bluuebunny/crossref_metadata_2025 huggingface dataset:
Disparities in Mangement of Patients with Benign Colorectal Disease: Impact of Urbanization and Specialized Care
Authors: Pandit Viraj , Khalil Mazhar , Joseph Bellal , Jandova Jana , Jokar Tahereh Orouji , Haider Ansab Abbas , Zangbar Bardiya , Asim Asad , Hassan Ahmed , Nfonsam Valentine
Published: June 2020

Disparities in the management of patients with various medical conditions are well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with noncancerous benign colorectal diseases. We hypothesized that there is no difference among rural versus urban centers (UC) in the surgical management for noncancerous benign colorectal diseases. The national estimates of surgical procedures for benign colorectal diseases from the National Inpatient Sample database 2011 representing 20 per cent of all in-patient admissions were abstracted. Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer and those who underwent emergency surgery were excluded. The population was divided into two groups: urban and rural, based on the location of treatment. Outcome measures were in-hospital complications, mortality, and hospital costs. Subanalysis of UC was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed. A total of 20,617 patients who underwent surgical intervention for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. Of the UC, 38.3 per cent centers had colorectal surgeons. Patients managed in UC had lower complication rate (7.6% vs 10.2%, P < 0.001), shorter hospital length of stay (4.7 ± 3.1 vs 5.9 ± 3.6 days, P < 0.001), and higher hospital costs ($56,820 ± $27,691 vs $49,341 ± $2,598, P < 0.001) compared with rural centers. On subanalysis, patients managed in UC with colorectal surgeons had 11 per cent lower incidence of in-hospital complications [odds ratio: 0.89 (95% confidence interval: 0.76–0.94)] and a shorter hospital length of stay [Beta: -0.72 (95% confidence interval: —0.81 to —0.65)] when compared with patients managed in UC without colorectal specialization. Disparities exit in outcomes of the patients with noncancerous benign colorectal diseases managed surgically in urban versus rural centers. Specialized care with colorectal surgeons at UC helps reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost-effective manner across rural as well as UC are warranted. Level of evidence: Level III, retrospective cohort analysis.
Using Electromagnetic Navigation Bronchoscopy and Dye Injection to Aid in Video-Assisted Lung Resection
Authors: Brown Jordan , Lee Thomas J. , Joiner Theresa , Wrightson William
Published: June 2020

Small (2 cm) peripheral lung lesions and ground glass opacities remain a difficult subset of lung lesions for the diagnosis and management of lung cancer. Surgical biopsy is more difficult for these lesions because intraoperative localization has to be made without the aid of direct visualization or manual palpation. Electromagnetic navigation bronchoscopy can be used in the operating room to identify a small peripheral lesion and marked using an injection of methylene blue, which can be seen on the visceral pleura of the lung. We present our initial experience using this technique. The sample was eight patients who had peripheral lesions with an average size of 19 mm. Surgical wedge biopsy was diagnostic in all cases, with an average procedure time of 28 minutes. There were no complications from this procedure. In conclusion, these data suggest that electromagnetic navigation bronchoscopy can be performed safely with high diagnostic accuracy by the operating thoracic surgeon, but further data are needed to establish its utility and safety.
Independent Preoperative Predictors of Prolonged Length of Stay after Laparoscopic Appendectomy in Patients over 30 Years of Age: Experience from a Single Institution
Authors: Wise Eric S. , Gadomski Stephen P. , Ilg Annette M. , Bermudez Camilo , Chan Emily W. , Izmaylov Michelle L. , Gridley Samantha J. , Kaczmarek Jessica V. , Melancon Norman T. , Ahmad Sarwat , Hocking Kyle M. , Diaz Jose J. , Kavic Stephen M.
Published: June 2020

Prompt discharge after laparoscopic appendectomy (LA) is a marker of quality of care, fiscally desirable and feasible in select patients. Patients over 30 comprise a more heterogeneous cohort known to experience worse outcomes after LA. We aimed to identify easily available preoperative risk factors portending a postoperative length of stay ≥2 days among patients above age 30. In this investigation, 296 included patients from a single institution who underwent LA for acute appendicitis from 2010 to 2014 were retrospectively reviewed for preoperative demographics, laboratory studies, comorbidities, presentation characteristics, radiographic finding, and other rationally selected factors for association with postoperative length of stay ≥2 days. Bivariate and multivariate analysis was conducted to determine independent risk factors, which were subsequently modeled via receiver-operating characteristic curve generation and Kaplan-Meier analysis. “Classic” presentation [odds ratio (OR) = 0.5, P = .02], elevated red cell distribution width (RDW; OR = 1.5/% increase, P = 0.004) as well as evidence of rupture on CT (OR = 6.9, P < 0.001) were independently associated with postoperative length of stay ≥ 2 days. Modeling length of stay using these factors generated an area under the curve of 0.713 ± 0.037. Kaplan-Meier analysis of “classic” presentation, elevated RDW, and evidence of rupture on CT through the fifth postoperative day generated log-rank P values of 0.02, 0.05, and ≤ 0.001, respectively. In summary, lack of “classic” presentation, elevated RDW, and CT evidence of rupture are novel risk factors for prolonged postoperative length of stay in LA patients over 30. These findings may help target patients most appropriate for prompt discharge.
A Review of Sleeve Gastrectomy Specimen Histopathology
Authors: Kinsinger Luke A. , Garber James C. , Whipple Oliver
Published: June 2020

With the increasing popularity of sleeve gastrectomy, many stomach specimens are being evaluated. Understanding the significance and treatment for unexpected pathology is important. This study examines the incidence of relevant histopathology of sleeve gastrectomy specimens. It evaluates previous data for each histopathology and provides recommendations for treatment. In this study, a retrospective review was performed for 241 patients who underwent sleeve gastrectomy from 2009 to 2014 at a single institution. Of the specimens, 122 had no significant histopathology, 91 had gastritis, 13 had lymphoid aggregates, 5 had hyperplasia, 3 had intestinal metaplasia, 3 had gastrointestinal stromal tumors (GISTs), and 3 had gastric polyps. Of the GISTs all had a low mitotic rate and the size of the tumor ranged from 1.5 to 4.5 cm. The findings of metaplasia may be a marker for increased risk of malignancy and may require additional surveillance. The findings of GIST may warrant interval imaging to survey for recurrence, though the likelihood of recurrence for the tumors in this study is less than 2 per cent based on previous studies.
Spontaneous Hepatic Hemorrhage: A Single Institution's 16-Year Experience
Authors: Rosales Armando , Que Florencia G.
Published: June 2020

Spontaneous hemorrhage from hepatic tumors is an uncommon but serious complication. Recently, interventional radiologic (IR) techniques are being used increasingly in the management of these patients. We report our 16-year experience in managing spontaneous hemorrhage from liver tumors. Twenty-six consecutive patients were diagnosed with spontaneous liver hemorrhage between 1995 and 2011. Initial management was operative in eight, IR in six, and supportive in 12 patients. Of those managed operatively, five were segmentectomies; one hemihepatectomy; one wedge resection; and one packing who later died from coagulopathy. In the IR patients, seven had an angiographic embolization; two required reembolization; one underwent resection of a hepatic adenoma 21 days after angiographic embolization. The malignant lesions included hepatocellular carcinoma (n = 6), angiosarcoma (n = 1), metastatic squamous cell carcinoma (n = 1), metastatic leiomyosarcoma (n = 1), nonsquamous cell carcinoma (n = 1), or metastatic angiosarcoma (n = 1). Benign diseases included hepatic adenoma (n = 5), end-stage liver disease (n = 1), and polycystic liver (n = 1). Spontaneous hemorrhage from the liver occurs evenly from benign or malignant causes, one-third of which are primary liver disease. If the patients presents emergently, angiographic embolization may control the bleeding and allow for elective resection once the sequelae of bleeding have resolved.
A Brief Overview of the Life and Work of Lyon Henry Appleby, M.D. (1895–1970)
Authors: Harrison Jon , Pucci Michael J. , Cowan Scott W. , Yeo Charles J.
Published: June 2020

The life and work of Dr. Lyon Henry Appleby, M.D., portrays the essence of a devoted clinician committed to scholarly excellence. Born in Deseronto, Ontario, in 1895 and passing in 1970, Dr. Appleby influenced all areas of general surgery, most notably popularizing a procedure that bears his name today. After a tour in World War I, he quickly proved himself to be a dedicated clinician with roots in academia, which translated into excellence within the Department of Surgery at St. Paul's Hospital in Vancouver, Canada. He served in various leadership roles including Chair of the Department of Surgery, President of the International College of Surgeons, and Fellow of the Royal College of Physicians and Surgeons. The Appleby procedure, or en bloc removal of the celiac axis, at the time of gastrectomy, is the technical focus of this paper, although reference is made to Appleby's extensive contributions to historical medicine.
Medical versus Surgical Patients with Clostridium difficile Infection: Is There Any Difference?
Authors: Silva-Velazco Jorge , Hull Tracy L. , Messick Craig , Church James M.
Published: June 2020

Severity of Clostridium difficile infection (CDI) varies from one patient to another. We aimed to test the hypothesis that surgical patients would suffer more severe CDIs than medical patients. Patients receiving in-hospital medical or surgical treatment for any underlying disease from 2007 to 2012, who developed CDI, were divided into two groups: “Medical group” and “Surgical group.” Demographics, disease characteristics, and outcomes including mortality and recurrence were compared. Of 3231 patients with CDI evaluated, 1984 (61.4%) and 1247 (38.6%) were medical and surgical patients, respectively. Surgical patients had more severe CDIs than medical. However, the long-term effects of CDI were worse in medical patients, with more and quicker deaths. Recurrence was comparable between groups. Surgical patients were more frequently male, older, and obese; had higher white blood cells but lower levels of hemoglobin, hematocrit, and prealbumin; and had a higher rate of severe CDI. Conversely, medical patients had fewer in-hospital days, CDI appeared earlier, and had greater 30-day mortality and total number of deaths, with death after CDI occurring earlier. Although surgical patients tend to have a stormier clinical course related to CDI, overall they do better than medical patients. Future studies focusing on modifiable risk factors for each group are needed.
Colonic Schwannoma: A Case Study and Literature Review of a Rare Entity and Diagnostic Dilemma
Authors: Uhr Alex , Singh Awinder P. , Munoz Jose , Aka Allison , Sion Melanie , Jiang Wei , Goldstein Scott D. , Rosato Ernest L.
Published: June 2020

An asymptomatic 73-year-old woman was found to have a submucosal mass in the descending colon on routine colonoscopy. A CT scan revealed a 31 X 28 X 31 mm lesion in the same location. Previous biopsy proved to be nondiagnostic, and the patient underwent a laparoscopic descending colon resection. Histologic evaluation of the tumor revealed a low grade spindle cell neoplasm with strong, diffuse positivity for S-100 protein by immunohistochemistry, leading to the diagnosis of schwannoma. A review of the literature revealed intestinal schwannoma to be a rare disease entity, with only about 50 cases previously reported.
Urban Bicyclist Trauma: Characterizing the Injuries, Consequent Surgeries, and Essential Sub-Specialties Providing Care
Authors: Warnack Elizabeth , Heyer Jessica , Sethi Monica , Tandon Manish , Dimaggio Charles , Pachter Hersch Leon , Frangos Spiros G.
Published: June 2020

In the United States in 2013, nearly 500,000 bicyclists were injured and required emergency department care. The objectives of this study were to describe the types of injuries which urban bicyclists sustain, to analyze the number and type of surgeries required, and to better delineate the services providing care. This is an observational study of injured bicyclists presenting to a Level I trauma center between February 2012 and August 2014. Most data were collected within 24 hours of injury and included demographics, narrative description of the incident, results of initial imaging studies, Injury Severity Score, admission status, length of stay, surgical procedure, and admitting and discharging service. A total of 706 injured bicyclists were included in the study, and 187 bicyclists (26.4%) required hospital admission. Of those admitted, 69 (36.8%) required surgery. There was no difference in gender between those who required surgery and those who did not (P = 0.781). Those who required surgery were older (mean age 39.1 vs 34.1, P = 0.003). Patients requiring surgery had higher Abbreviated Injury Scores for head (P ≤ 0.001), face (P ≤ 0.001), abdomen (P = 0.012), and extremity (P ≤ 0.001) and higher mean Injury Severity Scores (12.6 vs 3.7, P < 0.001). Sixty-nine patients required surgery and were brought to the operating room 82 times for 89 distinct procedures. Lower extremity injuries were the reason for 43 (48.3%) procedures, upper extremity injuries for 14 (15.7%), and facial injuries for 15 (16.9%). Orthopedic surgery performed 50 (56.2%) procedures, followed by plastic surgery (15 procedures; 16.8%). Trauma surgeons performed five (5.6%) procedures in four patients. The majority of admitted patients were admitted and discharged by the trauma service (70.1%, 56.7%, respectively) followed by the orthopedics service (13.9%, 19.8%, respectively). Injured bicyclists represent a unique subset of trauma patients. Orthopedic surgeons are most commonly involved in their operative management and rarely are the operative skills of a general traumatologist required. From a resource perspective, it is more efficient to direct the inpatient care of bicyclists with single-system trauma to the appropriate surgical subspecialty service soon after appropriate initial evaluation and treatment by the trauma service.
Clinical Outcomes after Surgery for Linitis Plastica of the Stomach: Analysis of a Population Cancer Registry
Authors: Chang James M. , Lara Kelly A. , Gray Richard J. , Pockaj Barbara A. , Wasif Nabil
Published: June 2020

Linitis plastica (LP), a subset of gastric adenocarcinoma (GA), has been considered as a fatal disease with few management options. Little evidence has been reported regarding the role for surgical therapy in treating LP. A retrospective review of GA patients with LP from the surveillance, epidemiology, and end results database (2004–2009) was performed. 29,440 patients with GA were identified, of whom 948 (3.2%) had LP. After matching for American Joint Commission on Cancer (AJCC) stage, LP patients had significantly worse 5-year disease specific survival (DSS) compared with GA (6 vs 34%, P < 0.001). For potentially resectable LP patients (i.e., stage I–III), 5-year DSS was 0 per cent for no treatment and for radiation therapy alone, 18 per cent for both and surgery and radiation, and 20 per cent for surgery alone(P < 0.001). LP is a marker of poor survival in patients with GA. However, surgical resection provides the best oncologic outcomes in these patients with a 20 per cent 5-year DSS in patients with loco-regional disease.
Management of Primary Hyperparathyroidism: Can We Do Better?
Authors: Sharata Ahmed , Kelly Tracy L. , Rozenfeld Yelena , Hammill Chet W. , Schuman Earl , Carlisle James R. , Aliabadi-Wahle Shaghayegh
Published: June 2020

The failure to follow national guidelines in management of various diseases has been previously established. We sought to quantify primary care providers’ familiarity with primary hyperparathyroidism as it affects adherence to the 2009 National Institute of Health (NIH) consensus recommendations in treatment of primary hyperparathyroidism. A large primary care group was surveyed to determine their familiarity with the 2009 NIH consensus recommendations for management of primary hyperparathyroidism (PHPT). Retrospective review of the group's records (2009–2011) was performed to verify compliance. Survey responders included 109 clinicians, 31 per cent were familiar with all criteria for surgical intervention in asymptomatic patients and 34 per cent correctly identified appropriate surveillance testing for patients undergoing observation. Chart review identified 124 patients with PHPT. Of the patients who met NIH criteria, 34 per cent had a parathyroidectomy. Younger age, higher intact parathyroid hormone, hypercalciuria, and history of nephrolithiasis were associated with surgery in multivariable analysis. Of the observed patients, 16 per cent had appropriate surveillance studies. In conclusion, this study confirms suboptimal adherence with consensus recommendations in management of PHPT. A minority of clinicians demonstrated solid familiarity with management strategies, paralleling their treatment approach. Educational efforts may improve adherence with upcoming national recommendations.
Periareolar or Peritumoral Injection of Isosulfan Blue and the Effect on the Number of Sentinel Lymph Nodes Examined
Authors: Weber Joseph J. , Wong Jan H.
Published: June 2020

The conduct of sentinel node biopsy (SLNBx) for breast cancer (BC) has evolved substantially since its original description. No national standards for the performance of SLNBx exist, therefore, we sought to determine the effect of isosulfan blue (ISB) injection technique on nodal harvesting and staging accuracy during SLNBx. Our main outcome measures included the number of SLNs examined and the number of positive axillae in patients undergoing SLNBx after injection of filtered sulfur colloid intradermally and either small volume ISB injected in the periareolar dermis (PA,∼0.75 cc) or large volume peritumoral (PT, 5 cc). Between January 1, 2009, and September 30, 2013, 1357 patients at an academic/community practice setting underwent SLNBx of which 966 (71.2%) were node negative. These patients ranged in age from 27 to 97 years (mean 60.1 years). The majority of patients (76%) underwent PT injection of ISB. There was no significant difference in the mean age of these two groups (61.2 PT vs 59.7 PA years). All were female. The majority of patients (72.7%) had T1 primaries. Nearly 73 per cent of patients were Luminal A/B, 10.8 per cent HER, and 16.4 per cent were triple negative. There was no significant difference in the distribution of T stage (P = 0.56) or breast cancer subtypes between the techniques (P = 0.59). The mean number of nodes examined was 3.1 (range, 1–18). PT patients had a mean of 3.5 (range, 1–18) nodes, whereas PA patients had a mean of 2.4 nodes (range, 1–10) (P < 0.001). The technical aspects of injecting ISB affect the number of nodes harvested during SLNBx but not staging accuracy.
The Hidden Story of Innovation: Charity Hospital, Angola Prison, and the Challenging of Surgical Dogma
Authors: Greiffenstein Patrick , Hastings Paul R.
Published: June 2020

The late 1960s was a period of significant upheaval of social, cultural, and scientific norms. The generally accepted notion of mandatory laparotomy for all penetrating abdominal injuries was among those norms being called into question across the country and many advocated expectant management of selected patients presenting with this type of injury. Leaders of the surgical community published opinions on either side of the argument. The house staff at Charity Hospital during this period was among the busiest in the nation in treating these injuries, many of them inmates of the Louisiana State Penitentiary who used self-inflicted stab wounds to the abdomen as a means of temporary respite from the inhumane conditions in the prison. Inspired, in part, by the overabundance of negative laparotomies among this group, F. Carter Nance went on to systematically challenge the standard of care. This effort constitutes one of the major forces for change of the surgical dogma of mandatory laparotomy for all abdominal stab wounds. It is the first major study to show conclusively that delayed laparotomy for perforated viscous was not significantly detrimental and posed less of a risk than unnecessary laparotomy. The circumstances surrounding this initiative constitute a powerful and heretofore unknown chapter in the history of surgical innovation.
The Effect of Omentoplasty on the Rate of Anastomotic Leakage after Intestinal Resection: A Randomized Controlled Trial
Authors: Nasiri Shirzad , Mirminachi Babak , Taherimehr Reyhaneh , Shadbakhsh Roya , Hojat Mohsen
Published: June 2020

Anastomotic leakage is a major postoperative complication after intestinal surgery leading to increased risk of morbidity and mortality. Omentoplasty has been evaluated to prevent anastomotic leakage in several studies. However, there is no consensus regarding whether or not omentoplasty should be used to decrease the rate of anastomotic leakage after intestinal resection. A prospective, randomized study was conducted to evaluate the influence of omentoplasty on anastomotic leakage after intestinal resection. A total of 124 patients who underwent intestinal resection were enrolled in this prospective study. Patients were randomly assigned to receive either the omentoplasty or nonomentoplasty. In the omentoplasty group, the omentum was wrapped around the anastomotic region. Age, gender, site and type of anastomosis, duration of hospital stay, and performance of omentoplasty were recorded. This study was registered in Iranian Registry of clinical trial (number: IRCT201412316925N3). The rate of anastomotic leakage was significantly lower in the omentoplasty group (P = 0.04). Patients in the omentoplasty group developed a significantly lower rate of postoperative infection and peritonitis (P < 0.05). There was no significant difference of abscess and fistula formation between the two groups (P > 0.05). The length of hospital stay was longer in the nonomentoplasty group, compared with that for omentoplasty patients (P < 0.05). No death occurred in the omentoplasty subjects, while six nonomentoplasty patients died (P < 0.05). Our data demonstrated that omentoplasty is useful to lower the rate of postoperative complications in patients underwent intestinal surgery.
The Statesmanship of William Crawford Gorgas, M.D., Surgeon General, Medical Corps, United States Army
Authors: Gandy Roy E. , Christopher Raven M. , Rodning Charles B.
Published: June 2020

If statesmanship can be characterized as a bed rock of principles, a strong moral compass, a vision, and an ability to articulate and effect that vision, then the fortitude, tenacity, imperturbability, and resilience of William Crawford Gorgas cannot be overestimated. As Chief Sanitary Officer in Cuba and as Chief Medical Officer in Panama, he actualized strategies to eradicate the vectors of yellow fever and malaria. His superiors initially pigeonholed his requisitions, refused to provide him with any authority, and clamored for his dismissal. Nevertheless, with dogged persistence he created a coalition of the willing, who eventually implemented those reforms. As Surgeon General in the United States Army, he organized and expanded the Active Duty and Medical Reserve Corps in anticipation of World War I. Skilled university affiliated surgeons and personnel from throughout North America, manned base hospitals in Europe. Those lessons impacted upon subsequent military and civilian surgical care—organizationally, logistically, and clinically. He was universally recognized for his bonhomie, savoir-faire, modesty, discretion, decorum, courtesy, and graciousness. To those attributes must be added his devotion to duty, discipline, integrity, and authenticity, which characterized his leadership and statesmanship. Those attributes are most worthy of emulation and perpetuation by clinicians, academicians, educators, and investigators.
Fast-Track Pancreaticoduodenectomy in the Elderly
Authors: Zouros Efstratios , Liakakos Theodoros , Machairas Anastasios , Patapis Paulos , Tzerbinis Helen , Manatakis Dimitrios K. , Papadimitriou-Olivgeris Matthaios , Dervenis Christos
Published: June 2020

It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD.
High-Resolution CT Angiogram for Lower Extremity Vein Mapping
Authors: Wright Mark P. , Smeds Matthew R. , Wright Lonnie , Ali Ahsan T.
Published: June 2020

High-resolution CTangiogram (CTA) has replaced traditional diagnostic angiography as the main preoperative imaging modality for vascular surgery patients. Although the use of CTA is increasing for arterial imaging, it has not been used routinely for vein mapping. The goal of this study was to evaluate the accuracy of CTA for venous anatomy and compare it to a standard venous duplex ultrasound (DUS). When the vein was used for bypass, the quality and size of the vein were evaluated in the operating room. As part of a preoperative workup before lower extremity revascularization, 16 patients underwent a CTA followed by a DUS. Although the CTA provided useful arterial anatomy, the greater saphenous vein (GSV) was also evaluated. In total, 22 GSV were evaluated in 11 patients. The vein diameter was measured by CTA at four locations: saphenofemoral junction, midthigh, knee joint, and midcalf region. Duplication or other anomalies were also noted, when present. These measurements were taken by an interventional radiologist independently and before the DUS. Routine vein mapping with diameter measurements were then performed with DUS in a vascular laboratory by registered vascular technicians. Measurements for each limb were then compared between CTA and DUS using linear regression (mean ± SD). There was no statistical difference in the diameter of the GSV when measured using a CT or a DUS at the standard points of measurements. Furthermore, the operative findings confirmed the CTA to be very accurate. There were four duplications in the GSV which were all seen on the CTA, whereas only two of these were identified by DUS. There was one vein found to be sclerotic and unusable by DUS that was not identified by CTA. CTA is as accurate as DUS for evaluation of superficial venous anatomy in the lower extremities. CTA can provide global anatomy and can be used as a one-stop imaging modality for both arterial and venous anatomy. However, sclerosis is not detected by CTA.
Pancreaticoduodenectomy Can be Performed Safely with Rare Employment of Surgical Drains
Authors: Kunstman John W. , Starker Lee F. , Healy James M. , Salem Ronald R.
Published: June 2020

Use of drain remains frequent following pancreaticoduodenectomy (PD) due to concern for postoperative pancreatic fistula (POPF) and anastomotic leak development. Despite controversy, a recent randomized trial suggested omitting drainage would result in a large increase in operative mortality. This study sought to comprehensively examine the effects of forgoing drainage in the large cohort of patients undergoing PD. A prospective cohort study of two consecutive groups undergoing PD was constructed. The initial group had operative drains placed in cases subjectively concerning for POPF development; the second cohort did not undergo operative drainage. Outcomes including POPF incidence, need for reintervention, and overall morbidity were examined. A total of 106 patients were evaluated in two consecutive cohorts of 53; in the first group, 30 per cent had operative drains placed; 22.6 per cent developed POPF versus 7.5 per cent of patients in the no drainage group (P = 0.06). Despite this, no significant difference in major morbidity (Clavien ≥3, 20.8% versus 17.0%) or need for procedural reintervention (18.9% versus 15.1%) was observed. A subsequent validation cohort of 237 additional patients where drains were used only in exceptional circumstances was examined. Operative drains were placed in only 3 per cent of patients (n = 7) and 90-day mortality was 1.3 per cent (n = 3). Incidence of POPF was 8.0 per cent and the overall major complication rate was 14.8 per cent. Given such findings, it appears that drainage after PD can be avoided resulting in acceptable operative morbidity and mortality in most cases.
Acute Respiratory Distress Syndrome Incidence, but Not Mortality, Has Decreased Nationwide: A National Trauma Data Bank Study
Authors: Fahr Michael , Jones Glenn , O'Neal Hollis , Duchesne Juan , Tatum Danielle
Published: June 2020

Acute respiratory distress syndrome (ARDS) incidence is reported to have decreased in recent years. However, no large-scale study to date has exclusively examined ARDS in the critically injured. We sought to examine the national incidence of ARDS and its associated outcomes exclusively in adult trauma patients. The National Trauma Data Bank (NTDB) was queried to evaluate the incidence of ARDS and associated outcomes over a 6-year study period (2007–2012). Included patients were ≥18 years old, with at least one ventilator day, and complications recorded. ARDS-associated outcomes and complications were also analyzed. Mean age increased over the study period (48.1–51.4 years, P < 0.003). ARDS incidence decreased from 21.5 to 8.5 per cent (P < 0.001). Length of stay (LOS), intensive care unit LOS (ICU LOS), and ventilator days decreased over time. Mortality increased from 21.3 to 24.9 per cent (P < 0.002). Incidence of pneumonia and acute kidney injury increased marginally (39.5–40.9% and 11.4–12.3%, respectively). Sepsis trended down from 2007 to 2010, after which comparable NTDB data were not available. ARDS incidence in mechanically ventilated adult trauma patients has decreased significantly in recent years. We theorize this is likely attributable to improved critical care strategies. Unlike ARDS incidence, mortality in this patient population has not improved despite these advancements.
Carotid Duplex Ultrasonography: Additional Imaging is Rarely Necessary for Appropriate Treatment Planning for Carotid Artery Disease
Authors: Ammar Chad P. , Helmer Stephen D. , Ammar Alex D.
Published: June 2020

This study was conducted to determine the utility of multiple imaging studies (CT angiography, magnetic resonance angiography, and/or conventional angiography), in addition to duplex ultrasonography (DU), in evaluating patients with carotid stenosis. A retrospective case series was conducted of patients with carotid stenosis who underwent DU alone or DU plus additional imaging. Concordance between DU and additional imaging and the effect on treatment plan was evaluated. Two hundred patients with carotid stenosis were evaluated. Sixty-four had DU plus additional imaging. Sixty-two of the patients (96.9%) had no change in treatment due to additional imaging. Only 2 of the 64 patients (3.1%) with additional imaging had a change in treatment plan. In conclusion, additional imaging, beyond DU, is rarely necessary for treatment planning in patients with carotid disease.
Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience
Authors: Nunn Andrew , Fischer Peter , Sing Ronald , Templin Megan , Avery Michael , Christmas A. Britton
Published: June 2020

We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004–2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.
Lethal Trauma Pulmonary Embolism is a Black Swan Event in Patients at Risk for Deep Vein Thrombosis: An Evidence-Based Review
Authors: Dunham C. Michael , Huang Gregory S.
Published: June 2020

We delineated the incidence of trauma patient pulmonary embolism (PE) and risk conditions by performing a systematic literature review of those at risk for deep vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence interval = 1.2–1.6) in at-risk patients. Of 10 conditions, PE was only associated with increased age (P < 0.01) or leg injury (P < 0.01; risk ratio = 1.6). As lower extremity DVT (LEDVT) proportions increased, mortality proportions (P = 0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P = 0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; P < 0.01). PEwas lower withCP (1.0%) than without CP (2.2%; P = 0.0004). Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP). LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVTsurveillance. Mortality was higher with LEDVTsurveillance (7.9%) than without (4.8%; P < 0.01). A PE mortality of 19.7 per cent (95% confidence interval = 18–22) 3 a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and death is a black swan event. LEDVTsurveillance did not improve outcomes. Because PE was not associated with LEDVT and most patients with PE had no LEDVT, preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.
Trends and Outcomes in the Operative Management of Traumatic Vascular Injuries: A Comparison of Open versus Endovascular Approaches
Authors: Richmond Bryan K. , Judhan Rudy , Sherrill William , Yacoub Michael , Aburahma Ali F. , Knackstedt Kimball , Chumbe Julton T. , Samanta Damayanti , Thompson Stephanie N.
Published: June 2020

Controversy exists in vascular trauma regarding the best method of treatment—open versus endovascular techniques. Little has been published on this complex topic. Patients from 2005 to 2013 at a Level I trauma center with vascular injuries were identified via a prospectively trauma registry. Patient data, injury type/severity, treatment, and 30-day outcomes were obtained from the trauma registry and the chart review. Adverse events (limb loss, major disability, and death) were outcomes of interest. Univariate analysis and multivariate logistic regression were used to identify predictors of adverse events. In all, 346 patients were included (median age 34, range 1–93 years). Median Injury Severity Score (ISS) was 10(1–59). Endovascular repairs (n = 52) increased from 0 per cent (2005) to 32 per cent (2013), and demonstrated equivalent outcomes to open approaches (P = 0.24). On multi-variate analysis, higher ISS (P = 0.001), increasing age (P = 0.01), and lower extremity injuries (P = 0.001) were associated with adverse outcomes across the entire series. Endovascular approaches were most commonly used in vascular injuries of the chest/abdomen (39 of 52, 75% of all endovascular procedures in the series, P < 0.001), older patients(P = 0.003), blunt injury mechanism (P < 0.001), and patients with a higher ISS at presentation (P < 0.001). In conclusion, this large series, the use of endovascular procedures increased over time, and was associated with equivalent outcomes to open approaches, despite their higher usage in older patients, those with chest/abdominal injuries, and those with a higher ISS at presentation. Although these retrospective results are encouraging, further prospective study into the role of endovascular therapies in the treatment of vascular injuries.
Nonoperative Management of the Damaged Spleen: A Community Surgeon Looks Back
Authors: Walker Mark L.
Published: June 2020

Blunt spleen injury is usually managed nonoperatively. An 8-year retrospective analysis by one community surgeon was done to provide an overview of the role of CT, angiography, and transfusion in the management algorithm. A total of 2750 patients were screened and 125 patients were identified with spleen injury. Of these 125 patients, 72 were managed without surgery. These were young (mean age 32 ± 16 years) patients with mean Injury Severity Score of 16 ± 8. Angiography was used in 14 patients. These patients received more blood (5 ± 6 vs 2 ± units of packed red blood cells) than their nonangiogram counterparts. Overall failure of nonoperative care was 3 per cent. Community surgeons can provide safe nonoperative care and current adjuncts including angi-ography may enhance splenic salvage.
Danger on the Farm: A Comparison of Agricultural and Animal-Related Injuries
Authors: Weaver Jessica L. , Kimbrough Charles W. , Broughton-Miller Kimberly , Frisbie Michelle , Wojcik Jodi , Pentecost Karina , Bozeman Matthew C. , Nash Nicholas A. , Harbrecht Brian G.
Published: June 2020

Animal-related injuries are common in rural areas. Agricultural workers can suffer severe injuries involving farm machinery or falls. The spectrum of injuries related to rural activities is poorly defined and characterizing these injuries will improve injury prevention efforts. Records for injured patients admitted between 2010 and 2013 were retrospectively reviewed. Patients with a mechanism of injury involving a large animal or with the injury site listed as “farm” were included. Patients with agricultural injuries (n = 85) were older with more multisystem injuries than patients injured by animals (n = 132) but the Injury Severity Score was equivalent. There was no difference in intensive care unit length of stay, ventilator days, or mortality. There was no difference in frequency of solid organ injury, pelvic fractures, rib fractures, or hemo- or pneumothorax between groups. Animal injuries had more frequent traumatic brain injuries (22.4% vs 10.5%, P = 0.03), whereas agricultural injuries had more vertebral fractures (20.5% vs 9.2%). Of toxicology screens performed, 25 per cent (22/88) were positive. No significant differences were found between occupational versus recreational animal injuries. Agricultural and animal-related injuries have different characteristics but Injury Severity Score and mortality were similar. Severe injuries from both mechanisms are common in rural communities and injury prevention activities are needed in both settings.
The G60 Trauma Center: A Future Consideration?
Authors: Bukur Marko , Simon Joshua , Catino Joseph , Crawford Margaret , Puente Ivan , Habib Fahim
Published: June 2020

With a considerably increasing elderly population, we sought to determine whether the volume of elderly trauma patients treated impacted outcomes at two different Level I trauma centers. This is a retrospective review of all elderly patients (>60 years) at two state-verified Level I trauma centers over the past five years. The elderly trauma center (ETC) saw a greater proportion (52%) of elderly patients than the reference trauma center (30%, TC). Demographic and clinical characteristics were abstracted and stratified into ETC and TC groups for comparison. Primary outcomes were overall postinjury complication and mortality rates, as well as death after major complication (failure to rescue). ETC patients were older (78.6 vs 70.5), more likely to be admitted with severe head injuries (head abbreviated injury score ≥ 3, 50.0% vs 32%), had a greater overall injury burden (injury severity score > 16 41.4% vs 21.1%), and required intensive care unit admission (81.3% vs 64%) than the TC group. Need for operative intervention, mechanism of injury, and comorbidities were similar between the two groups. Overall complications were higher in trauma patients admitted to the TC (21.9% vs 14.3%), as well as failure to rescue (4.0% vs 1.8%). Adjusting for confounding factors, ETC had significantly lower chance of developing a postinjury complication (adjusted odds ratios [AOR] = 0.4, 95% confidence interval [CI] = [0.3, 0.5]), failure to rescue (AOR = 0.3, 95% CI = [0.1, 0.5]), and overall mortality (AOR = 0.3, 95% CI = [0.2, 0.4]). Improved outcomes were demonstrated in the Level I center treating a higher proportion of elderly patients. Exact etiology of these benefits should be determined for quality improvement in care of the injured geriatric patient.
Travel Time Influences Readmission Risk: Geospatial Mapping of Surgical Readmissions
Authors: Turrentine Florence E. , Buckley Patrick J. , Sohn Min-Woong , Williams Michael D.
Published: June 2020

The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients’ residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01–1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.
Complex Abdominal Wall Hernia Repair in Contaminated Surgical Fields: Factors Affecting the Choice of Prosthesis
Authors: LÓPez-Cano Manuel , Teresa Quiles MarÍA , Antonio Pereira José , Armengol-Carrasco Manuel , ArbÓ S VÍA MarÍA Antonia
Published: June 2020

To compare patients with complex abdominal wall hernias undergoing surgical repair using synthetic nonabsorbable or biologic meshes in contaminated fields. Retrospective review of 62 patients with complex abdominal wall hernia with surgical repair in an elective setting and in the context of a clean-contaminated or contaminated fields (January 2009–April 2015). Two groups according to the prosthesis (synthetic nonabsorbable, n = 48 or biologic, n = 14). Mean follow-up was 24.6 (15.8) months. Clean-contaminated wounds were significantly more frequent in the synthetic group. Contaminated wounds were significantly more frequent in the biologic group. Enterocutaneous fistula, recurrent hernia, and removal of chronic infected mesh were significantly more frequently in the biologic group. Differences in postoperative complications and surgical site infections were not found. Recurrence was higher in the biologic group (35.7% vs 8.3%, P = 0.03). In the elective repair of complex hernia, the level of contamination, a recurrent hernia, an enterocutaneous fistula or removal of chronic infected mesh were the factors affecting the choice of prosthesis. In the clean-contaminated setting, the use of a synthetic nonabsorbable mesh versus a biologic mesh did not increase the rate of postoperative infections. Recurrences are significantly higher with biologic meshes.