bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk Factors for Delirium in Trauma Patients: The Impact of Ethanol Use and Lack of Insurance
Authors: Branco Bernardino C. , Inaba Kenji , Bukur Marko , Talving Peep , Oliver Matthew , David Jean-Stephane , Lam Lydia , Demetriades Demetrios
Published: June 2020

The purpose of this study was to examine independent risk factors, and in particular the impact of alcohol on the development of delirium, in a cohort of trauma patients screened for ethanol ingestion on admission to hospital. The National Trauma Databank (v. 7.0) was used to identify all patients 18 years or older screened for ethanol on admission. Patients who developed delirium were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for the development of delirium. A total of 504,839 patients with admission ethanol levels were identified. Of those, 2,909 (0.6%) developed delirium. Patients developing delirium were significantly older, more frequently male, and more likely to sustain thermal injuries and falls. Patients developing delirium had more comorbidities including chronic ethanol use (19.1% vs 4.5%, P < 0.001) and cardiovascular disease (21.5% vs 12.2%, P < 0.001). On admission, patients developing delirium were more likely to be intoxicated with ethanol (55.4% vs 26.5%, P < 0.001) and were more likely to be uninsured (17.8% vs 0.9%, P < 0.001). A stepwise logistic regression model identified lack of insurance, positive ethanol on admission, chronic ethanol use, Intensive Care Unit admission, age ≥ 55 years, burns, Medicare insurance, falls, and history of cardiovascular disease as independent risk factors for the development of delirium. The incidence of delirium in this trauma patient cohort was 0.6 per cent. The above risk factors were independently associated with the development of delirium. This data may be helpful in designing interventions to prevent delirium.
Intraoperative Ultrasound Can Facilitate the Wire Guided Breast Procedure for Mammographic Abnormalities
Authors: Bouton Marcia E. , Wilhelmson Krista L. , Komenaka Ian K.
Published: June 2020

Wire guided breast procedures are the most commonly used breast conserving operation for nonpalpable cancers. We did a retrospective review of all patients who underwent the wire guided breast procedure at a county hospital with an associated surgical residency program. Twenty-eight patients underwent the procedure with intraoperative ultrasound from June 2009 to March 2010. Breast cancer patients who underwent a wire-guided lumpectomy with intraoperative ultrasound had a lower rate of positive margins (9% vs 26%, P = 0.28) and a smaller volume of tissue removed (126 cm3 vs 146 cm3, P = 0.57). For wire guided excisional biopsy, the volume of tissue removed was smaller in the intraoperative ultrasound group (30 cm3 vs 44 cm3, P = 0.17) and the targeted area was more likely to be removed in one specimen (1.1 vs 1.5, P = 0.03). Intraoperative ultrasound can improve surgical outcomes of the wire guided breast procedure.
Reversal of the Hartmann Procedure Through Only a Stomal Orifice
Authors: Aydin Cemalettin , Olmez Aydemir , Isik Sevil , Sumer Fatih , Kayaalp Cuneyt
Published: June 2020

We performed reversal of the Hartmann procedure only through the stoma site and we did not use either any other incision nor laparoscopic assistance. A total of 8 patients (7 males), ages between 23 and 80 years, were treated by means of a defined technique. The indications of the Hartmann procedure were sigmoid volvulus (4), sigmoid cancer obstruction (2), rectal trauma (1), and Fournier gangrene (one). The duration from the first procedure was a mean of 5 months (range, 2 to 8 months). The length of the rectal stump was at least 5 cm over the pelvic peritoneum and the body mass indices of all patients were less than 30 kg/m2. The diameter of the stoma opening was a mean of 50 mm (range, 40 to 55 mm). Incision extensions from the stomal orifice (accepted as conversion) were needed for two cases as a result of injury on the intestine and inability to identify the distal bowel stump (25%). The mean operative blood loss and duration of operation were 50 mL (range, 30 to 100 mL) and 65 minutes (range, 45 to 80 minutes), respectively. Fecal discharge of all patients was weighed before hospital discharge and the length of postoperative hospital stay was a mean of 5.5 days (range, 4 to 9 days). Neither anastomosis leakage nor surgical site infections were observed in any of the patients and all had an uneventful postoperative course. The described technique can be the least invasive one than the previously described techniques for the reversal of the Hartmann procedure by only using the stoma site, particularly for nonobese patients with a long distal rectal stump.
Early Individual Experience with Distal Venous Arterialization as a Lower Limb Salvage Procedure
Authors: Djoric Predrag
Published: June 2020

This prospective randomized study reported early results of the treatment of 36 unreconstructable patients with critical lower limb ischemia. The patients were divided into two groups: 12 were treated with distal venous arterialization (DVA) and 24 were conservatively (CT) using antiplatelet drugs. There were seven men and five women with an average age 64.3 ± 9.9 in DVA and 13 men and 11 women with a average age 67.1 ± 10.8 in CT groups of patients. The aim of this study was to estimate the validity of DVA as the limb salvage procedure. During the period of monitoring, morbidity and mortality rates were 50 and 0 per cent at DVA versus a mortality rate in the CT group of 33.3 per cent ( P < 0.05). The mean follow-up period for DVA was 4.8 ± 3.9 months (range, 1 to 14 months) versus 4.9 ± 2.4 months (range, 1 to 9 months) for the CT group ( P > 0.05). Graft patency was 83.3 per cent with two early graft thromboses. There were significant differences between the two groups in limb salvage (91.7% DVA vs 12.5% CT, P < 0.001), pain relief (75% DVA vs 8.3% CT, P < 0.001), and wound healing rates (77.8% DVA vs 0% CT, P < 0.001). Lactate level in the blood of deep venous system after repeated measuring was significantly decreased after the multivariate analysis of variance method was applied (F = 7.691, P < 0.01). Hemodynamic parameters such as systolic digital pressure and digitobrachial systolic pressure index were increased after revascularization using Student's t test ( P < 0.001). The DVA may improve the outcome of the treatment of the patients for whom the conventional bypass procedure mainly was not possible.
Efficacy of Short-Term Antibiotic Therapy for Consecutive Patients with Mild Appendicitis
Authors: Park Hyoung-Chul , Kim Byoung-Seup , Lee Bong Hwa
Published: June 2020

Although antibiotic therapy seemed to be a safe treatment option for acute appendicitis, indications of this treatment have not been fully evaluated. We hypothesized that clinical and radiologic mild appendicitis may be a candidate for short-term antibiotic therapy. The purpose of present study was to examine the efficacy and the recurrence rate of short-term antibiotic therapy for consecutive patients with mild appendicitis. A prospective observational study was conducted over 3 years. The mild appendicitis was defined as the intermediate Alvarado score (4-8) and dilated appendix from 6 mm to 10 mm in radiologic study. All patients received initial antibiotics administration with clinical observation during 48 hours. The failure to respond to therapy and the incidence of recurrence were assessed. There were 107 enrolled patients with the mean Alvarado score of 6 ± 1 and the mean appendiceal diameter of 7.4 ± 1 mm. Of these, 97 (91%) exhibited improved symptoms and were discharged. The remaining 10 patients underwent surgery because of clinical aggravation, and pathology revealed true appendicitis in six of them. Of the 97 patients in whom the initial treatment was successful, five patients (5%) exhibited recurrent symptoms during a median follow-up period of 18 months. Of these five patients, three were treated with surgery (all true appendicitis), and the remaining two were once again treated with antibiotics. Patients with suspected appendicitis, those in whom mild appendicitis was diagnosed after clinical and radiologic evaluations, were found to benefit from short-term antibiotic therapy.
Advanced Age May Limit the Survival Benefit of Open Abdominal Decompression
Authors: Cheatham Michael L. , Safcsak Karen , Fiscina Creighton , Ducoin Christopher , Smith Howard G. , Promes John T. , Lube Matthew W.
Published: June 2020

Open abdominal decompression (OAD) and temporary abdominal closure (TAC) are widely performed for the treatment of intra-abdominal hypertension and/or abdominal compartment syndrome. During 2005 to 2009, 405 consecutive patients required OAD/TAC (trauma 68%, surgery 24%, medicine 5%, burn 3%). Overall patient survival to hospital discharge was 65 per cent regardless of age and was significantly decreased among patients older than 70 years of age ( P < 0.0001). Survival by decade of life exceeded 50 per cent through the eighth decade but decreased to 19 per cent for the ninth decade (older than 80 years of age). Survival varied significantly by service (trauma 72%, surgical 56%, burns 55%, medical 33%) ( P < 0.0001). Successful definitive fascial closure rates (range, 75 to 100%) were equivalent among all age groups ( P = 0.78). Survival after OAD/TAC varies by decade of life and mechanism of injury/illness. Age alone should not negate the use of OAD/TAC. Reasonable survival rates may be expected for patients younger than 80 years of age.
Hepatic Arterial Therapy as a Bridge to Ablation or Transplant in the Treatment of Hepatocellular Carcinoma
Authors: Farmer Russell Ware , Kralj Ivan , Valdata Alessandr , Urbano Jose , Enguix Daniel P. , Monaco Ricardo Garcia , Scoggins C. R. , Mcmasters K. M. , Rustein Lisa , Martin Robert C. G.
Published: June 2020

Hepatocellular carcinoma (HCC) is a challenging malignancy as a result of the advanced course at presentation. Recent interventional advances have improved treatment of lesions unamenable to resection using drug-eluting microbeads delivered into the hepatic circulation. We hypothesize that the use of hepatic arterial therapy (HAT) will safely identify appropriate patients who can proceed to ablation and/or transplantation. We evaluated our open-label, multicenter, multinational, single-arm study including 240 patients with intermediate-staged HCC who received drug-eluting beads and were not initial candidates for transplantation or resection. We reviewed the resulting clinical data to determine factors leading to possible ablation or transplant. Of 240 patients undergoing HAT, 14 (5.8%) received ablation or transplant. We compared those receiving ablation or transplant with those receiving only HAT. Groups were similar regarding sex, age, median number of tumors (one; range, 1 to 25), Child's score, tobacco and alcohol abuse, and treatment type. Patients who were downstaged were more likely to have: hepatitis-related tumors (76 to 66%, P = 0.02), distinct lesions on imaging (92 to 76%, P = 0.004), and less than 25 per cent parenchymal involvement (84 to 59%, P = 0.0001). These patients typically had one tumor frequently in the left lobe (58.8 vs 30.9%, P = 0.0001), accessible through segmental arteries (47 vs 17%, P = 0.001), with increased segmental branch occlusion (57 vs 39%, P = 0.02). HAT should be considered a potential bridging therapy to eventual ablation or transplant in the multimodal treatment of HCC.
Risk Factors for Pancreatic Fistula after Stapled Gland Transection
Authors: Subhedar Preeti D. , Patel Sameer H. , Kneuertz Peter J. , Maithel Shishir K. , Staley Charles A. , Sarmiento Juan M. , Galloway John R. , Kooby David A.
Published: June 2020

The objective of this study was to identify risk factors for pancreatic fistula (PF) after stapled transection in distal pancreatectomy (DP). Patients undergoing DP using a stapler for transection between 2005 and 2009 were identified from a pancreatic resection database. Variables examined included patient and tumor characteristics, staple size, and the use of mesh reinforcement. Univariate and multivariate regression analyses were performed to identify risk factors for postoperative PF. One hundred forty-nine had stapled transection, and of these, 25 (17%) had mesh reinforcement. The overall morbidity and mortality rates were 28 per cent and less than 1 per cent; 34 (23%) were diabetic. The rate of clinically significant PF was 14 per cent. On univariate analysis, diabetes ( P = 0.04), a firm pancreas ( P = 0.03), use of mesh staple line reinforcement ( P = 0.02), use of a 4.1-mm staple cartridge ( P = 0.01), and blood loss greater than 100 mL ( P = 0.01) were associated with higher pancreatic fistula rates. On multivariate analysis, only the presence of diabetes (OR, 4.17; 95% CI, 1.1-15.3; P = 0.03) and the use of a 4.1-mm cartridge (OR, 8.57; 95% CI, 1.2-60.2; P = 0.03) were independently associated with pancreatic fistula formation. Stapled pancreatic transection provides an acceptable PF rate after DP. Diabetes and staple size influence PF rates. In our experience, use of mesh staple line reinforcement did not reduce the incidence of PF after stapled transection.
Biliary Obstruction During Cholecystectomy: Endoscopic Retrograde Cholangiopancreatography, Evade, or Explore?
Authors: Poulose Benjamin K. , Kummerow Kristy L. , Nealon William H. , Shelton Julia S. , Masys Daniel R. , Holzman Michael D.
Published: June 2020

Biliary obstruction discovered during cholecystectomy remains a challenging problem. To determine the best management, this retrospective study compared intervention during the same admission (SA) versus delayed/no intervention (DN). Furthermore, this study demonstrates the power of a deidentified research database derived from electronic medical records. Patients undergoing cholecystectomy and intraoperative cholangiogram (IOC) were identified in the Vanderbilt Synthetic Derivative database. Patients with biliary obstruction discovered during IOC were included and a cohort study was performed. Interventions for biliary obstruction included endoscopic retrograde cholangiopancreatography or common bile duct exploration. A composite measure of any biliary complication served as the primary outcome. A total of 1899 patients who underwent cholecystectomy were evaluated; 151 met inclusion criteria. Mean age was 44 years with 69 per cent women. Sixty-three per cent of patients had intervention during the SA for cholecystectomy compared with 37 per cent for DN. Nineteen per cent of patients in the SA group had biliary complications versus 16 per cent for DN ( P = 0.656). Patients in the SA group had a significantly increased length of stay (4.7 vs 2.1 days, P < 0.05). These data suggest an aggressive approach to biliary obstruction seen on IOC does not reduce postoperative biliary complications and may incur unnecessary resource use.
Helicobacter Pylori Is Not the Predominant Etiology for Peptic Ulcers Requiring Operation
Authors: Zelickson Marc S. , Bronder Cathy M. , Johnson Brent L. , Camunas Joseph A. , Smith Dane E. , Rawlinson Dustin , Von Stephen , Stone H. Harlan , Taylor Spence M.
Published: June 2020

As the number of patients requiring operation for peptic ulcer disease (PUD) declines, presumed contemporary ulcer etiology has largely been derived from medically treated patients not subjected to surgery. The purpose of this study was to examine the specific causes of PUD in patients requiring surgery. Our Acute Care Surgical Service registry was reviewed for patients operated on for complications of PUD from 2004 to 2009. Emphasis was placed on individual etiologic factors for PUD. There were 128 patients (52% male, 81% white) who underwent emergency operation including: simple patch closure (n = 61, 48%); gastric resection (n = 22, 17%); gastric resection with vagotomy (n = 21,16%); vagotomy and pyloroplasty (n = 18,14%); or other procedures (n = 6, 5%). Complications necessitating operation were perforation (n = 79, 62%); bleeding (n = 29, 23%); obstruction (n = 12, 9%); and intractability (n = 8, 6%). Perioperative mortality was 12.5 per cent. Risk factors for PUD included tobacco use (50%), alcohol abuse (34%), and steroids (21%). Nonsteroidal anti-inflammatory use was confirmed in 68 (53%) patients. Of the 128 patients, 82 (64%) were tested for Helicobacter pylori, 33 (40%) of which were positive and 49 (60%) negative. Helicobacter pylori, thus, was the confirmed ulcer etiology in only 26 per cent of cases. Unlike contemporary series of medically treated PUD, Helicobacter pylori may not be the predominant etiologic factor in patients who experience complications requiring surgery. A “traditional” surgical approach with liberal use of vagotomy, not antibiotic triple therapy, may well be the preferred treatment consideration in such cases.
Temporal Artery Biopsy as a Means of Diagnosing Giant Cell Arteritis: Is There Over-Utilization?
Authors: Goslin Brent J. , Chung Mathew H.
Published: June 2020

Temporal artery biopsy (TAB) is often recommended for patients suspected of having temporal arteritis. The sensitivity of TAB varies widely and is dependent upon a number of factors (e.g., number of biopsy specimens, corticosteroid pretreatment, specimen length). The purpose of this study was to determine the clinical utility of TAB in patients who are suspected of having giant cell arteritis (GCA). A retrospective review of patients who underwent TAB at Spectrum Health from January 1, 1998 to December 31, 2007 was performed. Forty-seven patients, ranging in age from 25 to 87 years (mean: 70.7 years), underwent 53 TABs. Females accounted for 72.3 per cent of the subjects. Positive biopsy results showing signs of GCA were obtained in 38.3 per cent of patients. Of patients who underwent biopsy, 78 per cent could have been excluded from the procedure based upon individual diagnostic criteria. Positive and negative biopsies had average lengths of 1.84 cm and 1.29 cm, respectively ( P < 0.05). In the community hospital setting, patients suspected of having GCA are frequently recommended to undergo unnecessary TAB. We advocate for more careful selection of patients to undergo this diagnostic surgical procedure. In cases where TAB is needed, we recommend a biopsy length of > 2 cm to increase the accuracy of diagnosis.
Sutures versus Staples for the Management of Surgical Wounds: A Meta-Analysis of Randomized Controlled Trials
Authors: Iavazzo Christos , Gkegkes Ioannis D. , Vouloumanou Evridiki K. , Mamais Ioannis , Peppas George , Falagas Matthew E.
Published: June 2020

Surgical sutures are conventionally used in skin closure of surgical wounds. Alternative wound closure techniques include staples and adhesive strips. We aimed to evaluate sutures versus staples as methods of surgical wound closure by performing a meta-analysis. We searched PubMed, Scopus, and Cochrane Central Register of Controlled Trials for randomized controlled trials that compared sutures with staples for surgical wound closure. Trials referring to orthopedic operations were excluded. Twenty studies (involving a total of 2111 patients) were included. Five studies referred to obstetrics/gynecological operations, seven to general surgery, four to emergency care treatment, three to head/neck operations, and one to vascular surgery. Regarding the time needed for wound closure, staples were superior to sutures; the mean difference observed between the sutures and staples groups was 5.56 minutes per wound (95% confidence intervals [CI], 0.05 to 11.07). Wound infections were significantly fewer in the staples group compared with the sutures group(s) (12 studies, 1529 patients; odds ratio, 2.06; 95% CI, 1.20 to 3.51). In five studies, the use of staples was associated with significantly more pain compared with sutures. The majority of studies with available relevant data reported nonsignificant differences regarding the cosmetic result and patient's satisfaction. Our findings suggest that staples are associated with fewer wound infections compared with sutures in the evaluated types of surgery. However, in a rather limited number of studies, the use of staples was associated with more pain. Further studies incorporating more objective methods for assessment cosmetic and patient satisfaction are required to clarify this issue.
Surgical Complications and Pathologic Complete Response after Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer
Authors: Duldulao Marjun P. , Lee Wendy , Le Maithao , Wiatrek Rebecca , Nelson Rebecca A. , Chen Zhenbin , Li Wenyan , Kim Joseph , Garcia-Aguilar Julio
Published: June 2020

Pathologic complete response (pCR) to neoadjuvant chemoradiation (CRT) in patients with rectal cancer is associated with improved prognosis, whereas postoperative surgical complications have been linked with poor oncologic outcomes. Our objective was to examine the association between postoperative complications and pCR. We analyzed 127 patients enrolled in a prospective multicenter study investigating rectal cancer response to CRT. Surgical complications were scored according to the Clavien-Dindo scale (Grade 1 to 4). Among the 127 patients analyzed, 28 (22%) patients had a pCR. In the pCR group, six surgical Grade 3+ complications occurred in five (18%) patients, including anastomotic leak (n = 2), ureteral injury (n = 2), pelvic abscess (n = 1), and pneumonia (n = 1). In the non-pCR group, there were 10 Grade 3+ complications in eight (8%) patients, including severe obstruction (n = 1), postoperative hemorrhage (n = 1), leak (n = 2), pelvic abscess (n = 2), ureteral injury (n = 1), and severe morbidity (stroke, n = 1; acute respiratory distress, n = 1; and cardiac event, n = 1). There was no significant difference in the frequency of total surgical complications between pCR and non-pCR patients; and no association was observed between pCR and major postoperative complications. In conclusion, postoperative complication rates do not differ between pCR and non-pCR groups. The occurrence of major postoperative complications is not associated with response to neoadjuvant CRT.
Preoperative Serum Albumin but Not Prealbumin Is an Excellent Predictor of Postoperative Complications and Mortality in Patients with Gastrointestinal Cancer
Authors: Lin Matthew Y. C. , Liu Wendy Y. , Tolan Amy M. , Aboulian Armen , Petrie Beverley A. , Stabile Bruce E.
Published: June 2020

Preoperative serum albumin level is well recognized as a general predictor of adverse surgical outcomes in patients with gastrointestinal (GI) malignancy. Whether serum albumin or prealbumin levels can better predict postoperative surgical complications and death remains unknown. A retrospective review of 641 consecutive patients operated nonemergently for GI malignancies between January 1, 1997, and July 31, 2008, disclosed that 104 patients (16.2%) had complications and 23 (3.6%) subsequently died. All 641 patients had preoperative determination of serum albumin level (cost $0.13 per test), whereas 379 (59.1%) also had preoperative determination of serum prealbumin level (cost $2.27 per test). An albumin level below the discriminatory threshold of 3.2 g/dL was a significant predictor of overall postoperative morbidity, infectious and noninfectious complications, and mortality (all P < 0.001). In contrast, a prealbumin level below the discriminatory threshold of 18 mg/dL was a predictor of only overall morbidity ( P = 0.014) and infectious complications ( P = 0.024), but not of noninfectious complications or mortality ( P = nonsignificant). We conclude that compared with the preoperative serum prealbumin level, the albumin level has superior predictive value for overall postoperative morbidity, both infectious and noninfectious complications, and mortality. The inclusion of serum prealbumin level in the routine preoperative testing of patients with GI malignancy for the purpose of predicting postoperative outcomes is neither clinically necessary nor cost-effective.
Are High-Dose Perioperative Steroids Necessary in Patients Undergoing Colorectal Surgery Treated with Steroid Therapy Within the Past 12 Months?
Authors: Zaghiyan Karen , Melmed Gil , Murrell Zuri , Fleshner Phillip
Published: June 2020

Patients previously on corticosteroids within 1 year before surgery are routinely treated with perioperative high-dose corticosteroids. However, there is little evidence to support this practice. We postulated that patients off steroids but treated with corticosteroids within 1 year before surgery may be safely managed without perioperative steroids. A chart review was performed on patients with inflammatory bowel disease (IBD) treated with corticosteroids within 1 year before surgery. Patients received either perioperative high-dose steroids (HDS) or no steroids (NS). Perioperative vital signs were assessed. Forty-nine operations were performed. Eleven patients received HDS and 38 patients received NS. Aside from a higher incidence of tachycardia (heart rate greater than 100 beats/min) in the HDS group (82%) compared with the NS group (42%), there was no significant difference in hemodynamic instability between the two groups. One patient in the NS group required a single dose of intraoperative vasopressor after aggressive beta-blockade. All other episodes of hemodynamic instability resolved with no intervention, fluid boluses, or blood transfusion. No patients required rescue high-dose steroids for adrenal insufficiency. In patients with IBD undergoing major colorectal surgery, treated with corticosteroids within the past year, management without perioperative steroids seems safe. A prospective study assessing perioperative corticosteroid dosing is in progress.
Are All Level I Trauma Centers Created Equal? A Comparison of American College of Surgeons and State-Verified Centers
Authors: Smith Jennifer , Plurad David , Inaba Kenji , Talving Peep , Lam Lydia , Demetriades Demetrios
Published: June 2020

Scant literature investigates potential outcome differences between Level I trauma centers. We compared overall survival and survival after acute respiratory distress syndrome (ARDS) in patients admitted to American College of Surgeons (ACS)-verified versus state-verified Level I trauma centers. Using the National Trauma Data Bank Version 7.0, incident codes associated with admission to an ACS-verified facility were extracted and compared with the group admitted to state-verified centers. Overall, there were 382,801 (73.7%) patients admitted to ACS and 136,601 (26.3%) admitted to state centers. There was no adjusted survival advantage after admission to either type (4.9% for ACS vs 4.8% for state centers; 1.014 [95% CI, 0.987 to 1.042], P = 0.311). However, in the 3,088 cases of ARDS, mortality for admission to the ACS centers was 20.3 per cent (451 of 2,220) versus 27.1 per cent (235 of 868) for state centers. Adjusting for injury severity and facility size, admission to an ACS center was associated with a significantly greater survival after ARDS (0.75 [0.654 to 0.860]; P < 0.001). Level I verification does not necessarily imply similar outcomes in all subgroups. Federal oversight may become necessary to ensure uniformity of care, maximizing outcomes across all United States trauma systems. Further study is needed.
Outcomes of Laparoscopic and Open Appendectomy for Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome
Authors: Masoomi Hossein , Mills Steven D. , Dolich Matthew O. , Dang Phat , Carmichael Joseph C. , Nguyen Ninh T. , Stamos Michael J.
Published: June 2020

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.
Reduction in Ruptured Aortic Aneurysms Is Not Due to Increases in Endovascular Repairs
Authors: Hadjibashi Anoushiravan Amini , Ng Tina , Mirocha James , Cossman David , Gewertz Bruce
Published: June 2020

We sought to determine if the shift from open abdominal aortic repair to endovascular methods has affected the incidence of rupture of abdominal aortic aneurysms (rAAA). The Nationwide Inpatient Samples 2001 to 2007 was used. The incidence of rAAA and myocardial infarction (MI) as well as the number and type of aneurysm repairs were tabulated. There were no significant changes in the number of diagnosed (56,991 to 51,122; P = 0.26) and repaired (45,828 to 43,900; P = 0.79) abdominal aortic aneurysms between 2001 and 2007. Open abdominal aortic repair decreased from 31,989 to 13,876 ( P < 0.001) whereas the number of endovascular aneurysm repairs increased from 13,839 to 30,025 ( P < 0.001). In the same time, rAAA decreased from 7,749 to 5,267 (-32%, P < 0.001). The reduction of rAAA was greatest (-35.5%) in patients 65 to 84 years of age and less in patients 85 years and older (-15%). The number of MI decreased from 773,871 to 624,936 ( P = 0.005). The decrease in rAAA was significantly correlated with decreases in MI (r = 0.97, P = 0.0003). Although endovascular aneurysm repair increased, the overall application of abdominal aortic aneurysms repair did not change and does not account for the reduction in rAAA. It is more likely that environmental or other risk factor modifications also predisposing to decreases in MI account for the reduction in rAAA.
The Role of Laparoscopic Evaluation to Detect a Contralateral Defect at Initial Presentation for Inguinal Hernia Repair
Authors: Draus John M. , Kamel Sarah , Seims Aaron , Rescorla Frederick J.
Published: June 2020

Our objective was to determine the accuracy of laparoscopic evaluation to detect a contralateral patent processus vaginalis (CPPV) at initial presentation for inguinal hernia (IH) repair and the rate of CPPV relative to age, sex, and initial hernia side. We performed a 5-year retrospective review of 1580 pediatric patients with unilateral IH in which surgeons selectively used laparoscopy to evaluate for a CPPV. There were 1205 boys and 303 girls; 980 (65%) presented with right IH (RIH) and 528 (35%) with left IH (LIH). Laparoscopic evaluation was performed in 459 (47%) patients presenting with RIH and 225 (43%) patients presenting with LIH. Laparoscopic evaluation was positive for CPPV in 32 per cent of patients with RIH and 42 per cent of patients with LIH ( P = 0.0168). CPPV was associated with prematurity ( P = 0.0003) and age younger than 6 months ( P = 0.0001) but not with sex ( P = 0.55). The future contralateral occurrence rate was 1.6 per cent and recurrence rate 0.2 per cent. This study supports the accuracy of CPPV evaluation by laparoscope Although the rate of CPPV decreases after 6 months of age, girls older than 2 years of age have a significantly higher rate of CPPV than boys, supporting laparoscopic evaluation in older girls.
Athletes Hernia—A True, Early Direct Inguinal Hernia: Diagnosis, Pathophysiology, and Surgical Treatment
Authors: Chernyavsky Victoriya S. , Davidov Tomer , Trooskin Stanley Z. , Boyarsky Andrew
Published: June 2020

Athlete's hernia (AH) is an activity limiting condition that presents as chronic inguinal pain in elite athletes. The diagnosis involves a thorough history and physical examination and can be aided by ultrasound interrogation of the groin. Operative treatment with a direct tissue repair of the inguinal floor successfully alleviates symptoms and allows for full return to activity. A retrospective analysis of patients with the diagnosis of AH from January 1998 to May 2010 who underwent operative repair was reviewed. Patients were evaluated based on age, gender, sport, time to presentation, subjective and objective physical findings, imaging findings, operative findings, length of follow-up, and return to activity. Ninety-six patients (6 females) with a median age of 22.6 years were evaluated. In the majority of these patients, operative exploration revealed a wide external ring with separation of the fibers of the external oblique aponeurosis and an unprotected and bulging transverses abdominis aponeurosis, very akin to an early direct inguinal hernia. The mean initial follow-up time was 6 weeks at which point all but two of the patients were able to resume their full level of activity without restrictions. The diagnosis of AH, although somewhat elusive, can be easily established with a high degree of suspicion after doing a thorough history and physical exam augmented with ultrasonography. AH is equivalent to an early direct inguinal hernia found in young athletes and can be surgically corrected allowing return to full activity.
Surgical Management of Complex Liver Trauma: A Single Liver Transplant Center Experience
Authors: Li Petri Sergio , Gruttadauria Salvatore , Pagano Duilio , Echeverri Gabriel J. , Francesco Fabrizio Di , Cintorino Davide , Spada Marco , Gridelli Bruno
Published: June 2020

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to Vaccording to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.
Indications and Long-Term Outcome after Elective Surgery for Hepatocellular Adenoma
Authors: Perrakis Aristotelis , Müller Volker , Oeckl Karin , Adamietz Boris , Demir Resit , Hohenberger Werner , Yedibela Sueleyman
Published: June 2020

The management of hepatocellular adenoma (HA) is dependent on several parameters, which are influencing the decision for further management. The aim of this study was to evaluate the clinical presentation, indications, and long-term outcome of surgical treatment in a single-institution analysis. Forty-nine patients underwent elective hepatectomy for HA between 1990 and 2007. Analysis parameters included demographic data, lesion number and size, diagnostic method, mode of surgery, and postoperative outcome. Mean follow-up was 108 months. Thirty-six patients underwent hormone therapy and four patients had a history of cancer before surgical treatment. The mean tumor diameter was 9.8 cm. Mild or moderate postoperative complications were recorded in 16 patients. There was no perioperative mortality. Symptoms were relieved in 95 per cent of the patients. Intratumoral hemorrhage was detected in 21 specimens (43%); malignant transformation was detected in zero specimens. Among patients with HA with clinical symptoms, tumor diameter greater than 5 cm and in male patients the indication for surgery should be given because of the high risk of tumor-related complications. Elective liver resection for HA is a safe procedure and results in a good long-term outcome.
Improved Removal Rates for Retrievable Inferior Vena Cava Filters with the Use of a ‘Filter Registry’
Authors: Kalina Michael , Bartley Marilyn , Cipolle Mark , Tinkoff Glen , Stevenson Scott , Fulda Gerard
Published: June 2020

The American Association for the Surgery of Trauma challenged the trauma community to improve a 22 per cent average removal rate for retrievable inferior vena cava filters (r-IVCFs). Since 2006, we maintained a “filter registry” documenting all IVCFs placed in trauma patients. Our goal was to improve removal rates for r-IVCF. Patients receiving an IVCF before implementation of filter registry, 2003–2005, comprised the control group. Patients receiving an IVCF after implementation of filter registry, 2006–2009, comprised the study group. Data obtained included age, gender, Injury Severity Score (ISS), length of stay (LOS), mortality, filter inserted, placement indication, removal rates, and reasons why removal did not occur. Fisher exact test and chi square were used for nominal variables. Stepwise logistic regression analysis was used to define predictors of removing and not removing an IVCF. Three hundred seven patients received an IVCF, 142 preregistry and 165 post-registry. No significant difference existed between groups in age, gender, ISS, placement indication, or mortality. A significant difference existed between groups in LOS and presence of deep vein thrombosis (DVT) and pulmonary embolism. A total of 98.2 per cent of postregistry patients received a Günther Tulip filter and all retrievals were performed by Interventional Radiology. Retrieval rates improved, 15.5 to 31.5 per cent post registry ( P < 0.001). No differences existed in lost to follow-up (LTF) between groups. Univariate analysis identified age, IVC clot, DVT, and LTF as predictors for not removing a filter. Stepwise logistic regression revealed the filter registry independently predicts the removal of an r-IVCF. A filter registry is effective in improving rates of removal for r-IVCFs.
Focal Organizing Pneumonia Mimicking Lung Cancer: A Surgeon's View
Authors: Zheng Zhi , Pan Youmin , Song Chaoguo , Wei Hao , Wu Shimin , Wei Xiang , Pan Tiecheng , Li Jun
Published: June 2020

Focal organizing pneumonia is a unique form of organizing pneumonia. Little is known regarding its clinical and radiological feature, diagnosis, management, and outcome. Twenty patients with focal organizing pneumonia were investigated and compared with 40 patients with bronchogenic carcinoma. There were 38 men (63.3%) and 22 women (36.7%). The mean age was 55 ± 9.9 years. No specific feature in clinical and radiological manifestation was found to distinguish between focal organizing pneumonia and bronchogenic carcinoma. In patients with focal organizing pneumonia, wedge resection was performed in 12 cases and lobectomy in eight cases. Follow-up was complete with a median period of 26 months (range, 6 to 104 months). All patients were free from recurrence of organizing pneumonia. Clinical and radiologic findings of focal organizing pneumonia are nonspecific, and this unique form of organizing pneumonia is difficult to differentiate from lung cancer. Surgical resection allows both diagnosis and cure. However, considering the benign nature of this disease, major pulmonary resections should be avoided.
Article Commentary: Optimizing Aesthetic Results in Skin Grafting
Authors: Hazani Ron , Whitney Ryan , Wilhelmi Bradon J.
Published: June 2020

The aesthetic goal in skin grafting is to provide a cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity. A skin graft should blend well with the color and texture of the surrounding skin, reduce wound size, and not interfere with the function of the reconstructed part. This review examines the key components of choosing the appropriate donor skin for a variety of defects. The decision-making process is based on the anatomic location of the defect; donor site availability; and graft size, thickness, and pigmentation. The aesthetic implications of using a sheet graft versus a meshed graft versus an expanded graft are discussed. Aside from addressing the aesthetic needs of the defect, attention is paid to the functional goals of the reconstructed part and reduced donor site morbidity. Partial graft failure can have significant deleterious effects on the aesthetic outcome of skin grafts. The need for further grafting or healing by secondary intention may result in additional scarring and deformity. Recommendations for improvement in graft take and infection control are presented.
Single versus Multi-Specialty Operative Teams: Association with Perioperative Mortality after Endovascular Abdominal Aortic Aneurysm Repair
Authors: Mazer Laura M. , Chiakof L. Elliot , Goodney Philip P. , Edwards Matthew S. , Corriere Matthewa
Published: June 2020

Endovascular abdominal aortic aneurysm repair (EVAR) requires both endovascular and open surgical skills. Although usually performed by a single operating specialist, EVAR may alternatively involve multiple teams from different specialties performing separate procedural components. We examined the relative frequencies of single versus multi-specialty EVAR in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and explored the influence of multi-specialty EVAR on 30-day mortality. EVARs were identified and classified as single or multiple-specialty procedures based on Current Procedural Terminology codes. Baseline and procedural characteristics were compared using χ2 or Fisher's exact test for categorical variables and t test for continuous variables. The association between multi-specialty EVAR and 30-day mortality was examined using a multivariate logistic regression model. Of 7269 EVAR patients identified, 7086 were single and 183 were multi-specialty. Multi-specialty patients had higher frequency of brachial or iliac artery exposure and longer operative times, but were otherwise similar in baseline and procedural characteristics. In the multivariate model, multi-specialty EVAR was associated with increased risk of 30-day mortality (odds ratio 2.35; 95% confidence interval 1.08–5.11; P value 0.031). Multi-specialty participation in EVAR procedures is associated with significantly higher 30-day mortality. Further research is warranted to determine whether multi-specialty participation reflects provider experience, institutional protocols, procedural complexity, non-surgical or other factors.
Outpatient Laparoscopic Appendectomy for Acute Appendicitis
Authors: Cash Cassadra L. , Frazee Richard C. , Smith Randall W. , Davis Matthew L. , Hendricks John C. , Childs Ed W. , Abernathy Stephen W.
Published: June 2020

Laparoscopic appendectomy is the widely accepted treatment for acute appendicitis. This approach offers the potential of less pain, shorter hospital stay, and quicker return to activities. Traditionally, patients are hospitalized for 24 hours after laparoscopic appendectomy. This practice can be questioned due to the good results of other outpatient laparoscopic surgery. A retrospective review of 119 patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis was undertaken from January through September 2009; outpatient and in-patient laparoscopic appendectomies were compared. Patients were selected for outpatient management based upon physician discretion and their clinical course in operation and recovery rooms. Forty-two patients were dismissed on the day of surgery and 77 were admitted for 1 to 5 days postoperatively. No significant differences in age, gender, and preoperative comorbidities between outpatient and inpatient groups were found. Postoperative complications occurred in 2.4 per cent of outpatients and 11.7 per cent of inpatients ( P = 0.16). Complications included superficial wound infections, urinary retention, urinary tract infection, intra-abdominal bleeding, pneumonia, and infected hematoma. Based upon this study, outpatient laparoscopic appendectomy can be performed safely in selected patients. This study provides the background for the present prospective protocol for routine outpatient laparoscopic appendectomy at our institution.
Management and Outcomes of Colovesical Fistula Repair
Authors: Lynn Elizabeth T. , Ranasinghe Nalin E. , Dallas Kai B. , Divino Celia M.
Published: June 2020

This large retrospective study presents the largest colovesical fistula (CVF) series to date. We report on recurrence risk factors and patient satisfaction based on quality of life after CVF repair. Approval was obtained from The Mount Sinai School of Medicine Institutional Review Board, and a retrospective review was performed from 2003 to 2010 involving 72 consecutive patients who underwent a colovesical fistula repair. The CVF recurrence rate was 11 per cent. Ten percent of our patients who had a history of radiation therapy were at a significantly higher risk of developing a recurrence. Noted recurrence rates were significantly higher in advanced bladder repairs compared with simple repair ( P = 0.022). The modified (Gastrointestinal Quality of Life Index) surveys showed overall patient satisfaction score was 3.6, out of a maximum score of 4, regardless of the type of repair or any postoperative complications. Our study found the CVF recurrence rate to be 11 per cent. Patients at higher risk of recurrence include those needing advanced bladder repair, those with “complex” CVF, and those whose fistulas involve the urethra. Patient satisfaction was found to be more closely linked to the resolution of CVF symptoms, irrespective of the type of repair performed or development of postoperative complications.
Perioperative Core Body Temperatures Effect on Outcome after Colorectal Resections
Authors: Geiger Timothy M. , Horst Sara , Muldoon Roberta , Wise Paul E. , Enrenfeld Jesse , Poulose Ben , Herline Alan J.
Published: June 2020

The World Health Organization has set a standard of maintaining a core body temperature above 36°C in the perioperative period. The purpose of this study was to examine the relationship between both intraoperative temperature (IOT) and immediate postop core body temperature as it relates to postop complications. A retrospective analysis of a prospective database of patients who underwent an elective segmental colectomy without a stoma, for 3 diagnoses was performed. Six postoperative outcomes were examined: length of stay (LOS), placement of a nasogastric tube, return to the operating room, placement of an interventional drain, diagnosed leak, and surgical site infection (SSI). Statistics were calculated using a two-sample Wilcoxon rank-sum (Mann-Whitney) test. Seventy-nine patients met the inclusion criteria and there were no preoperative differences between the groups (those with a postop complication vs without). LOS > 9 days (36.64°C vs 35.98°C; P = 0.011) and clinical leak (37.06°C vs 35.99°C; P = 0.005) both had a statistically higher average IOT than those who did not. Patients with SSI trended to a higher IOT (36.44°C vs 35.99°C; P = 0.062). When the last IOT recorded was compared with the six outcomes, again length of stay and leak both were statistically significant ( P = 0.018, P = 0.012) showing a higher temperature related to a higher complication rate. No other complications were related to IOT, nor did postop temperature relate to complication. In our data, relatively lower IOTs were protective for LOS and clinical leaks, with a trend of lower SSI rates. Further research is needed to fully endorse or refute the absolute recommendations for core body temperature.