bluuebunny/crossref_metadata_2025 huggingface dataset:
Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair for Recurrent Inguinal Hernia
Authors: Hawasli Abdelkader , Thao Umeng , Chapital Alyssa
Published: November 2022

Laparoscopic transabdominal preperitoneal inguinal herniorrhaphy (TAPP) was attempted on 989 hernias in 708 patients. Of these 137 (14%) hernias were recurrent after conventional anterior repair. Laparoscopic repair was performed on 135 recurrences in 120 patients (the study cohort). There were 119 males and three females with an average age of 59 years (22–83 years). One hundred twelve (83%) were the first recurrences, and 23 (17%) were multiple recurrences. In 90 recurrences (66.7%) the last repair was performed more than 10 years previously. Seventy-seven patients (64%) had a prior or concomitant repair of a contralateral hernia. Direct recurrences and right-side recurrences were more common (73% and 61% respectively). Postoperative complications occurred in 18 repairs (13%). These included 15 hematomas, two seromas, and one urinary retention. Re-recurrence occurred in one patient (0.7%) in whom hernia staples were not used. No recurrence has occurred since the hernia staples became available. We conclude that the overall incidence of recurrent inguinal hernia is high (14%). Patients with recurrent hernia have a tendency toward a contralateral hernia (64%). Most recurrences occurred 10 or more years after the previous repair (66.7%). The laparoscopic repair (TAPP) offers a good repair for recurrent inguinal hernia avoiding the scar tissue and with low complication and recurrence rates.
Indicators for Tracheostomy in Patients with Traumatic Brain Injury
Authors: Gurkin Mystan A. , Parikshak Manesh , Kralovich Kurt A. , Horst H. Mathilda , Agarwal Vikas , Payne Nicole
Published: November 2022

Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived <7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3 ± 7.0 days). Logistic regression analysis identified presenting GCS ≤8, ISS ≤25, and ventilator days <7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days ( P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS ≤9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS ≤8, an ISS ≤25, and ventilator days <7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.
Extended Lymphadenectomy for Gastric Cancer: Results in a Teaching Hospital
Authors: Liu Katherine J.M. , Atten Mary Jo , Donahue Philip E. , Attar Bashar M.
Published: November 2022

Lymphadenectomy including second-echelon lymph nodes (D2 resection) for gastric cancer has not been widely adopted partly as a result of a reported increase in operative morbidity and mortality. In the present study we examined the operative risk of D2 resection in a public teaching hospital. From 1995 to 1998, 57 patients underwent exploratory laparotomy for gastric neoplasm: nine with curative D2 resection (Group I), 17 with curative but less than D2 resection (Group II), 16 with palliative resection (Group III), and 15 with no resection (Group IV). Among the four groups, patients with curative D2 resection (Group I) were older and had increased operative time and estimated blood loss, but their need for blood transfusion, the operative morbidity and mortality, and the mean hospital stay were not increased. In contrast, those patients with palliative resection (Group III) had the highest morbidity among all groups, the only fatality, and prolonged hospital stay. Therefore, curative D2 resection can be performed safely even with significant resident involvement. The advanced patient age or the extensive dissection does not increase its surgical risk. Hence, D2 dissection should be considered whenever curative resection is feasible because it allows accurate staging with the added benefit of possible improvement in patient survival.
Outcomes from Peptic Ulcer Surgery Have Not Benefited from Advances in Medical Therapy
Authors: Towfigh Shirin , Chandler Charles , Hines Oscar J. , Mcfadden David W.
Published: November 2022

Given the advancements in medical treatment of peptic ulcer disease such as Helicobacter pylori eradication and proton-pump inhibitors, we sought to assess their impact on the need for surgical intervention. Patients who underwent peptic ulcer surgery between 1981 and 1998 were evaluated in a retrospective chart review from a tertiary-care hospital (n = 222). The number of operations performed for peptic ulcers decreased annually (24 vs 11.3). Seventy-seven per cent of all cases were done urgently; most were performed for acute perforated ulcers. The overall 30-day mortality rate was 13 per cent, which remained unchanged over the past two decades. The highest mortality rate (82%) was in the transplanted population (n = 11). Our institutional experience demonstrates that despite the lower volume of patients requiring operative management a greater percentage of these patients are presenting with urgent need for surgery. Also despite the aggressive endoscopic management of acutely bleeding ulcers there was no change in the percentage of patients taken to the operating room for uncontrollable hemorrhage. Improvements in medical management of peptic ulcer disease have decreased the surgical volume; nevertheless we show a rising proportion of urgent operations performed annually, and mortality remains high.
Giant Adrenal Myelolipoma
Authors: Lamont Jeffrey P. , Lieberman Zelig H. , Stephens Jeffrey S.
Published: November 2022

Myelolipoma of the adrenal gland is a benign tumor comprising adipose cells and mature hematopoietic elements. Most of these lesions are small and asymptomatic. Giant myelolipomas weighing greater than 4 kg are quite rare with three other cases reported in the literature. A case is presented of a giant myelolipoma that was resected surgically. The literature is reviewed regarding this topic with emphasis on diagnostic and therapeutic implications.
Outcome with Postmastectomy Radiation with Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction
Authors: Proulx Gary M. , Loree Thomas , Edge Stephen , Hurd Thelma , Stomper Paul
Published: November 2022

The effects of radiation on the outcome of patients undergoing transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have not been extensively studied. Concern still exists of a possible negative impact secondary to irradiation as related to control of disease, cosmetic outcome, and flap viability. Thirty-six patients underwent both a modified radical mastectomy (MRM) with TRAM flap reconstruction and irradiation to the chest wall to include the TRAM flap and/or regional nodes either before reconstruction or after TRAM flap reconstruction. Fifteen patients had all of their treatment and follow-up at our institution and were retrospectively reviewed to assess treatment and outcome. During a median follow-up of 36 months there were no local-regional failures. One patient at Stage IIIA failed with distant metastases 3 years after treatment. One patient had a flap loss from a nonhealing wound after reconstruction performed 2 years after MRM and radiotherapy. Only one patient expressed dissatisfaction with the cosmetic outcome. Patients undergoing MRM with TRAM flap reconstruction and irradiation before or after reconstruction can achieve excellent local-regional control and satisfactory cosmesis. Risk of flap loss is low. Further follow-up is needed for assessing longer-term outomes in this patient group. Larger prospective studies are necessary for more definitive conclusions.
Trauma Management in the End-Stage Renal Disease Patient
Authors: Blake Anna-Maria , Toker Steven I. , Dickerman Richard , Dunn Ernest L.
Published: November 2022

More than 230,000 patients in the United States are being treated for end-stage renal disease (ESRD). This group of patients has not been evaluated for trauma resource use. When these patients are involved in trauma the need for dialysis and awareness of chronic disease processes must be considered in addition to their injuries. There were 4,894 patients admitted to a Level II trauma center over a 4-year period. Fifty-nine of these patients were considered to have ESRD before admission. The charts of these patients were reviewed and compared with those in the general trauma population. The average age of the ESRD patients was 58 years with an average Injury Severity Score of 8 as compared with 31 years of age and Injury Severity Score of 10.9 for the general trauma population. Thirty-four patients required hemodialysis within 48 hours of admission. Ten patients required mechanical ventilation. Eight patients in this study died. The complication and mortality rates among the ESRD patients were 50.8 per cent and 13.5 per cent respectively as compared with 16.3 and 4.7 per cent among the general trauma population. The trauma complication and mortality rates among ESRD patients are approximately three times greater than those in the general trauma population. Because of their coexisting medical problems and the need for dialysis trauma patients with ESRD should be cared for in trauma centers with dialysis capability and access to multidisciplinary services.
Pneumoperitoneum after Rough Sexual Intercourse
Authors: Johnson Eric K. , Choi Yong U. , Jarrard Stephen W. , Rivera David
Published: November 2022

Our objective is to report on a case of nonsurgical pneumoperitoneum and review the mechanism/gynecologic causes of such. We present a case report and review of the literature based on a MEDLINE search using the keywords pneumoperitoneum and nonsurgical. Radiographic evidence of free intraperitoneal air suggests hollow viscus rupture and usually warrants urgent surgical management. Findings of diffuse rebound tenderness and guarding solidify the decision for urgent surgical exploration. We present a case of a patient who presented with all of the above findings that subsequently underwent a negative laparotomy. On the day after surgery she admitted to having had rough sexual intercourse 3 days before presentation. Nonsurgical pneumoperitoneum has a number of unusual causes. Intra-abdominal, thoracic, gynecologic, iatrogenic, and miscellaneous etiologies are encountered. It was determined that the pneumoperitoneum in this case was secondary to rough sexual intercourse. We concluded that pneumoperitoneum secondary to nonsurgical causes represents a diagnostic dilemma. In the patient with free intraperitoneal air on plain X-ray one should be suspicious of less common nonsurgical etiologies. The majority of patients will require laparotomy. Thorough sexual and gynecologic/obstetrical history is a valuable adjunct in identifying the patient who does not.
A Study of Added Costs of Laparoscopic Cholecystectomy Based on Surgery Preference Cards
Authors: Allen Jeff W. , Polk Hiram C.
Published: November 2022

Hospitals are pressured to cut expenses to generate a profit, but many current surgical procedures still fall below a “break-even” point. Laparoscopic cholecystectomy is a high-volume surgical procedure that can be profitable for hospitals if costs are reduced and complications minimized. Our limited liability corporation of independent surgical specialists examined the preference cards of ten surgeons who performed laparoscopic cholecystectomies in August 2000. We wished to determine whether these surgeons differed in their use of disposable equipment and devices for the same surgical procedure. All of the disposable equipment and devices studied were assigned a price by the hospital purchasing department that was representative of the hospital costs and not what was billed to the patient. The sum total of disposable instruments for a single operative case in which laparoscopic cholecystectomy was performed ranged from $92 to $637 (mean $333) depending on the preference of the surgeon. Our study points out the differences in expenses between surgeons. Maintaining this type of expense tracking can apply to other procedures and is a good place to start a surgeon-led and hospital-based cost-saving initiative.
Do Facial Fractures Protect the Brain or are they a Marker for Severe Head Injury?
Authors: Martin Robert C.G. , Spain David A. , Richardson J. David
Published: November 2022

Facial fractures (FF) have been suggested to protect the brain from severe injury. However, others have stated that facial fractures are a marker for increased risk of brain injury. The aim of this study is to evaluate the association between facial fractures, brain injury, and functional outcome. A retrospective review of our prospective trauma database was performed for blunt trauma patients during a 7-year period (January 1993 through December 1999) at the University of Louisville Hospital. We identified 7324 blunt trauma patients at a Level 1 trauma center. Severity of head injury in patients with and without FF was compared. The severity of brain injury was evaluated by admission Glasgow Coma Score (GCS) as well as specific head, neck, cervical spine, and face Acute Injury Score (AIS). Length of intensive care unit (ICU) stay, hospital stay, and Functional Independence Measures (FIM) score were also identified. A total of 1068 (14.6%) patients were diagnosed with FF; of these 848 (79.4%) patients suffered some form of brain injury by CT abnormality, clinical examination, or both. A total of 2192 patients were treated for head injury without FF; 220 patients were treated for FF without head injury. FF with traumatic brain injury (TBI) were found to occur significantly greater than FFs without TBI ( P < 0.001). The mean GCS on admission for FF with head injury was 12, which was similar to that of patients with head injury alone with a GCS of 10 but was significantly less than that of patients with FF alone with a GCS of 15 ( P < 0.05). Injury Severity Score for patients with FF and head injury was significantly worse compared with patients with head injury alone and those with FF alone ( P < 0.0001). Mean ICU stay and hospital stay were similar for all three groups (ranges 3–6 and 6–12 days); and were not significant ( P < 0.06). FIM score was significantly lower for patients with FF and head injury compared with FF alone ( P = 0.0003) and similar to that of patients with head injury. FF were found to have a significantly greater incidence of TBI. FF with TBI had a similar severity of head injury when compared with patients with head injury alone by demonstrating similar GCS, AIS of the head and neck, and early functional recovery. This analysis does not support the hypothesis that the face provides a protective effect for the brain and therefore leading to a more favorable short-term outcome. Thus patients with facial fractures should be treated with the same caution as patients with significant blunt head trauma.
Career Disaffection among Surgeons in the Era of Managed Care
Authors: Knight T.T. , Richardson J. David , Kalbfleisch John H.
Published: November 2022

The purpose of this paper is to assess career satisfaction of surgeons in the era of managed care. The method of this assessment is by membership survey of the Southeastern Surgical Congress and the Western Surgical Association. Members were queried about their demographic characteristics, some aspects of the business of their practices, their attitudes toward retirement, their perception of the effectiveness of organized medicine as a socioeconomic advocate, and a comparison of each surgeon's career satisfaction before and during the era of managed care. Three hundred seventy-three usable surveys were returned, computerized, and analyzed statistically. Summaries of categorical variables are presented as percentages for various groupings of the categorical set. Results reveal a broad-based career disaffection in all areas queried, most notably in the business of surgical practice, attitude toward retirement and retirement alternatives, and the advocacy role of organized medicine for their issues. There is an almost unanimous desire for the American College of Surgeons to become their aggressive socioeconomic advocate. The data support a conclusion that surgeons perceive they are not represented in a realistic manner with the insurance companies and the government when their core issues are decided.
Postmastectomy Radiation in Patients with Four or More Positive Nodes
Authors: Timothy Stephania K.C. , Teng Stephen , Stolier Alan J. , Bolton John S. , Fuhrman George M.
Published: November 2022

Postmastectomy radiotherapy (PMR), a local therapeutic modality, is recommended to treat breast cancer patients with multiple involved axillary lymph nodes (a marker of increased systemic risk). Bothered by this conceptually flawed treatment approach we evaluated the impact of PMR on the treatment of women with four or more involved axillary lymph nodes. We identified 1164 patients treated from 1982 through 1999 with mastectomy. We reviewed the records of the 223 who demonstrated four or more positive axillary lymph nodes. Of these 128 were treated by mastectomy only and 95 by PMR. The mastectomy-only group demonstrated a mean tumor size of 3.5 cm, a median of seven axillary nodes involved, and a median of 24.9 nodes harvested. The PMR group had a mean tumor size of 4.3 cm with nine positive nodes out of a median total of 23.3 harvested. The difference in mean tumor size was statistically significant ( P = 0.01). The locoregional recurrence (10.9% vs 12.6%), distant recurrence rates (42.2% vs 35.8%), and 5-year survival (51% vs 55%) were not statistically different between the mastectomy-only group versus the PMR group, respectively. Adding PMR to breast cancer treatment demonstrated no improvement in outcome. Despite limitations of this retrospective study the results strongly support evaluation of PMR by a high-quality randomized prospective trial.
Biliary Reconstruction is Enhanced with a Collagen-Polyethylene Glycol Sealant
Authors: Wise Paul E. , Wudel L. James , Belous Andrey E. , Allos Tara M. , Kuhn Samuel J. , Feurer Irene D. , Washington M. Kay , Pinson C. Wright , Chapman William C.
Published: November 2022

Bile leaks occur in up to 27 per cent of liver transplant patients after biliary reconstruction. Synthetic sealants have not been investigated for these biliary procedures. We performed a randomized controlled study to evaluate a novel absorbable polyethylene glycol/collagen bio-polymer sealant (CT3™ Surgical Sealant) after incomplete end-to-end choledochocholedochostomy (CDCD) in pigs. Pigs (n = 18) underwent transection of the common bile duct and incomplete CDCD over a T-tube, leaving a one-sixth circumferential defect anteriorly. Animals were randomly assigned to treatment (CDCD with sealant, n = 9) or control (no sealant, n = 9). Drains were used to monitor leak volume and bilirubin (bili) concentration. Cholangiography was performed on postoperative day 3. Leaks were defined as drain bili/serum bill > 3, total drain output > 10 mL/kg, and/or extravasation on cholangiography. Animals sacrificed at 3 and 8 weeks (n = 4 and n = 5 from each group, respectively) underwent pathologic examination of the CDCD site. Statistical methods included Student's t test, χ2, linear regression, and analysis of variance procedures. The control group had a higher drain output rate over the first 4 postoperative days than the treatment group ( P < 0.05, analysis of variance). Five of nine (56%) control and one of nine (11%) treatment animals had a bile leak ( P < 0.05, χ2). There was no major inflammatory response to the sealant versus controls. We conclude that CT3 is effective in decreasing biliary leaks in an incomplete CDCD porcine model with no major adverse pathologic changes. This sealant should be considered for trials for biliary reconstruction in humans.
Preoperative Anemia in Colon Cancer: Assessment of Risk Factors
Authors: Dunne James R. , Gannon Christopher J. , Osborn Tiffany M. , Taylor Michelle D. , Malone Debra L. , Napolitano Lena M.
Published: November 2022

Anemia is common in cancer patients and is associated with reduced survival. Recent studies document that treatment of anemia with blood transfusion in cancer patients is associated with increased infection risk, tumor recurrence, and mortality. We therefore investigated the incidence of preoperative anemia in colorectal cancer and assessed risk factors for anemia. Prospective data were collected on 311 patients diagnosed with colorectal cancer over a 6-year period from 1994 through 1999. Patients were stratified by age, gender, presenting complaint, preoperative hematocrit, American Joint Committee on Cancer (AJCC) stage, and TNM classification. Discrete variables were compared using Pearson's Chi-square analysis. Continuous variables were compared using Student's t test. Differences were considered significant when P < 0.05. The mean age of the study cohort was 67 ± 9.2 with 98 per cent of the study population being male. The mean AJCC stage was 2.2 ± 1.2 and the mean preoperative hematocrit was 35 ± 7.9 with an incidence of 46.1 per cent. The most common presenting complaints were hematochezia (n = 59), anemia (n = 51), heme-occult-positive stool (n = 33), bowel obstruction (n = 26), abdominal pain (n = 21), and palpable mass (n = 13). Preoperative anemia was most common in patients with right colon cancer with an incidence of 57.6 per cent followed by left colon cancer (42.2%) and rectal cancer (29.8%). Patients with right colon cancer had significantly lower preoperative hematocrits compared with left colon cancer (33 ± 8.5 vs 36 ± 7.4; P < 0.01) and rectal cancer (33 ± 8.5 vs 38 ± 6.0; P < 0.0001). Patients with right colon cancer also had significantly increased stage at presentation compared with left colon cancer (2.3 ± 1.3 vs 2.1 ± 1.2; P < 0.02). Age was not a significant risk factor for preoperative anemia in colorectal cancer. We conclude that there is a high incidence of anemia in patients with colon cancer. Patients with right colon cancer had significantly lower preoperative hematocrits and higher stage of cancer at diagnosis. Complete colon evaluation with colonoscopy is warranted in patients with anemia to improve earlier diagnosis of right colon cancer. A clinical trial of preoperative treatment of anemic colorectal cancer patients with recombinant human erythropoietin is warranted.
Bilateral Giant Adrenal Myelolipomas: A Case Report
Authors: Wrightson William R. , Hahm Thomas X. , Hutchinson Julie R. , Cheadle William
Published: November 2022

Myelolipoma is a relatively rare benign tumor composed of fatty tissue and bone marrow elements. It is frequently associated with the adrenal glands but may exist as a solitary mass elsewhere. Adrenal myelolipomas are typically nonfunctioning and asymptomatic. They may be associated with an endocrine disorder such as Cushing's disease, Addison's disease, or hyperal-dosteronism; however they are most often discovered incidentally. Their size is usually less than 5 cm and they are managed nonoperatively. We report a case of bilateral giant adrenal myelolipoma producing abdominal pain in a 54-year-old man, who presented to his primary care physician with complaints of right shoulder pain with vague abdominal discomfort. Imaging studies identified bilateral suprarenal masses measuring 12 x 14 cm on the right and 8 x 10 cm on the left. These masses were consistent with fatty tissue radiographically. In addition a focal 5 x 4-cm mass was identified in the transverse colon. Because the patient was symptomatic and a diagnosis of liposarcoma could not be excluded he was taken to the operating room for exploratory laparotomy with excision of the masses and a transverse colectomy. Final histologic analysis identified bilateral adrenal myelolipomas and a solitary lipoma of the transverse colon. His postoperative course was uneventful with relief of the pain. Despite its benign nature and rare growth beyond 5 cm myelolipoma of the adrenal gland is best managed with excision in the symptomatic patient. Preservation of adrenal tissue is vital so as not to commit patients to a lifetime of steroid replacement.
The Incidence and Significance of Free Air after Percutaneous Endoscopic Gastrostomy
Authors: Dulabon George R. , Abrams Jeffrey E. , Rutherford Edmund J.
Published: November 2022

Percutaneous endoscopic gastrostomy (PEG) is well established as a safe and effective means of providing enteral feeding access in patients unable to tolerate oral feeding. There is some question, however, as to the true incidence of free air after PEG and the clinical significance of free air in these patients. We report our experience with 119 patients over 4 years who underwent placement of a percutaneous gastrostomy tube. This study is a retrospective review of percutaneous endoscopic gastrostomies performed by the Critical Care Service for Surgery (CCSS). A database of percutaneous endoscopic gastrostomies performed by the CCSS was maintained from September 1997 through December 2001. Complications of percutaneous gastrostomies were added to the database when noted. The electronic medical record of all patients was reviewed for the results of radiographic studies. Prior abdominal operations were noted as well as gastrostomy tube complications and outcome. A total of 115 intensive care unit patients underwent PEG placement by the CCSS. This total includes 18 patients who had undergone prior upper abdominal surgery, Three additional patients who underwent placement of a gastrostomy tube by vascular interventional radiology and one patient who underwent PEG placement by the ear, nose, and throat service were brought to the attention of CCSS secondary to complications for a total of 119 patients. Only four patients (3.4%) were found to have free air on subsequent chest radiograph. Six patients (5.2%) were found to have free air on abdominal CT scans. Two patients with free air on CT underwent exploratory celiotomy as a result of additional signs of peritonitis. Both were negative explorations. The incidence of free air after PEG in our experience is significantly less than the incidence in previous studies. In patients with free air after PEG placement exploratory celiotomy is not indicated in the absence of other clinical findings of peritonitis. Additionally it was noted that PEG placement could safely be performed in patients with prior upper abdominal surgery with a low incidence of complications.
There is no Difference in Survival between African-American and White Women with Breast Cancer
Authors: English William P. , Cleveland Kenneth E. , Barber W. Henry
Published: November 2022

A difference in survival by race in women with breast cancer has been reported. We examined survival of African-American (AA) and white (W) women diagnosed with breast cancer and evaluated variables that may affect survival at a university teaching hospital. A retrospective review of tumor registry data for breast cancer was performed in all AA and W female breast cancer patients diagnosed between the years 1990 and 1999 at a university hospital. Survival between AA and W women diagnosed with breast cancer during that period was compared using Kaplan-Meier analysis. Variables including age and stage of disease at diagnosis, receptor status, treatment, and tobacco exposure were evaluated utilizing Chi-square testing. A P value <0.05 was considered statistically significant. A total of 585 AA and W women were diagnosed with breast cancers between the years 1990 and 1999. Mean ages were 51.8 years for AA and 56.9 years for W ( P = 0.001). Overall survival (7.8 years AA and 7.6 years W) and survival by stage were not statistically different between the groups. AA patients were younger ( P = 0.001), presented with higher-stage tumors ( P = 0.017), more often had positive axillary lymph nodes ( P = 0.012), more often were estrogen and progesterone receptor negative ( P = 0.004), and more often were premenopausal ( P = 0.048). AA women were more likely treated with chemotherapy while W women tended to receive hormone therapy ( P = 0.01). Statistical significance was not reached for differences in tumor histology or tobacco exposure. We conclude that despite presenting with worse prognostic indicators AA women experience survival equivalent to their W counterparts.
A Novel Lymphatic Mapping Technique to Improve Localization and Staging of Early Colon Cancer during Laparoscopic Colectomy
Authors: Tsioulias George J. , Wood Thomas F. , Spirt Mitchell , Morton Donald L. , Bilchik Anton J.
Published: November 2022

Encouraging results from our previous studies of sentinel lymph node (SLN) mapping in colorectal cancer (CRC) prompted investigation of its feasibility and accuracy during laparoscopic colectomy for early CRC. Between 1996 and 2000,14 patients with clinically localized colorectal neoplasms underwent colonoscopic tattooing of the primary site and SLN mapping. In each case 0.5 to 1 cm3 of isosulfan blue dye was injected submucosally via the colonoscope. The blue-stained lymphatics were visualized through the laparoscope and followed to the SLN, which was marked with a clip, and laparoscopic colectomy was completed in the routine fashion. All lymph nodes were examined by hematoxylin and eosin (H&E) staining; in addition each SLN was subjected to focused examination by multisectioning and immunohistochemical staining using cytokeratin antibody. In all 14 patients the primary neoplasm and an SLN were identified laparoscopically. An average of 13.5 total lymph nodes and 1.7 SLNs per patient were identified. The SLN correctly reflected the tumor status of the nodal basin in 93 per cent of the cases. In four cases with unexpected lymphatic drainage, the extent of mesenteric resection was altered. In two cases (14%), nodal involvement was micrometastatic, confined to an SLN, and identified only by immunohistochemical staining. Lymphatic mapping caused no complications and added only 10 to 15 minutes to the overall operative time. Comparison of results in this group with results for a matched group of 14 patients undergoing SLN mapping during open colon resection showed that the laparoscopic technique had similar rates of accuracy and success. These preliminary findings indicate that colonoscopic/laparoscopic SLN mapping during laparoscopic colon resection is a feasible and technically simple means of identifying the primary colorectal neoplasm and its SLN. Focused pathologic examination of this node can upstage CRC and thereby may improve selection of patients for adjuvant chemotherapy.
Hemoperitoneum from Spontaneous Rupture of a Liver Cell Adenoma in a Male with Hyperthyroidism
Authors: Adusumilli Prasad S. , Lee Byrne , Parekh Kalpaj , Dolgopolov Sergei
Published: November 2022

Spontaneous liver rupture is uncommon, is difficult to diagnose, and carries a high mortality. Liver cell adenoma is a rare benign liver tumor with increasing incidence in women on oral contraceptive pills, and they have been reported to rupture spontaneously. In men such a phenomenon is an extreme rarity. In animal experiments thyroid hormone is proven to play a role in the growth of liver cell-derived neoplasms as they do in normal hepatocyte proliferation. An association of liver cell adenoma and hyperthyroidism in humans has not been previously reported. We present the successful management of an unusual case of spontaneous hemoperitoneum from rupture of a liver cell adenoma in a young man with hyperthyroidism.
Major Lower-Extremity Amputation: Contemporary Experience in a Single Veterans Affairs Institution
Authors: Toursarkissian Boulos , Shireman Paula K. , Harrison Amy , D'Ayala Marcus , Schoolfield John , Sykes Mellick T.
Published: November 2022

Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 ± 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status ( P > 0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics ( P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level ( P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA ( P = 0.04). At an average follow-up of 10 ± 8 months only 65 per cent were alive. Although 51 per cent were discharged to rehabilitation units only 26 per cent regularly wore a prosthesis with 23 per cent ambulating. BKA patients were more likely to ambulate than AKA (34% vs 9%; P = 0.001), and dialysis patients were less likely to ambulate than nondialysis patients (5% vs 25%; P < 0.02). During follow-up 17 per cent of patients discharged with an intact contralateral limb required amputation of that limb and 7 per cent had bypass surgery on that limb. Complication rates were higher in African Americans and Hispanics than in whites (59%, 45%, and 23%, respectively; P < 0.001), although mortality and ambulation rates were similar. Despite an acceptable perioperative mortality complication rates remain high especially in nonwhites. One-year mortality is high. Low rehabilitation rates especially in dialysis patients mandate further efforts in this regard. Vigilant follow-up of the contralateral limb is essential.
Incidental Cholecystectomy during Laparoscopic Antireflux Surgery
Authors: Klaus Alexander , Hinder Ronald A. , Swain James , Achem Sami R.
Published: November 2022

Cholelithiasis and gastroesophageal reflux are both very common diseases that may occur simultaneously. Management of asymptomatic gallstones is still controversial. Because severe complications due to gallstones may occur incidental cholecystectomy during nonrelated abdominal surgery may be offered to patients with coexisting gallbladder disease. The aim of this study was to assess the clinical outcome of patients after laparoscopic fundoplication and incidental cholecystectomy for cholelithiasis compared with the outcome of patients after fundoplication alone. We conducted a retrospective chart review and prospective analysis using a questionnaire of the clinical outcome of patients who underwent laparoscopic fundoplication and incidental cholecystectomy from June 1991 to January 2000 in comparison with sex- and age-matched patients who had antireflux surgery alone. Sixty-seven (6.3%) of 1065 patients had a laparoscopic cholecystectomy at the time of laparoscopic antireflux surgery; 101 (75%) of 134 answered the questionnaire. The mean follow-up time was 4.6 years. Laparoscopic cholecystectomy did not influence surgical morbidity or mortality. Postoperative symptom score (1–10) did not show a statistically significant difference regarding bloating, diarrhea, abdominal pain, nausea, vomiting, biliary problems, jaundice, pancreatitis, dysphagia for liquids and solid, heartburn, regurgitation, and chest pain when the two groups were compared. We conclude that incidental cholecystectomy during laparoscopic antireflux surgery is safe and does not appear to influence the clinical outcome of the antireflux procedure.
Pattern of Injury from Personal Watercraft
Authors: Haan James M. , Kramer M.E. , Scalea T.M.
Published: November 2022

Injury from personal watercraft has continued to increase. Prior attempts to delineate patterns of injury and relative frequencies have yielded varied results. We retrospectively reviewed Trauma Registry data and charts of all patients who suffered personal watercraft injury treated at the R. Adams Cowley Shock Trauma Center between August 1996 and January 2001. Patient demographics included mechanism of injury, injuries sustained, and outcomes. Attempts were made to correlate events around the injury and injury pattern. During the study period 24 patients were treated. Mechanisms consisted of direct collision, fails from the watercraft, handlebar straddle injuries, axial loading, and hydrostatic jet injury. Traumatic brain injury was most common occurring in 54 per cent of patients. Spinal injury was also common occurring in 29 per cent of patients. Axial loading from falls while wave jumping seemed to correlate with skeletal injury. Thoracolumbar spine injury were often skeletally unstable requiring either brace or operative fixation. Inexperience and reckless behavior were found to be the greatest contributing factors. Substance abuse did not influence injury.
Solid-Pseudopapillary Tumor of the Pancreas Masquerading as a Pancreatic Pseudocyst
Authors: Patel Vijaykumar G. , Fortson James K. , Weaver William L. , Hammami Amir
Published: November 2022

Solid-pseudopapillary tumor of the pancreas is a very rare low-grade malignancy, predominantly occurring in adolescent girls and young women. Accurate diagnosis of this unusual tumor is important because the prognosis after surgical resection is excellent. We report a rare case of solid-pseudopapillary tumor of the pancreas in a 22-year-old woman that was misdiagnosed as a pancreatic pseudocyst on abdominal CT scan. This case emphasizes the importance of biopsying the pseudocyst wall at the time of drainage procedure if misdiagnosis is to be avoided. CT scan findings alone can not reliably rule out malignant cystic lesions of the pancreas.
The Diagnostic Dilemma of Diaphragm Injury
Authors: Patselas Timothy N. , Gallagher Edgar G.
Published: November 2022

Prompt diagnosis of acute traumatic injury to the diaphragm remains a challenge when the admission chest X-ray is unrevealing and immediate laparotomy or thoracotomy is not indicated. Diagnostic delay may contribute to significant morbidity and mortality. A retrospective review of our 15-year experience with diaphragm injury (DI) revealed 13 patients (nine male/four female; mean age, 40 ± 34 years) who sustained injuries to the left (77%) and right (23%) diaphragm respectively as a result of motor vehicle crashes (MVCs) (69%), penetrating trauma (30%), and pedestrian- versus-car accidents (1%). Nine (69%) patients with timely diagnosis of DI underwent laparotomy for suggestive chest X-rays or other indications for immediate exploration. Four (31%) patients sustaining blunt trauma had DI missed on initial evaluation; all patients had initial radiographic evaluations of the chest and abdomen which ascribed abnormalities to intrathoracic pathology. In the one-day delay the diagnosis (right sided) was made at exploratory laparotomy for persistent abdominal pain. This 74-year-old patient, who also had sustained a duodenal injury, succumbed to sepsis. In the 17-day delay the patient had two chest CT scans and multiple bronchoscopies yet failed to wean from the ventilator before exploratory laparotomy which revealed the diagnosis. The third patient sustained multiple injuries after a MVC and underwent multiple imaging studies and back stabilization before discharge. Ten years later, after multiple negative gastrointestinal workups for abdominal pain a contrast study finally diagnosed herniated transverse colon in the left chest. This patient underwent successful repair via laparotomy. The fourth delayed diagnosis was made in a 72-year-old women who had been involved in an MVC 8 years earlier and had sustained multiple back fractures. She is scheduled for exploration in the near future. DI particulary after blunt trauma and on the right side may be missed in the absence of other indications for immediate surgery because radiographic abnormalities of the diaphragm particularly on the right are often attributed to thoracic pathology or may be absent initially. A high index of suspicion for DI may help lead to an earlier diagnosis especially when the patient's clinical condition fails to improve.
Elevated Admission White Blood Cell Count in Pregnant Trauma Patients: An Indicator of Ongoing Placental Abruption
Authors: Shah Shuchi , Miller Preston R. , Meredith J. Wayne , Chang Michael C.
Published: November 2022

Placental abruption (PA) is a common cause of fetal demise in pregnant trauma patients. Diagnosis of PA may be difficult, and multiple diagnostic clues are currently used including uterine/ abdominal pain and tenderness, bleeding, maternal hemodynamic instability, and evidence of PA by ultrasonography or other fetal monitoring. Although diagnosis may be problematic fetal and maternal survival are dependent on early diagnosis and intervention. The purpose of this study is to determine predictive factors present at admission associated with PA in trauma victims. Records of all pregnant trauma patients admitted to Wake Forest University Baptist Medical Center over a 5-year period were reviewed for injury characteristics and outcome. Inclusion criteria included a confirmed pregnancy and fetal disposition. Specific admission parameters evaluated included temperature, heart rate, systolic blood pressure, partial pressure of CO2 in arterial blood, total white blood cell count (WBC) and differential, hematocrit, base deficit, and lactic acid. PA is defined as a spontaneous abortion in the first trimester or abruptio placenta in the second or third trimester. Between April 1, 1996 and October 30, 2000, 30 patients met study criteria. Six of 30 patients were found to have PA (20%). Of the studied parameters WBC was significantly elevated in PA patients (27 ± 4.6 vs 17 ± 7.8 WBC x 103/mm3; P = 0.005) as was band count (10 ± 6.6% vs 4 ± 6.1%; P = 0.03). Hematocrit was lower in the PA group (27 ± 4.3% vs 32 ± 5.4%; P = 0.04). Within this group of variables which differed on univariate analysis, WBC was the best discriminator between patients with and without PA (sensitivity 100%, specificity 79%, negative predictive value 100%, and positive predictive value 54%). In pregnant trauma patients WBC >20,000/mm3 on admission should raise suspicion of the possibility of PA, and close monitoring is warranted. Conversely WBC <20,000/mm3 rules out PA in the pregnant trauma patient (negative predictive value of 100%).
Surgical Management of Primary Breast Sarcoma
Authors: Shabahang Mohsen , Franceschi Dido , Sundaram Magesh , Castillo Manuel H. , Moffat Frederick L. , Frank Daniel S. , Rosenberg Ethan R. , Bullock Karen E. , Livingstone Alan S.
Published: November 2022

Primary sarcoma constitutes less than one per cent of breast malignancies. A retrospective review of this disease at our institution was undertaken to assess the effect of different treatment modalities on outcome. Over a 24-year period 28 patients were identified. Follow-up ranged from one to 228 months. Partial mastectomy was done in seven patients, whereas ten underwent total mastectomy and nine had modified radical mastectomy. Two refused surgery. All margins of resection were negative. In total ten axillary lymph node dissections were done with no positive nodes identified. Pathologic analysis of tumors revealed a variety of sarcomas including high-grade malignant cystosarcoma phyllodes in 13. Recurrence of disease occurred in two women, both with malignant cystosarcoma phyllodes. One was a local recurrence in a patient who had undergone partial mastectomy. This was successfully treated with a total mastectomy. The second recurrence involved a distant metastasis in a patient treated with modified radical mastectomy that eventually led to her death. For the entire group the disease-free survival was 75 per cent at 10 years whereas overall survival was 87.5 per cent. In conclusion an adequate margin of resection is the single most important determinant of long-term survival. Axillary lymph node dissection is not necessary for the treatment of these tumors.
A Comparison of Total Thyroidectomy and Lobectomy in the Treatment of Dominant Thyroid Nodules
Authors: Farkas Emily A. , King Tari A. , Bolton John S. , Fuhrman George M.
Published: November 2022

Patients with a clinically concerning dominant thyroid nodule have been managed by lobectomy or total thyroidectomy at our institution. We determined the complications associated with both approaches and the ability of thyroid lobectomy to avoid the need for thyroid hormone replacement therapy. Records of all patients with a dominant thyroid nodule managed with surgery from August 1993 through December 2000 were reviewed for demographics, history of head and neck radiation, indication for surgery, preoperative fine-needle aspirate results, final pathologic evaluation, perioperative complications, determinations of need for subsequent thyroid surgery after lobectomy, and need for thyroid hormone replacement therapy after surgery. Patients with a preoperative diagnosis of malignancy or bilateral or diffuse disease were excluded because these conditions would uniformly be managed by bilateral thyroidectomy. The complications for the lobectomy group (n = 131) compared with the total thyroidectomy group (n = 84) were: recurrent laryngeal nerve paresis (4.6% vs 2.4%), recurrent laryngeal nerve injury (0.8% vs 0), and transient hypoparathyroidism (1.5% vs 9.5%; P = 0.007). No permanent hypoparathyroidism was identified in either group. Postoperative thyroid hormone replacement was required in 64 of 131 lobectomy patients (48.8%). Complications associated with either surgery were low. Total thyroidectomy was not associated with clinically significant additive morbidity. Patients treated by lobectomy should be aware of a nearly 50 per cent chance of requiring thyroid hormone replacement. Total thyroidectomy avoids future thyroid surgery; lobectomy patients remain at risk. When complications can be minimized total thyroidectomy should be considered an option in the management for patients with dominant thyroid nodules that require surgery.