bluuebunny/crossref_metadata_2025 huggingface dataset:
Pancreatic Stent Placement is Associated with Resolution of Refractory Grade C Pancreatic Fistula after Left-Sided Pancreatectomy
Authors: Grobmyer Stephen R. , Hunt Darrell L. , Forsmark Christopher E. , Draganov Peter V. , Behrns Kevin E. , Hochwald Steven N.
Published: June 2020

Pancreatic fistula have been a source of significant morbidity and mortality after left-sided pancreatectomy. The majority of fistulas are classified as Grade A and resolve quickly with no intervention. Grade C pancreatic fistulas, which require percutaneous or operative drainage, are less common and may be associated with morbidity and mortality. We used postoperative endoscopic pancreatic stent placement as an adjunctive strategy in the management of refractory Grade C pancreatic fistulas. Patients undergoing endoscopic pancreatic stent placement for persistent, refractory peripancreatic fluid collections/pancreatic fistula after left-sided pancreatectomy were identified. Eight patients underwent endoscopic pancreatic stent placement for refractory Grade C pancreatic fistulas. Six patients had percutaneous catheter placement; two patients had trans-gastric drainage. Endoscopic retrograde cholangiopancreatography (ERCP) showed extravasation of contrast from the distal end of the pancreatic duct in seven patients. Pancreatic stents were placed in all patients at a median time of 48 days postoperation and left for a median of 47 days. Before stent removal, ERCP demonstrated pancreatic fistula closure. Median time to complete resolution of the fistula was 41 days after stent placement. Endoscopic pancreatic stents were associated with resolution of Grade C fistulas. After distal pancreatectomy, pancreatic stent placement should be considered in the postoperative period for refractory pancreatic fistulas.
Incidence of Surgical Site Infections Postcolorectal Resections without Preoperative Mechanical or Antibiotic Bowel Preparation
Authors: Howard Drew D. , White Cassandra Q. , Harden Tara R. , Ellis C. Neal
Published: June 2020

This study was performed to determine the incidence of surgical site infections (SSIs) after colorectal resection in patients without mechanical or antibiotic bowel preparation. A retrospective review of the medical records of 136 consecutive patients undergoing an elective colorectal resection between April 2004 and April 2006 was performed. Indications for colon resection in this series were malignant neoplasia (48%), inflammatory bowel disease (18%), diverticular disease (17%), or other benign disease (17%). Overall, an SSI occurred in 31 patients (23%). An SSI occurred in 16 of 90 patients (17.8%) who received antibiotics within 1 hour before surgery and in 15 of 46 patients (33.3%) who did not receive antibiotics in a timely manner ( P < 0.05). An SSI occurred in seven of 15 patients (46.7%) who received bowel preparation but in only 24 of 121 patients (19.8%) who did not receive either mechanical or antibiotic bowel preparation ( P < 0.029). SSIs were not associated with age, gender, diagnosis, length of procedure, preoperative steroid use, diabetes mellitus, or previous celiotomy. This series shows administration of perioperative antibiotics within 1 hour before surgery is associated with a significant decrease in the incidence of SSI and bowel preparation can be safely omitted.
Blood Utilization at a Level I Trauma Center: Is this as Good as it Gets?
Authors: Harrison Sebron W. , Griffin Russell L. , Kerby Jeffrey D. , Marques Marisa B. , Rue Loring W. , Weinberg Jordan A.
Published: June 2020

Recognition of the adverse effects of allogeneic blood resulted in the decreased use of red blood cell (RBC) transfusion in surgical practice in the 1990s. Our objective was to evaluate patterns of RBC transfusion utilization among trauma patients during the current decade. Blunt trauma patients admitted to a regional trauma center between 2000 and 2007 were identified (n = 16,011). Annual trends in RBC utilization were estimated (negative binomial regression for continuous dependent variables and logistic regression for dichotomous variables). Models were stratified by Injury Severity Score to adjust for injury severity. Although the proportion of patients receiving a blood transfusion within 48 hours of hospitalization significantly increased ( P < 0.0001), there was no significant change in the rate of units transfused ( P = 0.5152) among transfused patients. After stratification by Injury Severity Score, a significantly decreasing trend in the proportion of severely injured patients transfused was observed ( P = 0.0243). Annual variation in the relatively less injured groups was not significant. In the current decade, transfusion utilization at a Level I trauma center has demonstrated minimal variation on a year-to-year basis. Among the severely injured, the temporal decrease in relatively early utilization of RBC transfusion may reflect increasing inclination to accept a greater degree of anemia in higher acuity patients.
Clinical Significance of p53 and bcl-2 Protein Coexpression Phenotypes in Molecular Breast Cancer Subtypes of Pre-menopausal and Post-menopausal African-American Women
Authors: Ihemelandu Chukwuemeka U. , Dewitty Robert L. , Leffall Lasalle D. , Suryanarayana Siram M. , Frederick Wayne A.
Published: June 2020

With the current classification of breast carcinoma into molecular subtypes with distinct prognosis and response to therapy, we sort to assess the clinical significance of p53 and bcl-2 coexpression phenotypes in invasive breast tumors and correlate this to the different molecular breast cancer subtypes in African-American women. We performed a retrospective analysis of data on p53 and bcl-2 expression. Results were correlated to molecular breast cancer subtypes, and clinicopathologic variables of prognostic significance. Our study sample included all African-American women diagnosed with breast cancer from 1998 to 2005. Twenty-seven (27.6%) per cent of cases in our study sample over-expressed p53, whereas 69.3 per cent over-expressed bcl-2 protein. A significant inverse correlation was observed between expression of p53 and bcl-2. Combined analysis of p53 and bcl-2 showed that 53.2 per cent of the tumors displayed p53(-)bcl-2(+) phenotype which was significantly associated with the luminal A subtype, whereas 11.6 per cent displayed the p53(+)bcl-2(-) phenotype which was significantly associated with the basal cell-like and Her-2/neu. Neither p53 expression nor bcl-2 expression individually or in combination were of independent prognostic significance. p53(+)bcl-2(-) phenotype is significantly correlated with the basal cell-like subtype and may be associated with the biologic aggressiveness of this cohort of molecular breast cancer.
Wasted Hospital Days Impair the Value of Length-of-Stay Variables in the Quality Assessment of Trauma Care
Authors: Jacobs David G. , Sarafin Jennifer L. , Norton H. James , Christmas A. Britt , Huynh Toan , Sing Ronald F.
Published: June 2020

Hospital length of stay (LOS) is frequently used to evaluate the quality of trauma care but LOS may be impacted by nonmedical factors as well. We reviewed our experience with delays in patient discharge to determine its financial consequences and its impact on LOS. We performed an analysis of linked trauma registry and “delayed discharge” databases. Actual LOS (A-LOS) values were compared with calculated ideal LOS (I-LOS) values, and the per cent increase in LOS was calculated. Linear regression analysis was used to identify significant predictors of prolonged LOS. One thousand, five hundred and seventeen patients were studied, with an A-LOS of 6.54 days. Seven per cent of patients experienced discharge delays, resulting in 580 excess hospital days. Calculated I-LOS was 6.15 days, 6.34 per cent lower than A-LOS. Other I-LOS estimates were as much as 25 per cent lower than A-LOS. Estimated excess patient charges associated with delayed discharges were $4,000,000 to $15,000,000. Discharge delays are an infrequent, although costly, occurrence that has a significant impact on LOS. LOS therefore may not be an appropriate metric for assessing the quality of trauma care, and should only be used if it has been corrected for discharge delays. Concerted efforts should be directed towards identifying and correcting the factors responsible for delayed discharge in trauma patients.
Clinical Implications of the Seat Belt Sign in Blunt Trauma
Authors: Sharma Om P. , Oswanski Michael F. , Kaminski Brian P. , Issa Nabil M. , Duffy Brian , Stringfellow Kathryn , Lauer Sherry K. , Stombaugh Heather A.
Published: June 2020

Patients with the seat belt sign (SBS) from motor vehicle crashes (MVCs) are prone to specific regional injury patterns. Investigators at a Level 1 trauma center analyzed the incidence, clinical implications, and spectrum of regional injuries in patients injured in MVC over 2 years. SBS was seen in 11.3 per cent of patients injured in MVCs and 20.5 per cent of patients with known restraint use. Restrained patients were less severely injured with lower injury severity scores (7.62 vs 11.33) and mortality (1.1 vs 5.7%). Patients with SBS had lower mortality rates than patients without SBS (1.4 vs 3.7%). Thoraco-abdominal injuries were present in 47 per cent (34 of 72) of patients with SBS. Compared with patients without SBS, patients had a higher incidence of hollow viscous injuries (HVI) and solid organ trauma (8 and 17% vs 1 and 3%, P < 0.05); splenic trauma was 24-fold higher (9.7 vs 0.4%), liver injuries 3.1-fold higher (6 vs 3%), and rib fractures 2.4-fold higher ( P < 0.05). Children had 2.8-fold higher rates of HVI (18 vs 9%, P < 0.05). SBS is associated with underlying regional injuries in nearly half of patients with a higher prevalence of HVI and solid organ trauma.
Postoperative Hypocalcemia after Parathyroidectomy for Renal Hyperparathyroidism in the Era of Cinacalcet
Authors: Meyers Michael O. , Russell Christina P. , Ollila David W. , Yeh Jen Jen , Kim Hong Jin , Calvo Benjamin F.
Published: June 2020

Chronic kidney disease is often accompanied by hyperparathyroidism. Cinacalcet, a recent addition to the medical armamentarium, has proven efficacious. It is unclear whether cinacalcet use has any impact on the postoperative course in patients progressing to surgery. The records of 77 patients operated on for renal hyperparathyroidism were reviewed. Sixty-three were treated before the use of cinacalcet and 14 after. Ten subtotal and 67 total parathyroidectomies were performed. Mean nadir serum calcium was similar (6.6 ± 1.3 vs 6.2 ± 1.4 mg/dL). More patients taking cinacalcet preoperatively required intravenous calcium postoperatively (62%) than those treated before its use (41%), although this did not reach statistical significance ( P = 0.09). In those undergoing total parathyroidectomy, cinacalcet use preoperatively (n = 11) led to a lower postoperative nadir calcium (5.8 ± 1.7 vs 6.6 ± 1.3 mg/dL) as compared with those who did not receive it (n = 56) ( P = 0.05). This translated to a greater need for intravenous calcium infusion postoperatively (72 vs 38%) ( P = 0.03). These data suggest a somewhat more aggressive postoperative course in patients who fail calcimimetic and require surgery. This may be useful to inform physicians and patients of expectations postoperatively, although it is not likely to alter management.
Disparities in the Surgical Management of Women with Stage I Breast Cancer
Authors: Olaya Windy , Wong Jan H. , Morgan John W. , Roy-Chowdhury Sharmila , Lum Sharon S.
Published: June 2020

We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile ( P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) ( P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.
A Disease-Based Comparison of Liver Transplantation Outcomes
Authors: Mailey Brian , Buchberg Brian , Prendergast Christie , Artinyan Avo , Khalili Joshua , Sanchez-Luege Nicelio , Colquhoun Steven D. , Kim Joseph
Published: June 2020

An increasing demand for transplant donor organs has made optimal allocation of resources a priority. Our objective was to evaluate outcomes for orthotopic liver transplantation (OLT) performed in the United States. A query of the United Network for Organ Sharing registry between 1988 and 2007 was performed for patients who underwent OLT for all etiologies. Patients were stratified by pathology necessitating OLT and clinical and pathologic factors were compared. Multivariate Cox-regression analysis was used to assess the association of pathology with survival. Of 61,823 patients, 33 per cent (n = 20,305) of OLTs were secondary to hepatitis C virus, 21 per cent autoimmune disease, 17 per cent alcohol-induced injury, 11 per cent cryptogenic cirrhosis, 8 per cent hepatocellular carcinoma (HCC), 6 per cent hepatitis B virus, and 4 per cent metabolic disease. Patients with autoimmune disease and HCC demonstrated the best and worst survival, respectively, after OLT (median survival 16.0 vs 6.4 yrs, respectively, P < 0.001). By multivariate analysis, OLT for HCC was significantly associated with poorer overall survival (hazard ratio [HR] 2.19,95% confidence interval [CI]: 2.02-2.37, P < 0.001). Our results indicate that outcomes for liver transplantation vary by primary hepatic pathology with HCC patients having the poorest overall survival. To optimize organ allocation for all patients with end-stage liver disease, a better understanding of poor survival for HCC is necessary.
Minimally Invasive Esophagectomy without the Use of Postoperative Nasogastric Tube Decompression
Authors: Nguyen Ninh T. , Slone Johnathan , Wooldridge James , Smith Brian R. , Reavis Kevin M. , Hoyt David
Published: June 2020

A nasogastric tube (NGT) is commonly used in the postoperative period after esophagectomy for decompression of the gastric conduit. The aim of this study was to evaluate the safety of a minimally invasive esophagectomy without the use of NGT decompression. We performed a retrospective review of 124 patients who underwent minimally invasive esophagectomy. Ninety-eight patients had an NGT placed for postoperative decompression and 26 patients did not. The main outcome measure was postoperative complications in regard to the gastric conduit and esophageal anastomosis. There were 96 males with a mean age of 65 ± 11 years. Three (3%) of 98 patients with operative NGT placement developed postoperative complications directly related to the NGT, which included perforation of the gastric conduit (n = 1) and perforation of the anastomosis (n = 2). In the 26 patients without operative NGT decompression, one patient (3.8%) had distention of the gastric conduit requiring placement of a NGT under fluoroscopic guidance on postoperative Day 1. There was no significant difference in the leak rate between the groups with NGT decompression compared with the group without NGT decompression (9.2 vs 7.7%, respectively). In conclusion, the use of NGT decompression during minimally invasive esophagectomy can be safely omitted. In cases with postoperative gastric conduit distention, an NGT can be safely placed under fluoroscopic guidance.
Increased Use of MRI for Breast Cancer Surveillance and Staging is Not Associated with Increased Rate of Mastectomy
Authors: Dang Catherine M. , Zaghiyan Karen , Karlan Scott R. , Phillips Edward H.
Published: June 2020

The use of MRI in preoperative staging of breast cancer has escalated recently. Breast MRI has greater sensitivity than mammography, ultrasound, and clinical examination in cancer detection. Because of its variable specificity, however, there has been concern that increased MRI use will result in increased rates of mastectomy for early-stage breast cancer. We postulated that mastectomy rates are not affected by trends in MRI use. We performed a retrospective analysis of imaging tests ordered by surgeons at our breast center from 2003 to 2007. We also reviewed all breast cancer cases reported to the National Cancer Database from our institution during the same time period and categorized them as having been treated with mastectomy or breast-conserving surgery. From 2003 to 2007, the number of breast MRIs ordered annually by surgeons increased from 68 to 358. The rate of MRI use increased from 4.1 per every 100 patients seen to 5.7 and from 1.6 per every 100 new patients seen to 2.9. The percentage of women undergoing mastectomy for breast cancer remained unchanged during this 5-year interval. Therefore, although MRI use in breast cancer staging and surveillance has increased, mastectomy rates have not.
In the Era of Routine Use of CT Scan for Acute Abdominal Vain, Should All Adults with Small Bowel Intussusception Undergo Surgery?
Authors: Olasky Jaisa , Moazzez Ashkan , Barrera Kaylene , Clarke Tatyan , Shriki Jabi , Sohn Helen J. , Katkhouda Namir , Mason Rodney J.
Published: June 2020

In contrast to adult colonic intussusception in which malignancy is the dominant cause, small bowel intussusceptions are mostly benign. Although surgery is the accepted standard treatment, its necessity in small bowel intussusceptions identified by CT scan is unknown. Twenty-three patients from 2005 to 2008 (16 males; median age, 44 years) with acute abdominal pain and CT-proven small bowel intussusception were studied. Factors associated with the necessity for surgery were determined. Among 11 patients who were managed operatively, surgery was deemed unnecessary in two patients based on negative explorations. Follow up in 10 of 12 patients managed nonoperatively was not associated with any recurrence of intussusception or malignancy (median follow up, 14 months). The only predictor of the need for surgery was CT evidence of small bowel obstruction and/or a radiologically identified lead point, which was present in 7 of 9 (78%) patients having a necessary operation and absent in 12 of 14 (86%) with no indication for surgery (P = 0.008). All small bowel intussusceptions found on CT scan in patients with acute abdominal pain do not require operative management. CT findings of small bowel obstruction and/or presence of a lead point are indications for surgery.
Groin Herniorrhaphy in Patients with Cirrhosis and after Liver Transplantation
Authors: Lawson Elise H. , Benjamin Elizabeth , Busuttil Ronald W. , Hiatt Jonathan R.
Published: June 2020

We report on 43 groin herniorrhaphy operations, 18 in 18 patients with documented cirrhosis and 25 in 24 patients after liver transplantation (LT), over a 10-year period at UCLA. Average follow up was 33 months. Most patients were males (84%) with reducible inguinal hernias (70%). Child's class of cirrhotic patients was B in 66 per cent and A and C in 17 per cent each; 7 patients (39%) went on to LT. Compared with post-LT patients, patients with cirrhosis had significantly lower platelets and significantly higher bilirubin, international normalized ratio, and Model for End-stage Liver Disease scores. Mesh was used in 33 per cent of the cirrhotic group and 48 per cent of the LT group. There were four minor wound complications but no deaths, major complications, infections, or ascitic leaks in either group. Two hernias recurred in the cirrhosis group (11%) and none after LT. We conclude that with proper patient selection, groin herniorrhaphy with or without mesh is a safe and durable procedure in patients with cirrhosis and after LT. This is the first large series of groin herniorrhaphy after LT.
Recent Experience with Abdominal Perineal Resection with Vertical Rectus Abdominis Myocutaneous Flap Reconstruction after Preoperative Pelvic Radiation
Authors: Hinojosa Marcelo W. , Parikh Dhavan A. , Menon Raman , Wirth Garrett A. , Stamos Michael J. , Mills Steven
Published: June 2020

Abdominoperineal resection (APR) after pelvic radiation can be complicated by an increased rate of difficult to treat perineal wound complications. In an effort to improve postoperative morbidity after APR, myocutaneous flap reconstructions have been used. We review our recent experience with APR with vertical rectus abdominis myocutaneous flap reconstruction (VRAM) after preoperative pelvic radiation. A retrospective review of patients who underwent APR with VRAM reconstruction after pelvic radiation from December 2004 to July 2008 was conducted. Outcome measures included demographics, comorbidities, length of stay, wound complications, and morbidity and mortality. Fifteen patients with a mean age of 61 ± 9 years underwent APR with VRAM reconstruction. Five patients also required posterior vaginectomy with the APR. Indications for APR were rectal cancer (n = 14, 93%) and anal canal cancer (n = 1, 7%). There were no intraoperative complications. Mean estimated blood loss was 635 ± 446 mL and mean intraoperative blood transfusion requirements were 1 ± 2 units. Mean length of hospital stay was 11 ± 4 days. Six (40%) patients had minor perineal wound complications. One (7%) patient had a perineal wound infection requiring reoperation with washout and reapproximation. There was no 30-day or in-hospital mortality. All VRAM flaps remained viable through follow-up. APR with VRAM flap reconstruction after preoperative pelvic radiation can be performed safely with limited wound complications and no mortality.
The Incidence and Clinical Significance of Pneumomediastinum Found on Computed Tomography Scan in Blunt Trauma Patients
Authors: Molena Daniela , Burr Nicole , Zucchiatti Andrea , Lovria Erik , Gestring Mark L. , Cheng Julius D. , Bankey Paul E. , Stassen Nicole A.
Published: June 2020

With the increased use of chest computed tomography (CT) scan in the initial evaluation of major trauma, findings that were not seen on a chest radiograph (CXR) are increasingly identified. Pneumomediastinum (PM) seen on CXR in blunt trauma patients is considered worrisome for airway and/or esophageal injury. The purpose of this study was to determine the incidence and clinical significance of PM found on CT in blunt trauma patients. Blunt trauma patients admitted to a single Regional Trauma Center over a 2-year period were identified. Records were reviewed for demographics, mechanism, diagnostic evaluations, injuries, and outcome. A total of 2052 patients met study criteria. Fifty-five (2.7%) had PM; 49 patients (89%) had PM identified on CT alone, whereas six patients (11%) had it identified on both CXR and CT. There was no significant difference in gender or age between the two groups. Associated injuries were similar between groups. No patients had tracheobronchial or esophageal injuries. In this study, PM seen on CT was found to have little clinical significance other than as a marker for severe blunt trauma. No patients with airway or esophageal injuries were seen in any of the PM patients.
Assessment of Acute Trauma Care Training in Kenya
Authors: Macleod Jana B.A. , Gravelin Sara , Jones Tait , Gololov Alex , Thomas Michelle , Omondi Benson , Bukusi E.
Published: June 2020

An Acute Trauma Care (ATC) course was adapted for resource-limited healthcare systems based on the American model of initial care for injured patients. The course was taught to interested medical personnel in Kenya. This study undertook a survey of the participants’ healthcare facilities to maximize the applicability of ATC across healthcare settings. The ATC course was conducted three times in Kenya in 2006. A World Health Organization (WHO) Needs Assessment survey was administered to 128 participants. The data were analyzed qualitatively and quantitatively. Ninety-two per cent had a physician available in the emergency department and 63 per cent had a clinical officer. A total of 71.7 per cent reported having a designated trauma room. A total of 96.7 per cent reported running water, but access was uninterrupted more often in private hospitals as opposed to public facilities (92.5 vs 63.6%, P = 0.0005). Private and public employees equally had an oxygen cylinder (95.6 vs 98.5%, P > 0.05), oxygen concentrator (69.2 vs 54.2%, P = 0.12), and oxygen administration equipment (95.7 vs 91.4%, P > 0.05) at their facilities. However, private employees were more likely to report that “all” of their equipment was in working order (53 vs 7.9%, P < 0.0001). Private employees were also more likely to report that they had access to information on emergency procedures and equipment (64.4 vs 33.3%, P = 0.001) and that they had learned new procedures (54.8 vs 25.4%, P = 0.002). Despite a perception of public facility lack, this survey showed that public institutions and private institutions have similar basic equipment availability. Yet, problems with equipment malfunction, lack of repair, and availability of required information and training are far greater in the public sector. The content of the ATC course is valid for both private and public sector institutions, but refinements of the course should focus on varying facets of inexpensive and alternative equipment resources. Furthermore, the implementation of this course should create a setting that advocates, promotes, and investigates resources. The WHO survey can guide future research in understanding impediments to implementing essential trauma care courses for resource limited healthcare systems.
The Use of Barbiturate Coma as Salvage Therapy in a Postoperative Jehovah's Witness Patient with Life-Threatening Anemia
Authors: Wang Steve W. , Badami Chirag D. , Deitch Edwin A.
Published: June 2020

Management of the patient who refuses blood products based on religious grounds poses ethical and clinical challenges, especially when the degree of anemia becomes life-threatening. In this report, we present the case of a 52-year-old Jehovah's Witness with sickle cell disease in whom he and his family refused blood products for the treatment of severe anemia associated with profound and progressive acidosis, acute oliguric renal failure, and hemodynamic instability. Attempts carried out during the first 3 hospital days to stabilize the patient using standard therapies to support oxygen delivery as well as the use of sedation, pain control, temperature control, neuromuscular blockade, and mechanical ventilation to reduce oxygen demand were not successful. Thus, because oxygen consumption by the brain represents approximately 20 per cent of the body's oxygen needs, and pentobarbital's primary action is as a central nervous system depressant, the induction of pentobarbital coma was instituted to reduce cerebral oxygen consumption. The institution of pentobarbital on hospital Day 3 was sufficient to acutely stabilize the patient's deteriorating metabolic state and ultimately was associated with survival. Thus, we conclude that there is a potential role for barbiturate coma in Jehovah's Witness patients who refuse blood transfusions and dying of anemia when other modalities of support are not sufficient.
Vasopressin in Hemorrhagic Shock: Review Article
Authors: Rajani Ravi R. , Ball Chad G. , Feliciano David V. , Vercruysse Gary A.
Published: June 2020

Trauma with resultant hypovolemic shock remains both prevalent and difficult to treat. Standard strategies using volume resuscitation and catecholamine support have historically yielded poor results. Vasopressin has emerged as a possible pharmacologic adjunct, particularly in patients with shock refractory to the administration of fluids and catecholamines. Much of the data regarding vasopressin is extrapolated from its usefulness in cases of nonhypovolemic human shock, which are supported by convincing animal studies. It is true that humans show a deficiency in vasopressin minutes after significant hemorrhage that can respond to administration of exogenous vasopressin. When given in physiological dosing regimens, vasopressin appears to be a safe adjunct to other therapy. Definite recommendations regarding indications for use, recommended dose, and long-term outcome in patients with hemorrhagic shock await a much needed prospective, randomized, controlled trial.
‘Normal’ Vital Signs Belie Occult Hypoperfusion in Geriatric Trauma Patients
Authors: Martin Jeremiah T. , Alkhoury Fuad , O'Connor Judith A. , Kyriakides Tassos C. , Bonadies John A.
Published: June 2020

Base deficit (BD) and lactic acid (LA) are accepted markers of hypoperfusion and predictors of outcome in the trauma patient and we aim to assess the value of these markers in the triage of the elderly with “normal” vital signs. Patients older than age 65 who presented between 1997 and 2004 but who did not have isolated head injuries were included. Three patient groups were established: normal, occult hypoperfusion (OH), and shock. Outcome measures included mortality, hospital length of stay, intensive care unit length of stay, and discharge disposition. One hundred six patients were included in the analysis and had similar Injury Severity Scores. Mean systolic blood pressure was similar in the normal and OH groups. Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH. These patients were more likely to have a longer intensive care unit length of stay (8.6 days vs 3 days; P = 0.01) and were also more likely to be discharged to a nursing facility ( P = 0.03). The trend was toward increased mortality in the OH group. OH is a common finding in elderly trauma patients. Outcomes in these patients are different and more like those presenting in shock.
Mannequin Simulation Improves the Confidence of Medical Students Performing Tube Thoracostomy: A Prospective, Controlled Trial
Authors: Hishikawa Shuji , Kawano Masaki , Tanaka Hozumi , Konno Kenjiro , Yasuda Yoshikazu , Kawano Ryutaro , Kobayashi Eiji , Lefor Alan T.
Published: June 2020

This study was undertaken to determine the educational benefits of mannequin simulation for performance of tube thoracostomy in a porcine model by medical students. Thirty medical students were randomized into two groups; the first performed tube thoracostomy on a mannequin simulator and then a porcine model; the second used only the porcine model. Performance measures included completion of subtasks, time to perform the procedure, a global score assigned by faculty raters, and a self-evaluation survey. Subtask completion rate was similar in both groups ( P > 0.05). Mean time to perform the procedure was 9.8 minutes (±0.9, simulator), and 9.3 minutes (± 1.0, nonsimulator, P > 0.05). Global scores were 12.3 (±1.3, simulator) and 11.0 (±1.4, non-simulator, P > 0.05). Self-evaluation of confidence (1= “very”, 7= “not at all”) showed the simulator group was significantly more confident (3.4 ± 0.42) than the nonsimulator group (4.7 ± 0.49, P < 0.05). All students met basic competencies to perform tube thoracostomy. The simulator group felt significantly more confident to subsequently perform the procedure on a patient, whereas performance was not statistically significantly different for the two groups. Further trials may be needed to delineate the optimal role for these simulators in teaching tube thoracostomy.
Surgical Anatomy of the Retroperitoneal Spaces, Part III: Retroperitoneal Blood Vessels and Lymphatics
Authors: Mirilas Petros , Skandalakis John E.
Published: June 2020

In this article, we discuss the surgical anatomy of the blood vessels and the lymphatic vessels and lymph nodes found in the retroperitoneum. Retroperitoneal blood vessels include the aorta and all its branches—parietal and visceral—from the diaphragm to the pelvis, and the inferior vena cava and its tributaries. The retroperitoneal lymphatics form a very rich and extensive chain. As a general rule, lymphatics follow the arteries and named lymph nodes are found at the root of the arteries. Retroperitoneal nodes of the abdomen comprise the inferior diaphragmatic nodes and the lumbar nodes. The latter are classified as left lumbar (aortic), intermediate (interaorticovenous), and right lumbar (caval). These nodes surround the aorta and the inferior vena cava. Around the aorta lie the paraortic nodes, preaortic nodes (include celiac, superior mesenteric, inferior mesenteric nodes collecting lymph from the splanchna supplied by the homonymous arteries), and retroaortic nodes. Similarly, around the vena cava lie the paracaval, precaval, and retrocaval nodes. Pelvic nodes include the common iliac, external and internal iliac, obturator, and sacral nodes.
All-Terrain Vehicle Safety in Florida: Is Legislation Really the Answer?
Authors: Winfield Robert D. , Mozingo David W. , Armstrong John H. , Hollenbeck John I. , Richards Winston T. , Martin Larry C. , Beierle Elizabeth A. , Lottenberg Lawrence
Published: June 2020

Florida is among the nation's leaders in all-terrain vehicle (ATV)-related injuries and fatalities. We hypothesized that patients sustaining injuries while in compliance with ATV laws would demonstrate less severe injury patterns and improved outcomes when compared with noncompliant patients. We reviewed patients treated for ATV-related injuries over a 36-month period. We grouped patients according to conformity with Florida statutes and compared demographics, admission status, injuries sustained, and outcome measures. Three hundred seventy-seven patients were treated for ATV-related injuries. In 294 cases, sufficient data existed to assess compliance with Florida's statutes regarding ATV rider safety: safety helmet use for persons younger than age 16 years and prohibition of ATV operation on roadways. Forty-three per cent (n = 126) had violated one or both statutes; 57 per cent (n = 168) had violated neither. The group in violation was younger (15 vs 24 years, P < 0.001) and wore helmets less often (6 vs 34%, P < 0.001). Groups required admission at similar rates (62% violators vs 60% nonviolators, P = 0.770), showed similar injury patterns, and had comparable mortality rates (2% violators vs 5% nonviolators, P = 0.451). Current Florida laws are inadequate to prevent ATV-related injuries and their sequelae. This issue should be addressed through an increased focus on safety education for ATV operators.
40-Slice Multidetector CT: Is MRI Still Necessary for Cervical Spine Clearance after Blunt Trauma?
Authors: Menaker Jay , Stein Deborah M. , Philp Allan S. , Scalea Thomas M.
Published: June 2020

We have recently demonstrated that 16-slice multidetector CT (MDCT) is insufficient for cervical spine (CS) clearance in patients with unreliable examinations after blunt trauma. The purpose of this study was to determine if a negative CS CT using 40-slice MDCT is sufficient for ruling out CS injury in unreliable blunt trauma patients or if MRI remains necessary for definitive clearance. In addition, we sought to elucidate the frequency by which MRI alters treatment in patients with a negative CS CT who have a reliable examination with persistent clinical symptoms. The trauma registry was used to identify all patients with blunt trauma who had a negative CS CT on admission using 40-slice MDCT and a subsequent CS MRI during their hospitalization from July 2006 to July 2007. Two hundred thirteen patients were identified. Overall, 24.4 per cent patients had abnormal MRIs. Fifteen required operative repair; 23 required extended cervical collar; and 14 had collars removed. A total of 8.3 per cent of patients with an unreliable examination and 25.6 per cent of reliable patients had management changed based on MRI findings. Overall, MRI changed clinical practice in 17.8 per cent of all patients. Despite newer 40-slice CT technology, MRI continues to be necessary for CS clearance in patients with unreliable examinations or persistent symptoms.
Application of Portal Parenchyma–Enterostomy after High Hilar Resection for Bismuth Type IV Hilar Cholangiocarcinoma
Authors: Cheng Yu , Chen Yuxin , Chen Hongqiang
Published: June 2020

For the surgical treatment of Bismuth Type IV hilar cholangiocarcinoma, it is difficult to achieve curative resection (R0 resection) with restrictive excision (local resection and parenchyma-preserving liver resection) as a result of the complexity and difficulty in biliary reconstruction. Extended hepatectomy with vessel resection can improve the rate of curative resection, but it can also give rise to postoperative complications and mortality. We proposed a high hilar resection and portal parenchyma–enterostomy method to improve the surgical procedure. Eleven patients with Bismuth IV hilar cholangiocarcinoma underwent high hilar resection (resection for tumors in bile ducts and 1 cm above the tumors including segments IVb, V, and part of the caudate liver lobe) and the biliary tract was reconstructed through a portal parenchyma–enterostomy. Biliary radicles were not ligated but were drained into the “bile lake.” No cases of perioperative death were observed. Four weeks after surgery, patients’ serum aspartate aminotransferase, alanine aminotransferase, and total bilirubin were decreased evidently. The average survival was 25.3 months. In conclusion, the portal parenchyma–enterostomy procedure can be performed with increased curative rate and reduced parenchyma resection, extending the survival time of patients and improving patients’ quality of life.
The Epidemiology of Dog Attacks in an Urban Environment and the Risk of Vascular Injury
Authors: Benfield Rodd , Plurad David S. , Lam Lydia , Talving Peep , Green Donald J. , Putty Brad , Inaba Kenji , Cestero Ramon , Demetriades Demetrios
Published: June 2020

We performed this study to determine the associated injuries after dog attacks and determine the incidence of vascular injury (VI) and potential associated factors. The registry at our Level I center was queried for admissions after dog bites between January 1,1992 and June 30, 2008. Demographic, injury, and outcome data were studied. We examined associations with VI. There were 86 eligible patients. Most were male (57,66.3%). Mean age was 34.1 (±20.1). Mean injury severity score was 3.9 (±4.3). The most common serious injury was upper extremity fracture and/or dislocation (26,30.2%), followed by VI (10,11.6%) to the extremities (8, 9.3%) and neck (2, 2.3%). There were 44 (51.2%) operative cases including 28 (32.6%) wound debridements and 22 (25.6%) orthopedic interventions. Nine (10.5%) VI patients required operation. Mean length of stay was 5.7 (±5.9) days. There were two (2.3%) deaths. Both were unrelated to the attack. No studied variable reliably predicted VI. Many patients admitted after dog attacks will require an operative intervention and several will harbor a VI. The presence of VI is unpredictable, lacking reliable associated patient and admission factors. A high index of suspicion is required in the evaluation of patients involved in dog attacks.
Surgical Anatomy of the Retroperitoneal Spaces, Part IV: Retroperitoneal Nerves
Authors: Mirilas Petros , Skandalakis John E.
Published: June 2020

We present surgicoanatomical topographic relations of nerves and plexuses in the retroperitoneal space: 1) six named parietal nerves, branches of the lumbar plexus: iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, femoral. 2) The sacral plexus is formed by the lumbosacral trunk, ventral rami of S1–S3, and part of S4; the remainder of S4 joining the coccygeal plexus. From this plexus originate the superior gluteal nerve, which passes backward through the greater sciatic foramen above the piriformis muscle; the inferior gluteal nerve also courses through the greater sciatic foramen, but below the piriformis; 3) sympathetic trunks: right and left lumbar sympathetic trunks, which comprise four interconnected ganglia, and the pelvic chains; 4) greater, lesser, and least thoracic splanchnic nerves (sympathetic), which pass the diaphragm and join celiac ganglia; 5) four lumbar splanchnic nerves (sympathetic), which arise from lumbar sympathetic ganglia; 6) pelvic splanchnic nerves (nervi erigentes), providing parasympathetic innervation to the descending colon and pelvic splanchna; and 7) autonomic (prevertebral) plexuses, formed by the vagus nerves, splanchnic nerves, and ganglia (celiac, superior mesenteric, aorticorenal). They include sympathetic, parasympathetic, and sensory (mainly pain) fibers. The autonomic plexuses comprise named parts: aortic, superior mesenteric, inferior mesenteric, superior hypogastric, and inferior hypogastric (hypogastric nerves).
Hematocrit, Systolic Blood Pressure and Heart Rate are not Accurate Predictors for Surgery to Control Hemorrhage in Injured Patients
Authors: Opreanu Razvan C. , Arrangoiz Rodrigo , Stevens Penny , Morrison Chet A. , Mosher Benjamin D. , Kepros John P.
Published: June 2020

Hematocrit (Hct), systolic blood pressure (SBP), and heart rate (HR) are considered to closely correlate with hypovolemia in injured patients. The clinical importance of these parameters in the early recognition of occult but clinically significant hemorrhage remains to be demonstrated. We undertook this study to assess the clinical importance of these parameters in the early recognition of occult hemorrhage in injured patients. A retrospective study of 7880 patients admitted to a Level I trauma center was carried out. Patients who underwent surgery were divided into the hemorrhage (n = 160) and no-hemorrhage group (n = 228). Hematocrit, SBP, and HR were correlated and receiver operating characteristic (ROC) curves were plotted. The ROC curves for Hct, SBP, and HR showed suboptimal areas under the graph. Even for different Hct thresholds and for hypotension and tachycardia, low predictive values were found. Although Hct, SBP, and HR levels were significantly altered among patients who require surgery for hemorrhage, the low predictive values of each parameter renders them as clinically unreliable individual tools for recognition of hemorrhagic patients who need surgery. Although useful in aggregate, as a pattern, or as indications for further diagnostic studies, these common parameters have limited usefulness individually
Malignant Phylloides Tumor in Pregnancy
Authors: Blaker Kristen M. , Sahoo Sunati , Schweichler Maria R. , Chagpar Anees B.
Published: June 2020

Malignant phylloides tumors are exceedingly rare with few cases being reported in pregnancy. We describe the first case ever reported of a malignant phylloides tumor presenting in the first trimester of pregnancy and provide insight into the complexities of management as well as a review of the known literature. An extensive PubMed literature search for “cystosarcoma,” “phylloides,” and “pregnancy” was performed. References of each citation were reviewed. Only six previous cases of phylloides tumor in pregnancy were found, none of which were in the first trimester. Medical records of a patient presenting to our institution at 9 weeks gestation with a malignant phylloides tumor were reviewed. We further provide a review of the current literature of the management of phylloides tumor in pregnancy. A 27-year-old white G2P0SA1 woman with no family history of breast cancer presented with a right breast mass at her first prenatal examination at 9 weeks of pregnancy. Ultrasound confirmed a solid mass measuring 24 mm. Core needle biopsy demonstrated a malignant phylloides tumor. She previously had a fibroadenoma removed from the same breast 7 years previously. The current tumor was excised to clear margins. Histopathological examination revealed a 4-cm fibroepithelial tumor with marked stromal cellularity and a high mitotic count (five to seven mitoses/high-power field), confirming the diagnosis of malignant phylloides tumor. The patient continued her pregnancy without complications. Six other cases of phylloides tumor presenting in pregnancy have been reported in the literature, one of which had bilateral disease. Of these, the average patient age was 32 years (range, 28 to 35 years). The majority of these patients presented in their third trimester (mean, 29 weeks; range, 20 to 36 weeks) and often had large tumors (mean, 15 cm; range, 5 to 21 cm). Four of the seven tumors (57%) required a mastectomy. Previous cases have shown phylloides tumors to present in the third trimester as large masses that require mastectomy. With early detection, malignant phylloides tumors can present in the first trimester of pregnancy at smaller sizes; in these patients, breast-conserving surgery is possible.
Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome
Authors: Munene Gitonga , Knab Michel , Parag Bhanot
Published: June 2020

Superior mesenteric artery (SMA) syndrome is an uncommon condition of duodenal obstruction secondary to extrinsic vascular compression. With the advent of laparoscopy, an emerging option to treat SMA syndrome is laparoscopic duodenojejunostomy. Given the rarity of the condition a critical appraisal of the effectiveness and safety of this relatively new surgical option has not been performed. Here we present a case report and a critical review of all published reports of laparoscopic duodenojejunostomy. A systematic literature review of all published reports describing laparoscopic duodenojejunostomy was performed by querying the MEDLINE database using keywords: laparoscopic duodenojejunostomy and SMA syndrome. Nine articles were reviewed which were mainly case reports and case series (level 5 data), reporting on a total of 13 patients, with 32 per cent of the patients being male and 68 per cent female. The diagnosis was established preoperatively in 62 per cent of the cases, the length of stay was 4.5 days, the morbidity rate was 7 per cent, and no mortalities were reported. The operation was considered successful in 100 per cent of patients. Laparoscopic duodenojejunostomy seems to be a safe and effective treatment for patients with SMA syndrome, but more data is required to recommend this operative option as the standard of care.
Article Commentary: The Role of Laparoscopic Donor Nephrectomy in Renal Transplantation
Authors: Eng Mary
Published: June 2020

Renal transplantation is an effective treatment for patients with end-stage renal disease. Unfortunately, the number of patients waiting for transplantation greatly exceeds the number of suitable organs. Use of live kidney donors can increase the donor pool. Historically, donor nephrectomy was performed as an open technique. Its associated prolonged convalescence and long-term morbidity was likely a disincentive to donate. Laparoscopic donor nephrectomy, however, has been shown to have fewer long-term complications without compromising graft function. Since its inception, there has been an increase in the number of live donor renal transplantations performed.