterotomy (LIS) group with FE showed that there is similar time of healing ( P = 0.58), no statistical difference in flatus incontinence rate ( P = 0.61), urinary retention ( P = 1.0), fissure recurrence ( P = 0.11), and prolonged healing ( P = 0.2). Patients in FE group more likely required additional treatment to complete wound healing ( P = 0.02). LIS is a safe and effective technique for treatment of CAF. Although there was no difference in complications rate and healing time, patients in the FE group required additional surgical or medical treatment more frequently to achieve complete healing.