bluuebunny/crossref_metadata_2025 huggingface dataset:
Causes and Timing of Nonelective Reoperations after Bariatric Surgery: A Review of 1304 Cases at a Single Institution
Authors: Thompson Erin , Ferrigno Lisa , Grotts Jonathon , Knox Jenna , Sobelman Samantha , Thoman David , Bounoua Farida , Zerey Marc
Published: June 2020

As the number of patients undergoing bariatric procedures for weight loss increases, an understanding of the causes and timing of complications requiring reoperation is critical. The aim of our study was to characterize the type and timing of nonelective (NE) reoperations in these patients. Over five years, 1304 patients undergoing index procedures were identified: 769 laparoscopic Roux-en-Y gastric bypasses (LRYGB), 301 laparoscopic sleeve gastrectomies, and 234 laparoscopic adjustable gastric bands. We identified 117 NE reoperations, which were grouped by index procedure as well as whether they occurred early (≤90 days) or late (>90 days). In the laparoscopic adjustable gastric bands group, slipped gastric band was the most common indication for early (n = 2) and late (n = 2) reoperations. Biliary disease was the most common cause for early reoperations (n = 4), and the only cause for late reoperations (n = 2) after laparoscopic sleeve gastrectomies. For LRYGB, diagnoses differed between the early and late groups, with the most common early indications being bowel obstruction (n = 8) and anastomotic leak (n = 4) of the 18 early reoperations, and internal hernia (n = 36) and biliary disease (n = 17) of the 82 late reoperations. The vast majority of NE reoperations were performed laparoscopically (92%), with conversions and primarily open procedures only occurring in the LRYGB group.
Esophageal Adenocarcinoma in Patients Younger than 40 Years: A Two-Decade Experience at a Public and Private Hospital
Authors: Boys Joshua A. , Oh Daniel S. , Lewis Justin S. , Demeester Steven R. , Hagen Jeffrey A.
Published: June 2020

Esophageal adenocarcinoma is typically observed in the older non-Hispanic white population. Changing demographics are altering the epidemiology of the disease. The aim of this study is to review the presentation and outcomes of esophageal adenocarcinoma patients <40 years old at our institution. A retrospective review was performed of patients diagnosed with esophageal adenocarcinoma between 1990 and 2013. Demographics, presentation, and outcomes were compared in those <40 years old and those ≥40 years old. There were 772 total cases with 42 (5%) <40 years old consisting of 37 (88.1%) males, five females and median age of diagnosis of 35 (interquartile range: 31–38). The two most common ethnicities were White non-Hispanic/Latino in 19 (45.2%), Hispanic /Latino in 18 (42.9%). Compared with patients 40 years and older, the younger group had more Hispanic/Latinos than the older group (43% vs 17%, P < 0.001), more frequently presented with stage IV disease (50% vs 29%) and had a shorter median survival. In conclusion, younger patients tend to present at a much later stage than the older counterparts, which may be due to a delay in diagnosis as well as more aggressive biology. Esophageal adenocarcinoma seems to be increasing in the Hispanic/Latino population.
Can Transfusions be Eliminated in Major Abdominal Surgery? Analysis of a Vive-Year Experience of Blood Conservation in Patients Undergoing Pancreaticoduodenectomy
Authors: Singer Matthew B. , Sheckley Marwan , Menon Vijay G. , Sundaram Vinay , Donchev Vladimir , Voidonikolas George , Nissen Nicholas N.
Published: June 2020

Pancreaticoduodenectomy (PD) has historically required perioperative blood transfusion in 40 to 60 per cent of cases. Growing data suggest that transfusions may be deleterious in the surgical patient. We recently initiated a minimal transfusion approach to PD consisting of limited postoperative blood draws, early iron supplementation, changes in surgical technique, and elimination of hemoglobin transfusion triggers. Predictors of perioperative transfusion were analyzed in 130 consecutive patients undergoing PD by a single surgeon between 2008 and 2013, divided into two eras with 65 patients each. Patients in each era were similar with respect to age, comorbidities, American Society of Anesthesiologists class, body mass index, and diagnosis. The transfusion rate for the entire group was 22 per cent. Nonsignificant predictors of perioperative transfusion include American Society of Anesthesiologists class ≥3 ( P = 0.41), vascular resections ( P = 0.56), body mass index ≥30 ( P = 0.72), and intraoperative blood loss ( P = 0.89). Significant predictors of transfusion include PD performed in Era 1 as well as preoperative hemoglobin levels <10 g/dL. In Era 1, 38 per cent of patients required transfusion compared with 6 per cent in Era 2 ( P < 0.01). Shorter length of stay and a trend toward decreased pancreatic fistulae were seen in Era 2. Transfusions can be almost completely eliminated in PD and this may contribute to improved outcomes.
The Role of Surgery in the Clinical Management of Primary Gastrointestinal Non-Hodgkin's Lymphoma
Authors: MacQueen Ian T. , Shannon Evan M. , Dawes Aaron J. , Ostrzega Nora , Russell Marcia M. , Maggard-Gibbons Melinda
Published: June 2020

Primary gastrointestinal non-Hodgkin's lymphoma (PGINHL) is a heterogeneous family of tumors, with treatment modalities including chemotherapy, surgery, and radiotherapy. Because the role of surgery in PGINHL remains disputed, this study aims to assess the impact of operative resection on survival. We used a pathology database to identify all cases of PGINHL diagnosed at a single academic-affiliated medical center from 1988 to 2013. Demographic and clinical data were abstracted from the medical record. We summarized the clinical courses of patients with PGINHL and then performed a survival analysis to compare overall and disease-free survival, stratified by demographic and clinical variables. We identified 33 patients diagnosed with PGINHL during the study period. Of 29 who subsequently received treatment at the institution, 15 initially underwent chemotherapy, 10 underwent surgical resection, and 4 underwent surgery for other reasons such as diagnosis without resection or management of disease complications. Three patients suffered surgical complications and two of these patients died. We found no difference in overall survival between patients receiving surgical resection and patients managed initially with chemotherapy. This case series supports a continued role for surgical resection in the management of patients with PGINHL, though anticipated benefits should be weighed against the risk of complications.
Increasing Body Mass Index is Inversely Related to Groin Hernias
Authors: Ravanbakhsh Samine , Batech Michael , Tejirian Talar
Published: June 2020

Few studies describe the relationship between obesity and groin hernias. Our objective was to investigate the correlation between body mass index (BMI) and groin hernias in a large population. Patients with the diagnosis of inguinal or femoral hernia with and without incarceration or strangulation were identified using the Kaiser Permanente Southern California regional database including 14 hospitals over a 7-year period. Patients were stratified by BMI. There were 47,950 patients with a diagnosis of a groin hernia—a prevalence of 2.28 per cent. Relative to normal BMI (20–24.9 kg/m2), lower BMI was associated with an increased risk for hernia diagnosis. With increasing BMI, the risk of incarceration or strangulation increased. Additionally, increasing age, male gender, white race, history of hernia, tobacco use history, alcohol use, and higher comorbidity index increased the chance of a groin hernia diagnosis. Complications were higher for women, patients with comorbidities, black race, and alcohol users. Our study is the largest to date correlating obesity and groin hernias in a diverse United States population. Obesity (BMI ≥ 30 kg/m2) is associated with a lower risk of groin hernia diagnosis, but an increased risk of complications. This inverse relationship may be due to limitations of physical exam in obese patients.
Predictive Factors of Ventilator Dependency after Colon and Rectal Surgery
Authors: Moghadamyeghaneh Zhobin , Hwang Grace , Hanna Mark H. , Carmichael Joseph C. , Mills Steven D. , Pigazzi Alessio , Stamos Michael J.
Published: June 2020

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005–2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.
Early Outcome of Treatment of Chronic Mesenteric Ischemia
Authors: Moghadamyeghaneh Zhobin , Carmichael Joseph C. , Mills Steven D. , Dolich Matthew O. , Pigazzi Alessio , Fujitani Roy M. , Stamos Michael J.
Published: June 2020

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.
Vertical Tunnel-based Low-site Peritoneal Dialysis Catheter Implantation Decreases the Incidence of Catheter Malfunction
Authors: Sun Cheng , Zhang Miao , Jiang Chunming
Published: June 2020

Peritoneal dialysis (PD) is often complicated by catheter dysfunction. We designed a PD catheter implantation technique to reduce catheter dysfunction. Between June 2008 and 2012, 89 patients with end-stage renal disease were enrolled into a prospective study and randomly assigned to receive traditional catheter implantation by open surgery (n = 41) or vertical tunnel-based low-site PD catheter implantation (n = 48). Both procedures used Baxter straight double-cuffed Tenckhoff catheters. The novel implantation technique involves a low-site (7 cm above the midpoint of the pubic symphysis), individually tailored intra-abdominal segment, and increased vertical subcutaneous tunnel. Patients were followed for 1-year after procedure. The vertical tunnel-based low-site method implanted catheters were 3.7 ± 0.9 cm long, with an 11.3 ± 0.9 cm intra-abdominal segment. The incidence of postoperative bleeding, PD fluid leakage, outer cuff extrusion, inflow or outflow pain, peritonitis, tunnel inflammation, or exit-site infection did not differ significantly between the two surgical techniques; however, the incidence of catheter displacement and non-catheter displacement malfunctions after the novel technique (4.2%) was significantly lower than that in traditional open surgery (19.5%, P < 0.05). In conclusions, vertical tunnel-based low-site PD catheter implantation can significantly reduce the occurrence of PD catheter malfunction, particularly catheter displacement.
Is 6-Month Radiologic Imaging Necessary after Benign Breast Biopsy? Review of Literature and Multicenter Experience
Authors: Mateo Alina M. , Frankel Arthur M.
Published: June 2020

A retrospective study of 786 patients was conducted to determine the necessity of a 6-month interval study after a benign stereotactic or ultrasound-guided breast biopsy. These results were compared with those of other centers. After reviewing the data, we found few patients developed cancer after their original biopsy, and for those that did, the 6-month study did not contribute to an earlier diagnosis. Those short-term interval radiologic studies that were interpreted as concerning were all benign when biopsied. A 6-month study contributes to higher costs of health care and can be inconvenient, painful, and anxiety producing to patients. Short-interval follow-up was found to be unnecessary.
Postoperative Morbidity in Curative Resection of Gastroesophageal Carcinoma Does Not Impact Long-term Survival
Authors: Samples Jennifer E. , Snavely Anna C. , Meyers Michael O.
Published: June 2020

Significant morbidity and mortality have historically been reported for surgical resection of gastric and gastroesophageal junction tumors. We evaluated our experience to determine morbidity and mortality and evaluated demographic and pathologic risk factors associated with postoperative outcome and long-term survival. A retrospective, Institutional Review Board-approved, single-institution database identified 102 patients who underwent resection with curative intent for gastroesophageal junction or gastric carcinoma from 2004 to 2012. The method of Kaplan and Meier was used to describe overall survival and estimate median survival. Of 102 patients, 74 were male and 28 were female. Of these, 24 patients were > 70 years of age at surgery (median = 62.9). Forty esophagectomies, 25 total gastrectomies, and 37 subtotal gastrectomies were performed. Two patients died (one esophagectomy and one gastrectomy). Forty-one developed a complication: 17 minor and 35 major, including six anastomotic leaks. Patients with low preoperative albumin ( P = 0.01) and increased age ( P = 0.05) were associated with having a postoperative complication; extent of nodal dissection ( P = 0.48), jejunostomy (0.24), performance status ( P = 0.77), type of surgery ( P = 0.74), and neoadjuvant therapy ( P = 0.24) were not associated. More extensive nodal dissection was associated with a decreased risk of death ( P = 0.007). Having any complication ( P = 0.20), an anastomotic leak ( P = 0.17), worse grade of complication ( P = 0.15), presence of feeding jejunostomy tube ( P = 0.17), and neoadjuvant therapy ( P = 0.30) were not associated with changes in overall survival. Thorough lymph node dissection improves survival without increasing postoperative morbidity. The data advocate for increased lymph node yield and close attention to nutritional support in gastroesophageal carcinoma patients.
Does Transumbilical Incision Influence Surgical Site Infection Rates of the Laparoscopic Sigmoidectomy and Anterior Resection?
Authors: Yamamoto Masashi , Tanaka Keitaro , Asakuma Mitsuhiro , Kondo Keisaku , Isii Masatsugu , Hamamoto Hiroki , Okuda Junji , Uchiyama Kazuhisa
Published: June 2020

Laparoscopic surgery is widespread and is safe and effective for the management of patients with colorectal cancer. However, surgical site infection (SSI) remains an unresolved complication. The present study investigated the comparative effect of supraumbilical incision versus transumbilical incision (TU) on the incidence of SSI in patients undergoing laparoscopic surgery for colon cancer. Medical records from patients with colorectal cancer who underwent laparoscopic sigmoid and rectosigmoid colon surgeries with either supraumbilical incision (n = 150) or TU (n = 150) were retrospectively reviewed. There was no difference in demographics, comorbidities, or operative variables between the two groups. The transumbilical group and the supraumbilical group were comparable with regards to overall SSI (6.0% vs 4.0%; P = 0.4062), superficial SSI (6.0% vs 3.3%; P = 0.2704), and deep SSI (0% vs 0.7%; P = 0.2385). SSI developed after laparoscopic sigmoid and rectosigmoid colon cancer surgery in 15 (5.0%) of the 300 patients. Of these superficial SSI, all wounds were in the left lower quadrant incision, and the transumbilical port sites did not become infected. Univariate analysis failed to identify any risk factors for SSI. Avoidance of the umbilicus offers no benefit with regard to SSI compared with TU.
A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See?
Authors: Darwazeh Ghaleb , Cunningham Steven C. , Kowdley Gopal C.
Published: June 2020

Patients with appendiceal abscess or phlegmon have been traditionally managed with antibiotics and radiologically guided drainage of the abscess. Many studies have questioned the need for interval appendectomy. A systematic review of the nonsurgical treatment of patients with an appendiceal abscess or phlegmon was undertaken. The rate of recurrence after nonsurgical management, morbidity and length of hospital stay was measured. PubMed and Cochrane databases were queried to identify 21 studies reporting the morbidity of nonsurgical treatment of appendiceal phlegmon or abscess, and five studies reporting the morbidity of performing interval appendectomy. Repeat nonsurgical management was compared with that of performing interval appendectomy. The studies included a total of 1943 patients, of which 1400 patients were managed nonsurgically and 543 patients underwent interval appendectomy. Nonoperative treatment had a mean recurrence of 12.4 per cent, a morbidity of 13.3 per cent, and the length of hospital stay was 9.6 days. The mean morbidity rate and length of hospital stay for patients who underwent interval appendectomy was 10.4 per cent and 5.0 days, respectively. Interval appendectomy and repeat nonoperative management in case of recurrence are associated with similar morbidity; however, elective interval appendectomy implies additional operative costs to prevent recurrence in one of eight patients.
The Charlson Comorbidity Index (CCI) as a Mortality Predictor after Surgery in Elderly Patients
Authors: Laor Anat , Tal Sari , Guller Vladimir , Zbar Andrew P. , Mavor Eli
Published: June 2020

The increasing range of surgery in elderly patients reflects the changing demography where in the next 10 years one quarter of the population will be 65 years of age or older. There is presently no consensus concerning the optimal predictive markers for postoperative morbidity and mortality after surgery in older patients with an appreciation that physical frailty is more important than chronological age. In this retrospective analysis, we have compared the impact of age and the calculated preoperative Charlson Comorbidity Index (CCI) on early (30-day) and late (one-year) mortality in a group of patients >75 years of age dividing them into an “older old” cohort (75–84 years of age, Group A) and an “oldest old” group (≥85 years of age, Group B). Increased age was associated with a higher death rate after emergency surgery, with late deaths after elective surgery exceeding those after emergency operations. A higher mean CCI was noted in both age groups in early nonsurvivors after both elective and emergency surgery with a more significant effect of the preoperative CCI than chronological age for the prediction of late postoperative death for both groups after elective and emergency operations. Although the CCI was not designed to predict perioperative mortality in surgical cohorts, it correlates with a greater risk than age for perioperative death in the elderly.
Reduction of Costs for Pelvic Exenteration Performed by High Volume Surgeons: Analysis of the Maryland Health Service Cost Review Commission Database
Authors: Althumairi Azah A. , Canner Joseph K. , Gorin Michael A. , Fang Sandy H. , Gearhart Susan L. , Wick Elizabeth C. , Safar Bashar , Bivalacqua Trinity J. , Efron Jonathan E.
Published: June 2020

High volume hospitals (HVHs) and high volume surgeons (HVSs) have better outcomes after complex procedures, but the association between surgeon and hospital volumes and patient outcomes is not completely understood. Our aim was to evaluate the impact of surgeon and hospital volumes, and their interaction, on postoperative outcomes and costs in patients undergoing pelvic exenteration (PE) in the state of Maryland. A review of the Maryland Health Services Cost Review Commission database between 2000 and 2011 was performed. Patients were compared for demographics and clinical variables. The differences in length of hospital stay, length of intensive care unit (ICU) stay, operating room (OR) cost, and total cost were compared for surgeon volume and hospital volume controlling for all other factors. Surgery performed by HVS at HVH had the shortest ICU stay and lowest OR cost. When PE was performed by a low volume surgeon at an HVH, the OR cost and total cost were the highest and increased by $2,683 ( P < 0.0001) and $16,076 ( P < 0.0001), respectively. OR costs reduced when surgery was performed by an HVS at an HVH ($-1632, P = 0.008). PE performed by HVS at HVH is significantly associated with lower OR costs and ICU stay. We feel this is indicative of lower complication rates and higher quality care.
Crawford Long, Alfred Blalock, Louis Wright, and Georgia's Surgical Heritage
Authors: Nakayama Don K.
Published: June 2020

Georgia and the Atlanta area are associated with three important figures in the history of surgery. Crawford Long (1815–1878) discovered the anesthetic effects of ether while in practice in Jefferson. Born in Culloden, Alfred Blalock (1899–1964) was a pioneer researcher in shock and resuscitation, and developed the Blalock–Taussig shunt for Tetralogy of Fallot. His technician, African-American Vivien Thomas (1910–1985), was a full partner in the landmark advances. Louis T. Wright (1891–1952) was born in LaGrange and grew up in the Jim Crow South. As the country's leading black surgeon, he led the integration of major hospitals and helped lay the groundwork for the landmark civil rights legislation of the 1960s that integrated American medicine. Their stories, with roots in small towns in Georgia, reveal the deep surgical traditions of the South.
Factors Associated with Return to Work Postinjury: Can the Modified Rankin Scale be Used to Predict Return to Work?
Authors: Kohli Anirudh , Chao Edward , Spielman Daniel , Sugano Dordaneh , Srivastava Abhishek , Dayama Anand , Lederman Andrew , Stern Michelle , Reddy Srinivas H. , Teperman Sheldon , Stone Melvin E.
Published: June 2020

The ability to return to work (RTW) postinjury is one of the primary goals of rehabilitation. The modified Rankin Scale (mRS) is a validated simple scale used to assess the functional status of stroke patients during rehabilitation. We sought to determine the applicability of mRS in predicting RTW postinjury in a general trauma population. The trauma registry was queried for patients, aged 18 to 65 years, discharged from 2012 to 2013. A telephone interview for each patient included questions about employment status and physical ability to determine the mRS. Patients who had RTW postinjury were compared with those who had not (nRTW). Two hundred and thirty-four patients met the inclusion criteria. Of these, 171 (72.5%) patients RTW and 63 (26.7%) did nRTW. Patients who did nRTW were significantly older, had longer length of stay and higher rates of in-hospital complications. Multivariate analysis revealed that older patients were less likely to RTW (odds ratio = 0.961, P = 0.011) and patients with a modified Rankin score ≤2 were 15 times more likely to RTW (odds ratio = 14.932, P < 0.001). In conclusion, an mRS ≤2 was independently associated with a high likelihood of returning to work postinjury. This is the first study that shows applicability of the mRS for predicting RTW postinjury in a trauma population.
Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: Adhesix™: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate
Authors: Tabbara Malek , Genser Laurent , Bossi Manuela , Barat Maxime , Polliand Claude , Carandina Sergio , Barrat Christophe
Published: June 2020

To review our experience and outcomes after inguinal hernia repair using the lightweight self-adhering sutureless mesh “Adhesix™” and demonstrate the safety and efficacy of this mesh. This is a 3-year retrospective study that included 143 consecutive patients who underwent 149 inguinal hernia repairs at our department of surgery. All hernias were repaired using a modified Lichtenstein technique. Preoperative, perioperative, and postoperative data were prospectively collected. Incidence of chronic pain, postoperative complications, recurrence, and patient satisfaction were assessed three years postoperatively by conducting a telephone survey. We had 143 patients with a mean age of 58 years (17–84), who underwent 149 hernia repairs using the Adhesix™ mesh. Ninety-two per cent (131 patients) were males. Only 10 patients (7%) had a postoperative pain for more than three years. In our series, neither age nor gender was predictive of postoperative pain. Only one patient had a hematoma lasting for more than one month and only four patients (2.8%) had a recurrence of their hernia within three years of their initial surgery. Ninety per cent of the patient expressed their satisfaction when surveyed three years after their surgery. In conclusion, the use of the self-adhering sutureless mesh for inguinal hernia repair has been proving itself as effective as the traditional mesh. Adhesix™ is associated with low chronic pain rate, recurrence rate, and postoperative complications rate, and can be safely adopted as the sole technique for inguinal hernia repair.
Right Internal Jugular Vein Cannulation: Carotid Artery-directed versus Sternocleidomastoid-directed Methods
Authors: Yu Zhao-Yan , Yuan Ping , Pan Yang , Zhang Zhong-Min
Published: June 2020

The aim of the present study was to explore a simple and safe method for central venous catheterization (CVC) from the right internal jugular vein (RIJV) by comparing carotid artery (CA) positioning with sternocleidomastoid (SCM) positioning. The medical records of patients who underwent CVC between January 2011 and January 2015 were retrospectively reviewed. Central venous catheters were inserted into the RIJV either above the level of the cricoid cartilage using the CA-directed method (419 patients, Group 1) or below the level of the cricoid cartilage using the SCM-directed method (436 patients, Group 2). Success rate and related complications of catheterization were evaluated in the two groups. The total success rate of RIJV cannulation in Group 1 (97.2%) was higher than that in Group 2 (94.5%). Moreover, the success rate at first attempt was significantly higher in Group 1 than in Group 2 (92.4% vs 86.9%). The incidence of hematoma was 1.6 per cent in Group 1 and 3.8 per cent in Group 2. The rate of other complications such as pneumothorax, catheter-related infections, and catheter occlusion did not significantly differ between the groups. In conclusions, CA-directed RIJV cannulation is more effective and simple to perform than the SCM-directed method, and should become the preferred CVC technique in the absence of ultrasound guidance.
Inter-rater Variability Interferes with Reproducibility of Splenic Injury Grades Reported to the American College of Surgeons Committee on Trauma
Authors: Ferguson Eric J. , Walsh Michael , Brown Megan
Published: June 2020

The objective of this study was to determine reproducibility of our splenic injury grading data, previously reported to the American College of Surgeons Committee on Trauma for our most recent site visit. The institutional registry of a Level I trauma center was queried to identify adult patients presenting with blunt splenic injury between January 1, 2013 and December 31, 2013. Original CT scans were scanned into the picture archiving and communication system and subsequently reviewed by four trauma surgeons and two radiologists for clinical impressions of splenic injury grade. Grades assigned by the clinician and the grade recorded in the registry were compared for inter-rater reliability using the intraclass correlation coefficient, as a means of assessing variance of ordinal data. The intraclass correlation coefficient in our model was 0.77, which indicates that 77 per cent of the observed variance was due to true variance and 23 per cent of the variance was due to error. Variability in grading may, in some cases, underestimate injury severity and compromise the clinician's expectation of clinical outcome, both in real-time, as well as during retrospective review processes such as those used during the trauma center reverification process.
Association between Insurance Status and Hospital Length of Stay following Trauma
Authors: Englum Brian R. , Hui Xuan , Zogg Cheryl K. , Chaudhary Muhammad Ali , Villegas Cassandra , Bolorunduro Oluwaseyi B. , Stevens Kent A. , Haut Elliott R. , Cornwell Edward E. , Efron David T. , Haider Adil H.
Published: June 2020

Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.
Ephraim McDowell's Ovariotomy on General Overton's Wife
Authors: Ikard Robert W.
Published: June 2020

Ephraim McDowell's removal of a massive ovarian tumor from Jane Todd Crawford in Danville, Kentucky, in 1809 revolutionized the practice of surgery. Most academic physicians then believed that operating in the abdomen would inevitably result in peritonitis and death. McDowell proved them wrong and performed numerous ovariotomies with an acceptable complication rate for the era. His expertise brought patients from afar. McDowell also operated on patients in their homes, sometimes far from Danville. This article addresses an operation done in Nashville, Tennessee, on Penelope Holmes Overton, wife of General Thomas Overton, a prominent Tennessean.
Obesity and the Risk for Surgical Site Infection in Abdominal Surgery
Authors: Winfield Robert D. , Reese Stacey , Bochicchio Kelly , Mazuski John E. , Bochicchio Grant V.
Published: June 2020

Obesity is a risk factor for surgical site infection (SSI) after abdominal procedures; however, data characterizing the risk of SSI in obese patients during abdominal procedures are lacking. We hypothesized that obesity is an independent risk factor for SSI across wound classes. We analyzed American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data for 2011. We calculated body mass index (BMI), classifying patients according to National Institute of Health (NIH) BMI groups. We excluded records in which height/weight was not recorded and patients with BMI less than 18.5. We examined patients undergoing open abdominal procedures, performing univariate and multivariate analyses to assess the relative contribution of obesity to SSI. Study criteria were met by 89,148 patients. Obese and morbidly obese patients had significantly greater SSI rates in clean and clean-contaminated cases but not contaminated or dirty/infected cases. Logistic regression confirmed obesity and morbid obesity as being independently associated with the overall SSI development, specifically in clean [Obesity odds ratio (OR) = 1.757, morbid obesity OR = 2.544, P < 0.001] and clean-contaminated (obesity OR = 1.239, morbid obesity OR = 1.287, P < 0.001) cases. Obesity is associated with increased risk of SSI overall, specifically in clean and clean-contaminated abdominal procedures; this is independent of diabetes mellitus. Novel techniques are needed to reduce SSI in this high-risk patient population.
Frank Netter: A Man of Art and Science
Authors: Shivakumar Natesh , Hammad Abdulrahman Y. , Gamblin T. Clark
Published: June 2020

Medical illustrations are highly used by medical professionals for various reasons. They have facilitated learning for many centuries and allowed a detailed analysis of subjects. Complex information on anatomy, histology, physiology, and even surgical procedures can be transformed by illustrations into a clear and accurate source that words could never fully describe. The idea that art can be used to enhance the study of science has been emphasized by many medical illustrators. One person who will always be remembered for his artwork in the modern era is Frank H. Netter. The New York native, born in 1906, is one of the era's most well-known medical illustrators. Almost all medical professionals, at one point or another, have come across one of his numerous artistic sketches during their career. Although best known for his Atlas of Human Anatomy, some of Netter's other projects include the CIBA Collection of Medical Illustrations, the “Transparent Women,” and the Clinical Symposia series. Medicine lost an educator and an artist in 1991; however, his collection of illustrations remains as his lasting gift to the field.
Institutional Improvement in Weight Loss after Laparoscopic Sleeve Gastrectomy
Authors: Mangieri Christopher W. , Strode Matthew A. , Sherman William E. , Pierotti Matthew L. , Faler Byron J. , Choi Yong U.
Published: June 2020

Laparoscopic sleeve gastrectomy (LSG) is a recent addition to the bariatric surgery armamentarium. It has been demonstrated to be an efficacious stand-alone bariatric procedure in regard to weight loss. This study evaluates the progress of our initial experience with LSG. Retrospective review of prospective data from 2008 to 2010. Compared data between our first operative year of experience with LSG (2008) and our third year of experience (2010). Data compared for up to three years postoperatively. End points were percentage of excess body weight loss (%EWL) and percentage of excess body mass index loss (%EBL). Institutional improvement in %EWL and %EBL rates as our collective experience increased with LSG. Mean increase in %EWL of 14 per cent and mean increase of %EBL of 22 per cent. In our first year performing LSG the institutional weight loss was <50 per cent EWL, which is often cited as a benchmark level for “success” after bariatric surgery. By our third year of experience with LSG we achieved an institutional weight loss >50 per cent EWL. Institutional improvement in weight loss results with LSG as the collective experience increased. Several factors could have contributed to this observation to include a surgical men-torship program and the institution of formal nutritional education. This study demonstrates that institutional experience is a significant factor in weight loss results with LSG.
Late Biliary Complications after Pancreaticoduodenectomy
Authors: Parra-membrives Pablo , Martínez-baena Darío , Sánchez-sánchez Fabricio
Published: June 2020

Since morbidity of pancreaticoduodenectomy (PD) has been improved, concerns about late complications have raised. We present a review of long-term biliary complications after PD attended at our institution. The data of 86 patients operated on from January 2001 to May 2014 were examined and incidence of late biliary complications was recorded. The preoperative features of the patients, timing of symptoms appearance, results of diagnostic imaging test, and the management strategies were analyzed. Late biliary complications occurred in 14 patients (16.3%). The median time to diagnosis was 9.50 months. The preoperative peak bilirubin level, need for pre-operative drainage and intraoperative blood loss were not significantly different for patients with long-term biliary events. Eight patients (57.14%) developed true biliary strictures. Three of them (37.5%) had experienced a postoperative biliary leak ( P < 0.0005) and resulted in benign strictures. The remaining five patients revealed tumor recurrence. Six patients had no biliary obstruction and cholangitis could only be explained through afferent-limb stasis. Late biliary strictures appear predominantly in the first postoperative year and develop more likely if a bile leak occurred in the postoperative period. However, biliary strictures are not always responsible for late biliary symptoms and afferent limb stasis may also be included in the differential diagnosis.
Discharge Destination after Elective Femoropopliteal Bypass in Patients without Critical Ischemia
Authors: Kauvar David S. , Osborne Candice L.
Published: June 2020

Femoropopliteal bypass (FPB) remains a widely accepted treatment option for symptomatic leg ischemia, even in patients without features of critical limb ischemia (CLI). These patients are revascularized to improve symptoms of exertional limb pain and the goal of such treatment is to increase their ability to ambulate within the community. Therefore, the anticipated initial discharge disposition for a patient without CLI undergoing FPB is back to their home. This study examined the disposition at initial discharge of such patients. Data from the 2012 National Surgical Quality Improvement Program registry was queried for all elective FPB performed in patients without CLI. Analysis was limited to patients surviving to initial discharge who were living independently at home before surgery. Initial disposition was defined as to HOME or to a FACILITY (either rehabilitation or skilled nursing); these constituting the study groups. Univariate analysis and multivariable logistic regression were performed to identify patient risk factors for failure to discharge to home. In-hospital and postoperative events were also recorded and compared. Significance was defined at P ≤ 0.05. In National Surgical Quality Improvement Program 2012, 1060 cases of elective FPB in patients without CLI were found. The mean6 SD age of the population was 65 ± 9 years; 359 (34%) of patients were female; 198 (19%) had a reported race other than white; and most (893, 84%) had hypertension. 60 (6%) patients failed to discharge to home (26 to rehabilitation, 34 to skilled nursing). On univariate analysis, age (FACILITY 68 ± 11 years vs HOME 65 ± 9 years, P = 0.009), female gender (55% vs 37%, P < 0.001), nonwhite race (30% vs 18%, P = 0.007), and a history of diabetes (48% vs 33%, P = 0.01), dialysis (5% vs 1.3%, P = 0.02) congestive heart failure (5% vs 1.1%, P = 0.01), or a stroke (cerebrovascular accident, 5% vs 2.6%, P = 0.01) were found to predict failure to discharge to home. On multivariate analysis, female gender [odds ratio (OR) = 2.4, 95% confidence interval = 1.4–4.1, P = 0.002], and a history of congestive heart failure (OR = 4.7, 1.2–18, 0.03] or cerebrovascular accident (OR = 3.4, 1.9–9.4, 0.02) independently predicted failure to discharge to home. FACILITY patients had higher rates of infectious complications (8.3% vs 1.4%, P < 0.001), myocardial infarction (3.3% vs 0.8%, P = 0.05), operative transfusion (22% vs 5.8%, P < 0.001), and unplanned reoperation (17% vs 2.4%, P < 0.001) during their initial hospitalization. Elective FPB results in a low but not negligible failure of initial return to the community in patients without CLI. Female gender and serious comorbidities predict initial discharge to a facility, which is associated with a complicated hospital course. Careful patient selection is important to achieve good outcomes in this population and furthermore study into the specific preoperative functional and socioeconomic factors predicting failure of early return to the community is warranted.
Article Commentary: Surgical Management of the Axilla in Breast Cancer
Authors: Mastrangelo Stephanie , McMasters Kelly , Ajkay Nicolas
Published: June 2020

This article offers a review of the literature on current surgical management of the axilla in breast cancer. This includes the decision-making process involved in clinically node-negative patients versus clinically node-positive patients, with discussion of the indications for sentinel lymph node biopsy versus axillary dissection. It also examines the surgical axillary management of patients who receive neoadjuvant chemotherapy. This article will help update practicing surgeons on the evolving research and guidelines for the management of breast cancer axillary disease.
Tubular Carcinoma of the Breast: A Single Institution's Experience of a Favorable Prognosis
Authors: Boyan William , Shea Brian , Farr Michael , Kohli Manpreet , Ginalis Ernest
Published: June 2020

Tubular carcinoma is a subtype of invasive breast cancer that comprises 1 to 4 per cent of invasive breast cancers. Prior studies show nearly 100 per cent 15 year survival rate for tubular carcinoma compared to the 89.2 per cent five year survival of all breast cancers. These encouraging statistics beg the question should tubular cancers be treated as other invasive cancers, or can some patients be spared an invasive procedure or the side effects of adjuvant therapy? Fifty-seven cases of tubular carcinoma over 16 years were analyzed. All relevant aspects of the patient's history, treatment, and outcomes were documented. The aim was compare treatment outcomes of tubular breast cancer outcomes to that of all invasive breast cancers. Of the 57 patients, local recurrence was seen in two patients (3.5%) only one of which recurred as a tubular carcinoma (1.75%). There were no cancer-related mortalities. A look into our institution's data supported the notion that tubular carcinoma of the breast is a less aggressive histological type. Of our 57 cases, only two recurrences (3.5%) were noted and there were no cancer-related mortalities. Interestingly only one patient (1.75%) recurred as tubular carcinoma. Without controlling for adjuvant therapy, recommendations cannot be made for a less aggressive treatment plan at this point. Future randomized controlled trials may lead to a less aggressive treatment plan for this favorable subtype. On the basis of this study and others like it, physicians can give evidenced-based favorable prognosis with a diagnosis of tubular carcinoma of the breast.
Timing of Abdominal CT Evaluation Impacts the Diagnosis of Paraduodenal Hernia
Authors: Liu Terrence H.
Published: June 2020

Internal hernias are the causes of 0.5 to 5.8 per cent of all cases of small bowel obstruction. Left paraduodenal hernia (PDH) is the most common congenital internal hernia encountered in adults. The symptoms and physical findings associated with PDH are vague and nonspecific before the onset of complicated intestinal obstruction. Diagnoses are most commonly established by CT. This case presentation and review is intended to promote clinicians’ awareness of this unusual but potentially highly morbid condition, discuss CT findings associated with PDH, and illustrate the importance of timing in the acquisition of diagnostic abdominal CT scans.
Right Versus Left-Sided Colectomies: A Comparison of Outcomes
Authors: Groene Steven A. , Chandrasekera Chamath V. , Prasad Tanushree , Lincourt Amy E. , Heniford B. Todd , Augenstein Vedra A.
Published: June 2020

Surgeons often consider that a right colectomy (RC) carries less risk than a left or sigmoid colectomy (L/SC). Our aim was to compare outcomes between RC and L/SC. Review of the Carolinas Medical Center National Surgical Quality Improvement Program data from 2013 to February 2015 was performed. Procedures were categorized as RC versus L/SC based on current procedural terminology codes for both open and laparoscopic colectomies. Demographics and minor and major complications were evaluated using standard statistical methods. A total of 164 RC and 211 L/SC were studied. RC patients were older (63.9 ± 14.2 vs 59.4 ± 13.0, P < 0.001). Patients undergoing RC had more comorbidities, and 64.6 per cent had an American Society of Anesthesiologist (ASA) Class III or above versus 51.7 per cent of those undergoing L/SC ( P = 0.02). RC had significantly higher rates of postop urinary tract infection (7.3% vs 2.8%, P = 0.04) and postop transfusions ( P = 0.01). Average length of stay was longer for RC (10.1 ± 8.6 days vs 8.3 ± 7.0 days, P < 0.01). After controlling for ASA class, preoperative hematocrit and surgical technique (lap versus open), multivariate analysis indicated that there were no longer any significant differences in outcomes between RC and L/SC. There were no differences between the group complications including superficial or deep surgical site infections, anastomotic leak, myocardial infarction (MI), pneumonia, or 30-day mortality. RC patients tended to be sicker and had more medical complications postop with initial evaluation of the data. However, when controlling for ASA, hematocrit, and techniques, there were no differences in complications when RC was compared to L/SC. The belief that L/SC has a higher rate of complications compared to RC is not supported.