bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of an Autotransfusion System during Endoluminal Repair of Abdominal Aortic Aneurysms: Does it Decrease the use of Allogeneic Blood?
Authors: Donayre Carlos , Adimora Uzoamaka , Song Tae , Kopchok George , Lippmann Maurice , White Rodney
Published: June 2020

Endoluminal repair of abdominal aortic aneurysms (AAA) is associated with decreased blood loss and transfusion requirements when compared to open AAA repair. We evaluated the use of an intraoperative autotransfusion system during endoluminal exclusion of AAAs. Fifty endoluminal AAA procedures selected at random were reviewed retrospectively. Patients were divided into 4 groups according to their estimated blood loss: Group I, 20 patients (0–500 cc); Group II, 18 patients (501–1,000 cc); Group III, 7 patients (1,001–1,500 cc); and Group IV, 5 patients (1,501–3,400 cc). The average blood loss was 327 cc for Group I, 728 cc for Group II, 1,217 for Group III, and 2,125, for Group IV. The overall blood loss was 834 cc, but 75 per cent was recovered. Hematuria was always present when greater than 1,000 cc of blood was retransfused, but renal function was not affected even with the concomitant administration of radiographic contrast. Only one patient required an autologous blood transfusion. The use of an autotransfusion device is safe, efficacious, and appears to further limit the need for homologous blood transfusion in patients undergoing endoluminal AAA repair.
Laparoscopic versus Open Appendectomy: Is the Postoperative Infectious Complication Rate Different?
Authors: Hoehne Francesca , Ozaeta Maria , Sherman Bill , Miani Peter , Taylor Edward
Published: June 2020

Despite the reported advantages of laparoscopic appendectomy (LA), there is debate about the postoperative infectious complication rate. Our study attempts to determine if the infectious complication rate between LA and open appendectomy (OA) is different. A retrospective review was conducted of all patients who underwent appendectomy at Kern Medical Center between 1999 and 2003. Age, sex, white blood cell count, temperature, pathology, and postoperative complications were identified. Fifty-seven patients underwent LA, and 159 patients underwent OA. The groups were well matched for demographics, white blood cell count, temperature, and percent perforated appendicitis. There was an overall 9.3 per cent complication rate. The infectious complication rate in OA versus LA group was statistically different (6.3% vs 17.6%, P = 0.04). The infectious complication rate in the LA group was significantly higher than in the OA group. Further large randomized trials are necessary to confirm our findings and to identify if LA is appropriate for a subset of appendicitis patients.
Does Initial Choice of Antimicrobial Therapy Affect Length of Stay for Patients with Complicated Intra-abdominal Infections?
Authors: Wilson Samuel Eric , Turpin Robin S. , Hu X. Henry , Sullivan Elizabeth , Mansley Edward C. , Ma Larry
Published: June 2020

Outcomes for complicated intra-abdominal infection are influenced by operation for source control, patient-related factors, and medical management, including antibiotic treatment. We analyzed length of stay (LOS) at 33 hospitals for 2,150 patients discharged between February 2002 and June 2003, who were >18 years, had intra-abdominal infection, and received one of 6 first-line antimicrobials. A regression tree analysis selected important variables, their interactions, and their order of significance in explaining LOS. A linear mixed model evaluated the difference in LOS between treatment groups. Adjusted LOS was calculated by the least squares means from the model and was used to assess treatment differences. Mean LOS analyzed by initial antimicrobial therapy and stratified by diagnosis showed LOS for ampicillin/sulbactam and ertapenem to be significantly shorter from levofloxacin, ceftriaxone, and piperacillin/tazobactam (all P < 0.05). Adjusting for all other factors, the variables associated with severity (e.g., diagnosis, ICU stay, and comorbidities) had the greatest impact on adjusted LOS (all P < 0.001). Our findings indicate ampicillin/sulbactam and ertapenem were associated with shorter hospital stays, which may be explained by unaccounted for underlying severity of infection and/or by surgeons stratifying antimicrobial selection according to severity of illness.
Hyaluronic Acid–Carboxycellulose Membrane (Seprafilm) Reduces Early Postoperative Small Bowel Obstruction in Gastrointestinal Surgery
Authors: Mohri Yasuhiko , Uchida Keiichi , Araki Toshimitu , Inoue Yasuhiro , Tonouchi Hitoshi , Miki Chikao , Kusunoki Masato
Published: June 2020

This study aimed to evaluate the efficacy of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) on early postoperative small bowel obstruction (EPSBO). It also examined whether using Seprafilm affected surgical site infection rates in gastrointestinal surgery. One hundred eighty-four patients who had Seprafilm placed during gastrointestinal surgery between October 2000 and December 2003 were included in the study (Seprafilm group) and were compared with a matched cohort (control group) of patients operated on without Seprafilm. All patients were retrospectively assessed for EPSBO and surgical site infections. The incidence of EPSBO was significantly lower ( P < 0.05) in the Seprafilm group (12/184) than in the control group (26/183). The incidence of surgical site infection between the Seprafilm (15.2%) and control (13.7%) groups was not statistically significant. The placement of Seprafilm helped to prevent EPSBO and had no significant adverse affect on surgical site infections.
Water-Soluble Upper GI Based on Clinical Findings is Reliable to Detect Anastomotic Leaks after Laparoscopic Gastric Bypass
Authors: Katasani V.G. , Leeth R.R. , Tishler D.S. , Leath T.D. , Roy B.P. , Canon C.L. , Vickers S.M. , Clements R.H.
Published: June 2020

Anastomotic leak after laparoscopic Roux- en-Y gastric bypass (LGB) is a major complication that must be recognized and treated early for best results. There is controversy in the literature regarding the reliability of upper GI series (UGI) in diagnosing leaks. LGB was performed in patients meeting NIH criteria for the surgical treatment of morbid obesity. All leaks identified at the time of surgery were repaired with suture and retested. Drains were placed at the surgeon's discretion. Postoperatively, UGI was performed by an experienced radiologist if there was a clinical suspicion of leak. From September 2001 until October 2004, a total of 553 patients (age 40.4 ± 9.2 years, BMI 48.6 ± 7.2) underwent LGB at UAB. Seventy-eight per cent (431 of 553) of patients had no clinical evidence suggesting anastomotic leak and were managed expectantly. Twenty-two per cent (122 of 553) of patients met at least one inclusion criteria for leak and underwent UGI. Four of 122 patients (3.2%) had a leak, two from anastomosis and two from the perforation of the stapled end of the Roux limb. No patient returned to the operating room without a positive UGI. High clinical suspicion and selectively performed UGI based on clinical evidence is reliable in detecting leaks.
All-Terrain Vehicle Injuries: Are They Dangerous? A 6-Year Experience at a Level I Trauma Center after Legislative Regulations Expired
Authors: Fonseca A.H. , Ochsner M.G. , Bromberg W.J. , Gantt D.
Published: June 2020

All-terrain vehicles (ATVs) have increased in popularity and sales since 1971. This rise in popularity led to an increase in injuries resulting in voluntary industry rider safety regulations in 1988, which expired without renewal in 1998. Our purpose was twofold, to determine the incidence and severity of ATV injuries in our patient population and what, if any impact the safety regulations had. To further characterize the risk of ATV use, we compared them to a vehicle generally recognized as dangerous, the motorcycle (MC). Our trauma registry was reviewed from January 1998 through August 2004 for ATV or MC injured. Data collected included age, gender, mortality, Injury Severity Score (ISS), helmet use, and injury distribution. These were compared to our data from the decade of regulation. There were 352 MC and 221 ATV patients. ATV injured demonstrated a higher proportion of pediatric and female patients ( P < 0.001 and P < 0.01, respectively), a decrease in helmet use (8.6% vs 64.7%, P < 0.001), and increased closed head injuries (CHI) (54.2% vs 44.9%, P < 0.05) compared with MC injured. ISS and mortality were similar. The average number of patients from 1988 to 1998 was 6.9/yr compared to 31.6/yr ( P < 0.001) during 1998–2004 with equal ISS. Our data show that there has been a dramatic and progressive increase in the number of ATV crashes since expiration of industry regulations. ATVs are as dangerous as MCs based on patient ISS and mortality. There are significantly more children and women injured on ATVs. The lower rate of helmet use in ATVs may account for the significantly greater incidence of CHI. These data mandate the need for injury prevention efforts for ATV riders, in particular children, through increased public awareness and new legislation.
Hyperacute Abdominal Compartment Syndrome: An Unrecognized Complication of Massive Intraoperative Resuscitation for Extra-abdominal Injuries
Authors: Rodas Edgar B. , Malhotra Ajai K. , Chhitwal Reena , Aboutanos Michel B. , Duane Therese M. , Ivatury Rao R.
Published: June 2020

Primary and secondary abdominal compartment syndrome (ACS) are well-recognized entities after trauma. The current study describes a “hyperacute” form of secondary ACS (HACS) that develops intraoperatively while repair of extra-abdominal injuries is being carried out simultaneous with massive resuscitation for shock caused by those injuries. The charts of patients requiring abdominal decompression (AD) for HACS at time of extra-abdominal surgery at our level I trauma center were reviewed. The following data was gathered: age, Injury Severity Score (ISS), mechanism, resuscitation details, time to AD, time to abdominal closure, and outcome. All continuous data are presented as mean ± standard error of mean. Hemodynamic and ventilatory data pre- and post-AD was compared using paired t test with significance set at P < 0.05. Five (0.13%) of 3,750 trauma admissions developed HACS during the 15-month study period ending February 2004. Mean age was 32 ± 7 years, and mean ISS was 19 ± 2. Four of five patients arrived in hemorrhagic shock (blunt subclavian artery injury, 1; chest gunshot, 1; gunshot to brachial artery, 1; stab transection of femoral vessels, 1) and were immediately operated upon. One of five patients (70% burn) developed HACS during burn wound excision on day 2. HACS developed after massive crystalloid (15 ± 1.7 L) and blood (11 ± 0.4 units) resuscitation during prolonged surgery (4.8 ± 0.8 hours). Pre- versus post-AD comparisons revealed significant ( P < 0.05) improvements in mean arterial pressure (55 ± 6 vs 88 ± 3 mm Hg), peak airway pressure (44 ± 5 vs 31 ± 2 mm Hg), tidal volume (432 ± 96 vs 758 ± 93 mL), arterial pH (7.16 ± 0.0 vs 7.26 ± 0.04), and PaCO2 (52 ± 6 vs 45 ± 6 mm Hg). There was no mortality among the group, and all patients underwent abdominal closure by fascial reapproximation in 2–5 days. Two (40%) of the five patients required extremity fasciotomy for compartment syndrome. HACS is a rare complication of massive resuscitation for extra-abdominal injuries. It should be considered in such patients in the face of unexplained hemodynamic and/or ventilatory decompensation. Prompt AD is life saving. Early abdominal closure is usually possible. Vigilance for compartment syndromes elsewhere in the body is warranted in any patient with HACS.)
Thoracoscopic Resection of a Mediastinal Intrathymic Parathyroid Adenoma
Authors: Karpinski Sylwia , Sardi Armando
Published: June 2020

Mediastinal parathyroid adenomas and thymomas can be resected via a transcervical approach, median sternotomy, or less invasive surgical option of video-assisted thoracoscopic resection and more recently by way of the da Vinci robot. We present a case of a mediastinal parathyroid adenoma in a 55-year-old female with primary hyperparathyroidism. MRI also confirmed a mediastinal adenoma localized on sestamibi scan. Significant laboratory values were elevated parathyroid hormone (PTH) of 171 pg/mL (normal range = 15 to 65 pg/mL) and calcium of 11.6 mg/dL (normal range = 8.5 to 10.5 mg/dL). Inability to hyperextend her neck due to cervical fusion made the transcervical approach unfavorable. To avoid a median sternotomy, we performed thoracoscopic resection of the adenoma via the left chest with the patient in a right lateral decubitus position. Three ports were placed; two in the anterior axillary line in the 4th and 6th intercostal spaces and one in the midaxillary line in the 5th intercostal space. Initial intraoperative PTH measurement was 192.9 pg/mL, and after adenoma removal the PTH level fell to 9 pg/mL. She was discharged home on postoperative day 1 without complications. At 3 months postprocedure, she remains asymptomatic with PTH and calcium levels within normal range. The 4 g, 2.4 cm intrathymic parathyroid adenoma had no evidence of malignancy. Thoracoscopic resection of an intrathymic parathyroid adenoma, a safe and less morbid alternative to median sternotomy, is an option when the transcervical approach is not viable.
Transversalis, Endoabdominal, Endothoracic Fascia: Who's Who?
Authors: Skandalakis Panagiotis N. , Zoras Odyseas , Skandalakis John E. , Mirilas Petros
Published: June 2020

In Terminologia Anatomica of 1998, the fasciae of the trunk are listed as parietal, extraserosal, and visceral. Parietal fascia is defined as the fascia located outside the parietal layer of a serosa (e.g., pleura, peritoneum) lining a body wall cavity. The parietal fascia of the thorax is endothoracic fascia, and that of the abdomen is endoabdominal fascia. According to Terminologia Anatomica, endoabdominal fascia comprises: 1) transversalis fascia and 2) investing abdominal fascia: deep, intermediate and superficial. Thus, transversalis fascia is the innermost layer of endoabdominal fascia and, consequently, not synonymous with it. We assert that transversalis fascia is the inner epimysium of transversus abdominis muscle; no separate deep investing fascia exists. Embryologically, deep, intermediate and superficial layers of investing fascia are produced as muscular primordia–originating from somites invading somatopleura–penetrate somatic wall connective tissue, and thus obtain epimysium on either side, which give layers of investing fascia. In the thoracic wall, muscle layers are not separated and no distinct investing fasciae are found on them. Furthermore, in the thorax extraserosal fascia does not exist. Therefore, only endothoracic fascia is found on the inner side of the innermost intercostal muscle, which is deprived of investing fascia, to separate this muscle from pleura.
Spigelian Hernia: Surgical Anatomy, Embryology, and Technique of Repair
Authors: Skandalakis Panagiotis N. , Zoras Odyseas , Skandalakis John E. , Mirilas Petros
Published: June 2020

Spigelian hernia (1–2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis (i.e., the aponeurosis of the transverse abdominal muscle limited by the linea semilunaris laterally and the lateral edge of the rectus muscle medially). Mostly, these hernias lie in the “spigelian hernia belt,” a transverse 6-cm-wide zone above the interspinal plane; lower hernias are rare and should be differentiated from direct inguinal or supravescical hernias. Although named after Adriaan van der Spieghel, he only described the semilunar line (linea Spigeli) in 1645. Josef Klinkosch in 1764 first defined the spigelian hernia as a defect in the semilunar line. Defects in the aponeurosis of transverse abdominal muscle (mainly under the arcuate line and more often in obese individuals) have been considered as the principal etiologic factor. Pediatric cases, especially neonates and infants, are mostly congenital. Embryologically, spigelian hernias may represent the clinical outcome of weak areas in the continuation of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleura, originating from the invading and fusing myotomes. Traditionally, repair consists of open anterior herniorraphy, using direct muscle approximation, mesh, and prostheses. Laparoscopy, preferably a totally extraperitoneal procedure, or intraperitoneal when other surgical repairs are planned within the same procedure, is currently employed as an adjunct to diagnosis and treatment of spigelian hernias. Care must be taken not to create iatrogenic spigelian hernias when using laparoscopy trocars or classic drains in the spigelian aponeurosis.
Laparoscopic Resection of a Paraganglioma of the Organ of Zuckerkandl in a Patient with a Carotid Body Tumor
Authors: Mithani Suhail K. , Marohn Michael R. , Freischlag Julie A. , Dackiw Alan P.B. , Zeiger Martha A.
Published: June 2020

Paragangliomas of the organ of Zuckerkandl are rare tumors with only several case reports noted in the literature. Synchronous paraganglioma occur sporadically, and on occasion, in association with several genetic syndromes. Paraganglioma of the organ of Zuckerkandl with synchronous carotid body paraganglioma is described herein. Traditionally, surgical resection of abdominal paraganglioma involved an exploratory laparotomy. In this manuscript, we describe one of the first reported laparoscopic resections of this tumor and review the literature on multiple paragangliomas and their associated genetic syndromes.
Lithopedion Presenting as Intra-abdominal Abscess and Fecal Fistula: Report of a Case and Review of the Literature
Authors: Odom Stephen R. , Gemer Mordechai , Muyco Arturo P.
Published: June 2020

A rare case of unrecognized and long-standing lithopedion (“stone baby”) with erosion into the bowel with fecal fistula formation is described. A literature review is also presented.
Spinal Clearance in the Difficult Trauma Patient: A Role for Screening MRI of the Spine
Authors: Adams John M. , Cockburn Mark I.E. , Difazio Louis T. , Garcia Felix A. , Siegel Brian K. , Bilaniuk Jaroslaw W.
Published: June 2020

Identifying spinal injuries in trauma patients with altered mental status can be difficult. CT scanning and clinical examination are the basis of our spinal clearance, but screening “trauma protocol” spinal MRI is used to exclude occult injuries. We sought to evaluate the sensitivity of CT scanning for spinal injuries compared with our MRI protocol. Ninety-seven patients underwent MRI cervical spine trauma protocol during 2004. Twenty-nine patients were obtunded, 29 had neurologic symptoms, and 39 had spine pain. MRI confirmed the initial CT findings without new injuries in 83 cases. MRI reclassified fractures as degenerative changes in 12 cases. In 2 cases, the MRI identified new injuries: one a stable partial ligament tear, the second a T7 Chance fracture with ligamental disruption requiring operative fixation. There was no morbidity or mortality documented in obtaining the MRI studies. Overall negative predictive value of CT scanning of the spine was 98 per cent, the positive predictive value was 78 per cent, and the sensitivity and specificity was 94 per cent and 91 per cent, respectively. CT scanning of the cervical and axial spine is sensitive for spinal trauma but not specific. MRI trauma protocol should be reserved for cases when initial CT scanning is suggestive of traumatic injury.
Endoscopic Approaches to Upper Gastrointestinal Bleeding
Authors: Stiegmann Greg V.
Published: June 2020

Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.
Isolated Chyle Duct Injury in Blunt Trauma
Authors: Dissanaike Sharmila , Griswold John A. , Halldorsson Ari , Frezza Eldo E.
Published: June 2020

We present a case of a patient sustaining an isolated injury to the right main branch of the cysterna chyli due to a high-speed motor vehicle accident. A 42-year-old man presented after a high-speed collision. CT revealed a collection of hypodense fluid in the gallbladder fossa, which was the clue to take him to the OR. We proceeded to laparoscopic exploration, and based on the milky white color of the fluid, identified a chyle leak. In an open fashion, the retroperitoneum was explored and the injury was identified as disruption of the right lumbar branch entering the cisterna chyli, and this was ligated with silk ties. Chyle duct injury secondary to blunt trauma is a rare finding. The use of CT imaging can identify this injury. Laparoscopy can confirm the injury. Open ligation of the injured duct is the best treatment.
Comparison between Site N-Category and Number N-Category for Nodal Staging in Carcinoma of the Gastroesophageal Junction: Our Experience and Literature Review
Authors: Aurello Paolo , D'Angelo Francesco , Nigri Giuseppe , Bellagamba Riccardo , Cicchini Claudia , Ruzzetti Romina , Ramacciato Giovanni
Published: June 2020

Gastroesophageal junction (GEJ) neoplasms have become more common over the past decade. Like mediastinal and abdominal lymph nodes and other gastric tumors, GEJ tumors spread to the retroperitoneal nodes. The TNM staging system does not consider this pattern and does not clinically distinguish GEJ tumors from gastric and esophageal cancers. The aim of the study is to compare the old and new TNM staging systems to assess whether the new TNM classifies lymph node involvement in these tumors as a prognostic factor. From January 1983 to December 1995, 438 patients underwent curative gastric resections for cancer at the Department of Surgery “P. Valdoni” of the University of Rome “La Sapienza.” Sixty-two had GEJ type II and III tumors according to the Siewert classification system. The old pN1 and new pN1 survival rates (P < 0.05) were statistically different; the old pN2 and new pN2 survival rates (P = 0.483) were not. The multivariate analysis of significant statistical prognostic factors showed that the pTNM staging in type II and type III GEJ tumors is the most important prognostic factor (P < 0.001), followed by the old pN and new pN (P < 0.001) and the pT (P < 0.005). Gender, age, Lauren type, and tumor location according to Siewert (II vs III) were not independently significant prognostic factors. This study concludes that the numbers and locations of metastatic lymph nodes are important prognostic factors that should be included in the next TNM edition.
The Use of Vacuum-Assisted Closure Therapy for the Treatment of a Large Infected Facial Wound
Authors: Schuster Rob , Moradzadeh Arash , Waxman Kenneth
Published: June 2020

Chronic wounds in difficult locations pose constant challenges to health care providers. Negative-pressure wound therapy is a relatively new treatment to promote wound healing. Laboratory and clinical studies have shown that the vacuum-assisted closure (VAC) therapy increases wound blood flow, granulation tissue formation, and decreases accumulation of fluid and bacteria. VAC therapy has been shown to hasten wound closure and formation of granulation tissue in a variety of settings. Accepted indications for VAC therapy include the infected sternum, open abdomen, chronic, nonhealing extremity wounds and decubitus ulcers. We report the first case of VAC therapy successfully used on a large infected wound to the face to promote healing.
Managing Breast Cancer in the Renal Transplant Patient: A Unique Dilemma
Authors: Self Michael , Dunn Ernest , Cox John , Brinker Karl
Published: June 2020

Improvements in immunosuppression have increased patient and graft survival in transplant recipients. As a result, there is greater risk of neoplastic processes such as breast cancer. Treatment in this population is complicated by the necessary immunosuppression, vascular accesses, and transplant grafts. General surgeons may expect to encounter more of these complex patients in the community setting. We sought to evaluate the surgical treatment of breast cancer in patients with renal transplants. Hospital and private physician records were queried to identify patients who developed breast cancer after a renal or pancreatic/renal transplantation. These charts were reviewed for demographics, type of breast cancer and treatment, location of dialysis access, and complications. From June 1, 1994, to May 31, 2004, 14 patients were identified. Eight patients had functioning transplants. All patients underwent operative interventions. Ten patients underwent adjuvant treatment. Three had functioning transplants and chose not to risk the graft with cessation of immunotherapy. However, no patient with functioning transplants who underwent chemotherapy developed organ failure. Breast cancer after transplantation poses a unique dilemma. The threat of transplanted organ failure is a major concern to these patients and often supersedes adjuvant therapies.
Kenneth Charles Appell, M.D.: The Surgeon who Performed the First Radiocephalic Fistulas for Hemodialysis
Authors: Polo Jose R.
Published: June 2020

Radiocephalic fistula for hemodialysis is the most effective vascular access since it was developed at the Bronx Veteran's Administration Hospital in New York by Charles Kenneth Appell in February 1965. The first fourteen cases were published in a classical paper (N Engl J Med 1966; 275:1089–1092). Some aspects of the biography of Dr. Appell, together with the history of the development of radiocephalic fistula are described in this historical communication. Dr Appel, aged 82, is currently living in New York's Hudson Valley.
Richter Hernia: Surgical Anatomy and Technique of Repair
Authors: Skandalakis Panagiotis N. , Zoras Odyseas , Skandalakis John E. , Mirilas Petros
Published: June 2020

Richter hernia (partial enterocele) is the protrusion and/or strangulation of only part of the circumference of the intestine's antimesenteric border through a rigid small defect of the abdominal wall. The first case was reported in 1606 by Fabricius Hildanus. The first definition of partial enterocele was given by August Gottlieb Richter in 1785. Sir Frederick Treves discriminated it from Littre hernia (hernia of the Meckel diverticulum). More often these hernias are diagnosed in the sixth and seventh decades of life. They comprise 10 per cent of strangulated hernias. Their common sites are the femoral ring, inguinal ring, and at incisional trauma. The most-often entrapped part of the bowel is the distal ileum, but any part of the intestinal tube may be incarcerated. These hernias progress more rapidly to gangrene than other strangulated hernias, and obstruction is less frequent. The gold standard technique for repair is the preperitoneal approach, followed by laparotomy and resection if perforation is suspected.
Littre Hernia: Surgical Anatomy, Embryology, and Technique of Repair
Authors: Skandalakis Panagiotis N. , Zoras Odyseas , Skandalakis John E. , Mirilas Petros
Published: June 2020

Littre hernia is the protrusion of a Meckel diverticulum through a potential abdominal opening. Alexis de Littre (1700) reported ileal diverticula and attributed them to traction. August Gottlieb Richter (1785) defined them as preformed, and Johann Friedrich Meckel (1809) postulated their embryologic origin. Sir Frederic Treves (1897) distinguished between Littre and Richter hernia (partial enterocele). Embryologically, Meckel diverticulum is the persistent intestinal part of the omphaloenteric duct through which the midgut communicates with the umbilical vesicle until the fifth week. It is found at the antimesenteric border of the ileum, usually located 30 to 90 cm from the ileocecal valve, measuring 3 to 6 cm in length and 2 cm in diameter. Usual sites of Littre hernia are: inguinal (50%), umbilical (20%), and femoral (20%). Meckel diverticulum may be accompanied in the sac by the ileal loop to which it is attached; rarely, it may undergo incarceration or strangulation, necrosis, and perforation. In children, it is mostly found in umbilical hernias, and the diverticulum is more prone to adhere to the sac. Repair of Littre hernia consists of resection of the diverticulum and herniorraphy; in perforated cases, care must be taken to not contaminate the hernia field.
A Rare Case of Diffuse Neonatal Hemangimatosis
Authors: Schulze S.M. , Moser R.L. , Bhattacharyya N.
Published: June 2020

Diffuse neonatal hemangiomatosis (DNH) is a rare neonatal condition in which cutaneous and visceral hemangiomas coexist. If left untreated, DNH is usually fatal at an early age. We report a case of a 6-month-old male infant who was brought to our institution with hepatosplenomegaly and a history of anemia and thrombocytopenia since 1 month of age. Cytogenetic analysis and liver biopsy were normal and bone marrow aspirate was nondiagnostic. Congenital red blood cell abnormality was ruled out. Ultrasound confirmed an increase in size of the spleen from 5 to 15 cm, and magnetic resonance imaging demonstrated intense splenic enhancement consistent with a hemangioma or vascular malformation. Despite severe thrombocytopenia, an exploratory laparotomy was done and the patient underwent a splenectomy and omentectomy. The final pathology confirmed hemangiomatosis of the spleen and omentum. In the neonate with unexplained anemia and thrombocytopenia, DNH should be considered as part of the differential diagnosis. In our case, the patient not only exhibited no obvious cutaneous involvement, but also had rare splenic involvement. Although there are risks involved when operating on a thrombocytopenic patient, the benefits of operating on a patient with DNH far outweigh the risks, and operative intervention should proceed without delay.
Recurrence after Complete Cryoablation of Colorectal Liver Metastases: Analysis of Prognostic Features
Authors: Yan Tristan D. , Nunn David R. , Morris David L.
Published: June 2020

This study critically evaluated the prognostic determinants for disease-free survival (DFS) after cryoablation for colorectal liver metastases. An observational cohort study of prospectively collected data on 135 patients who underwent cryoablation with or without resection for colorectal liver metastases was performed. Univariate and multivariate analyses were used to determine the prognostic factors for overall DFS, cryosite DFS, remaining liver DFS, and extrahepatic DFS. Overall, 115 patients (85%) developed recurrence at the cryosite (44%), and the remaining patients developed recurrence at the liver (62%) and extrahepatic site (71%). In univariate analysis, pre-operative and postoperative carcinoembryonic antigen (CEA) were significant for overall DFS. Distribution of metastases, operation type, total number of metastases, number of cryotreated metastases, largest size of cryotreated metastasis, and postoperative CEA were significant for cryosite DFS. The number of cryotreated metastases and postoperative CEA were significant for remaining liver DFS. The largest size of cryotreated metastasis, and preoperative and postoperative CEA were significant for extrahepatic DFS. In multivariate analysis, resection plus cryoablation, ≤7 liver metastases and ≤3 cm cryotreated metastasis were independently associated with an improved cryosite DFS. Preoperative CEA of ≤5 ng/mL was independently associated with an improved overall and extrahepatic DFS. The role of CEA in colorectal metastasis is important. Resection plus cryoablation rather than cryoablation alone should be used for larger lesions.
A Prospective, Randomized Trial of Cognitive Intervention for Postoperative Pain
Authors: Gavin Michael , Litt Mark , Khan Ahmed , Onyiuke Hilary , Kozol Robert
Published: June 2020

A single-blind, randomized prospective trial was performed at a university hospital to determine if preoperative relaxation training will decrease pain and narcotic demand postoperatively. A convenience sample of 49 patients undergoing lumbar and cervical spine surgery was randomized to receive instruction on relaxation techniques or routine preoperative information before surgery. Pain score and narcotic demand in the first 48 hours after surgery were the primary outcomes. Pain scores were higher in the relaxation (4.8 ± 1.7) versus the standard preparation group (3.9 ± 1.7) on postoperative day one (POD) 1, but lower on POD 2 (3.9 ± 1.9 vs 4.1 ± 1.9), whereas narcotic use (milligrams of IV morphine per hour) was higher in the relaxation group on POD 1 (1.14 ± 0.94 vs 0.54 ± 0.55) and POD 2 (0.86 ± 0.73 vs 0.50 ± 0.61). The differences were significant for narcotic demand (P = 0.01) but not for pain (P = 0.94). In conclusion, our results could not support the use of relaxation training for reducing postoperative pain and narcotic demand in this selected surgical population.
Surgical Residents’ Perception of Simulation Training
Authors: Boyd K. Brian , Olivier Jake , Salameh J.R.
Published: June 2020

Laparoscopic surgical simulation is a valuable and validated training tool. We examined its perception and use among general surgery residents at our institution. Questionnaires were sent to all 29 general surgery residents with a 93 per cent response rate. Residents were divided into junior residents (JR; PGY 1–2) and senior residents (SR; PGY 3–5). JR spent more hours in the simulation center and completed their assigned tasks faster than SR (14 vs 52 days). Thirty-three per cent of SR felt that simulation training should be limited to JR in contrast to only 8 per cent of JR. However, 93 per cent of residents agreed that the program improved their laparoscopic skills. Most residents feel that simulation training is essential and mandatory in current surgical residency (75% of JR and 67% of SR) and needs to be extended to open surgery (67% JR and 60% SR). Seventy-five per cent of JR, but only 13 per cent of SR, feel that residents’ involvement in procedures should be based on performance in surgical simulation. JR ranked simulation training first in useful ways to learn new skills, whereas SR ranked proctorship highest. JR have a higher use of simulation training and a higher perception of its utility.
Pediatric Blunt Trauma: A Retrospective Analysis in a Level I Trauma Center
Authors: Sharma Om P. , Oswanski Michael F. , Stringfellow Kathryn C. , Raj Shekhar S.
Published: June 2020

This study consisted of an 8-year retrospective trauma registry analysis of blunt trauma and comprised of 2458 children (<18 years of age) and 4568 adults (18–64 years of age). Falls and motor vehicular crashes were seen in 30.4 per cent (749) and 23 per cent (566) of children, and 25.4 per cent (1158) and 41.9 per cent (1914) of adults. Children had a higher mean revised trauma score (7.69 vs 7.66) and Glasgow Coma Score (14.5 vs 14.3), and a lower Injury Severity Score (ISS; 6.68 vs 7.83 and hospital length of stay (2.8 vs 3.8 days) with P < 0.05. Overall mortality was 1.3 per cent in children and 1.9 per cent in adults (P = 0.05). Pedestrian accidents resulted in a 3.8 per cent (6/161) mortality rate. Pediatric nonsurvivors had a 6.4-fold higher ISS than survivors compared with a 5.2-fold increase in adults. Mortality progressively increased with higher ISS; 0.09 per cent in <15, 1.3 per cent, in 15 to 24, and 17 per cent in children with ≥25 ISS. Mortality in multiple chest injuries was 19 per cent. The presence of chest trauma resulted in a 46-fold higher mortality in children. Most lethal injuries were combined head, chest, and abdomen trauma with a 25 per cent mortality in children and 28 per cent in adults. Admission Glasgow Coma Score <9 and systolic blood pressure below 100 mm Hg carried high mortality: 39 and 6 per cent in children vs 31 and 24 per cent in adults. Ninety-seven per cent of children and 89 per cent of adults were discharged home.
Portal Vein Resection for Hilar Cholangiocarcinoma
Authors: Hemming Alan W. , Kim Robin D. , Mekeel Kristin L. , Fujita Shiro , Reed Alan I. , Foley David P. , Howard Richard J.
Published: June 2020

Hilar cholangiocarcinoma remains a difficult challenge for the surgeon. Achieving negative surgical margins when resecting this relatively uncommon tumor is technically demanding as a result of the close proximity of the bile duct bifurcation to the vascular inflow of the liver. A recent advance in surgical treatment is the addition of portal vein resection to the procedure. Resection of the portal vein increases the number of patients offered a potentially curative approach but is technically more difficult and may increase the risk of the procedure. This study reviews the results of portal vein resection for hilar cholangiocarcinoma. Between 1998 and 2005, 60 patients underwent potentially curative resections of hilar cholangiocarcinoma. Mean patient age was 64 ± 12 years (range, 24–85 years). Liver resections performed along with biliary resection included 49 trisegmentectomies (37 right, 12 left) and 10 lobectomies (8 left, 2 right). One patient had only the bile duct resected. Four patients also had simultaneous pancreaticoduodenectomy performed. Twenty-six patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. Operative mortality was 8 per cent with an overall complication rate of 40 per cent. Patients who underwent portal vein resection had an operative mortality of 4 per cent, which was not different from the 12 per cent mortality in patients who did not undergo portal vein resection (P = 0.39). There was no difference in actuarial patient survival between patients who underwent portal vein resection and those who did not (5-year survival 39 per cent vs. 41 per cent, P = not significant). Negative margins were achieved in 80 per cent of cases and were associated with improved survival (P < 0.01). Five-year actuarial survival in patients undergoing resection with negative margins was 45 per cent. There was no difference in margin status or long-term survival between those patients who underwent portal vein resection and those who did not. Only negative margin status was associated with improved survival by multivariate analysis. Portal vein resection for hilar cholangiocarcinoma is safe and allows a chance for long-term survival in otherwise unresectable patients.
Left-Sided Gastroschisis
Authors: Gow Kenneth W. , Bhatia Amina , Saad Daniel F. , Wulkan Mark L. , Heiss Kurt F.
Published: June 2020

Gastroschisis is a periumbilical, abdominal wall defect arising to the right of the umbilicus. We describe the clinical course of a left-sided gastroschisis in a term female born at 39 weeks’ gestation. To our knowledge, there have been only 14 left-sided abdominal wall defects reported in the literature. We discuss our case and review the literature to try to determine if there is any clinic difference between right- versus left-sided lesions to make recommendations as to management.
Antibiotic Modulation in a Clinically Relevant Model of Chronic Intraabdominal Infection
Authors: Woods Dustin R. , Heffley Susan , Peyton James C. , Cheadle William G.
Published: June 2020

Continuous and twice-daily cefoxitin dosing was used in a highly lethal model of acute peritonitis in mice using intraperitoneal (IP) Klebsiella pneumoniae (Kpn). The purpose was to use antibiotics to create a model of chronic infection. Male Balb/c mice (averaging 20 g body weight) were inoculated IP with 103 colony-forming units (CFU) Kpn serotype 2. Controls received subcutaneous saline either twice daily or continuously. Antibiotic groups received 300 mg/kg per day of cefoxitin either twice daily or continuously. Survival and daily weight losses were determined. Another group was inoculated with 103 Kpn given twice daily saline or cefoxitin and harvested at 24 hours. Leukocyte counts were performed on peritoneal exudate cells (PEC) and peripheral blood. Cultures determined Kpn counts in blood, lung, and PEC. By 24 hours, saline-treated animals had lost more weight than cefoxitin mice (1 g vs. 2 g, P < 0.05). Continuous cefoxitin showed significant advantage with 50 per cent mortality at 5 days. Kpn levels were not significantly altered by cefoxitin. Cefoxitin treatment extended chronicity by preventing weight loss and increasing survival in a highly lethal, monomicrobial peritonitis model. This model will allow future study of specific host defense mechanisms over a prolonged time period.
Article Commentary: Soft Tissue Sarcoma of the Extremity and Trunk: Issues for the General Surgeon
Authors: Wells Gerame , Martin Robert C.G. , Mcmasters Kelly M. , Scoggins Charles R.
Published: June 2020

Soft tissue sarcomas represent a heterogeneous group of malignant tumors that arise from mesenchymal tissues. The majority of these tumors arise on the extremity or trunk. Despite their rarity, soft tissue sarcomas continue to generate vigorous academic interest, and as a result, the ever-expanding medical literature dealing with sarcomas continues to grow. Many general surgeons will see few of these tumors during their careers, and a review of the current literature and how it applies to patients afflicted with soft tissue sarcoma of the extremity or trunk is warranted.
Results after Laparoscopic Fundoplication: Does Age Matter?
Authors: Cowgill Sarah M. , Arnaoutakis Dean , Villadolid Desiree , Al-Saadi Sam , Arnaoutakis Demetri , Molloy Daniel L. , Thomas Ashley , Rakita Steven , Rosemurgy Alexander
Published: June 2020

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward population of older patients. One hundred eight patients more than 70 years of age (range, 70–90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18–59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores ( P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved ( P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores ( P < 0.01) and lower reflux scores ( P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.
Experienced Radio-Guided Surgery Teams Can Successfully Perform Minimally Invasive Radio-Guided Parathyroidectomy without Intraoperative Parathyroid Hormone Assays
Authors: Caudle Abigail S. , Brier Sarah E. , Calvo Benjamin F. , Kim Hong Jin , Meyers Michael O. , Ollila David W.
Published: June 2020

Minimally invasive parathyroidectomy is an accepted treatment option for primary hyperpara-thyroidism. The need for intraoperative parathyroid hormone assays (iPTH) to confirm adenoma removal remains controversial. We studied minimally invasive radio-guided parathyroidectomy (MIRP) performed using preoperative sestamibi localization studies, intraoperative gamma detection probe, and the selective use of frozen section pathology without the use of iPTH. This is a single institution review of patients with primary hyperparathyroidism treated with MIRP by surgeons experienced in radio-guided surgery between October 1, 1998 and July 15, 2005. Information was obtained by reviewing computer medical records as well as contacting primary care physicians. Factors evaluated included laboratory values, pathology results, and evidence of recurrence. One hundred forty patients were included with a median preoperative calcium level of 11.3 mg/dL (range, 9.6–17) and a PTH level of 147 pg/mL (range, 19–5042). The median postoperative calcium level was 9.3 mg/dL. All patients were initially eucalcemic postoperatively except for one who had normal parathyroid levels. However, five (4%) patients required re-exploration for various reasons. Of the failures, one was secondary to the development of secondary hyperparathyroidism, and therefore would not have benefited from iPTH, one had thyroid tissue removed at the first operation, and three developed evidence of a second adenoma. One of these three patients had a drop in PTH level from 1558 pg/mL preoperatively to 64 pg/mL on postoperative Day 1, indicating that iPTH would not have prevented this failure. Thus, only three (2.1%) patients could have potentially benefited from the use of iPTH. MIRP was successful in 96 per cent of patients using a combination of preoperative sestamibi scans, intraoperative localization with a gamma probe, and the selective use of frozen pathology. This correlates with reported success rates of 95 per cent to 100 per cent using iPTH. We conclude that minimally invasive parathyroidectomy can be successfully performed without using iPTH assays.