bluuebunny/crossref_metadata_2025 huggingface dataset:
The Influence of Age and Gender on the Utility of Computed Tomography to Diagnose Acute Appendicitis
Authors: Antevil Jared , Rivera Louis , Langenberg Bret , Brown Carlos V.R.
Published: November 2022

Few studies have examined the effects of age and gender on the utility of diagnostic computed tomography (CT) for appendicitis. We retrospectively studied all adult patients undergoing appendectomy from January 2000 through December 2002 (633 patients). Patients 15–30 years old (“younger”) were compared to patients >30 (“older”) and further subdivided by gender. CT accuracy and the influence of CT on negative appendectomy (NA) rates for each group were evaluated. CT was associated with a lower NA rate in older patients (23% vs 8%, P = 0.004) but had no effect on NA rate in younger patients (26% vs 20%, P = 0.2). Appendiceal CT had greater sensitivity, negative predictive value, and accuracy in older than in younger patients. When subdivided by gender, CT was associated with lower NA rates for all female patients but had no effect in either age group of men. Although CT may be more accurate in patients older than 30 years, it has the greatest benefit in female patients, where it is associated with lower NA rates in all adult patients. CT should be strongly considered for all female patients before operation for suspected appendicitis. Further study is needed to determine which, if any, male patients benefit from preoperative CT.
The Efficacy of Postoperative Oral Antibiotics in Appendicitis: A Randomized Prospective Double-Blinded Study
Authors: Taylor Edward , Berjis Amir , Bosch Theodore , Hoehne Francesca , Ozaeta Maria
Published: November 2022

The conventional treatment of acute appendicitis is appendectomy followed by intravenous (IV) antibiotics until intraabdominal infection has resolved. It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics. All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study. Perforated/gangrenous appendicitis was equally represented in the two study arms. After appendectomy, and when IV antibiotics were ready to be discontinued, patients were randomized to receive a 7-day outpatient course of either placebo (Group 1) or oral antibiotics (Group 2). Patients were monitored for infectious complications for a minimum of 3 months, and there was no statistical difference (11.5% in Group 1 vs 12.1% in Group 2, P = 0.61). The data suggest that adding a course of outpatient oral antibiotics, after completing a course of IV antibiotics, does not decrease postoperative infectious complications in appendicitis patients.
Application of Robotics in General Surgery: Initial Experience
Authors: Nguyen Ninh T. , Hinojosa Marcelo W. , Finley David , Stevens Melinda , Paya Mahbod
Published: November 2022

Robotic surgery was recently approved for clinical use in general abdominal surgery. The aim of this study was to review our experience with the da Vinci™ surgical system during laparoscopic general surgical procedures. Eighteen patients underwent robotically assisted laparoscopic abdominal surgery between June 2002 and March 2003. Main outcome measures were operative time, room setup time, robotic arm-positioning and surgical time, blood loss, conversion to laparoscopy, length of stay, and morbidity. The types of robotically assisted laparoscopic procedures were excision of gastric leiomyoma (n = 1), Heller myotomy (n = 1), cholecystectomy (n = 2), gastric banding (n = 2), Nissen fundoplication (n = 4), and gastric bypass (n = 8). The mean room setup time was 63 ± 14 minutes, and the mean robotic arm-positioning time was 16 ± 7 minutes. Conversion to laparoscopy occurred in two (11%) of 18 cases because of equipment difficulty (n = 1) and technical difficulty (n = 1). Estimated blood loss was 91 ± 71 mL. The mean operative time was 156 ± 42 minutes, and the robotic operative time was 27% of the total operative time. The mean length of hospital stay was 2.2 ± 1.5 days. There was one postoperative wound infection and one anastomotic stricture. Robotically assisted laparoscopic abdominal surgery is feasible and safe; however, the theoretical advantages of the da Vinci™ surgical system were not clinically apparent.
Colonoscopic Perforation and Bleeding of the Colon Can be Treated Safely without Surgery
Authors: Ker Tim S. , Wasserberg Nir , Beart Robert W.
Published: November 2022

The incidence of colonoscopic perforation of colon is about 0.3 per cent. The incidence of colonoscopic bleeding is about 0.6 per cent. Many of those patients undergo unnecessary operations. In order to assess the outcome of nonoperative management of those patients with postcolonoscopic perforation and bleeding, the records of 5120 patients who underwent colonoscopies from September 1, 1988 to June 30, 2003 were retrospectively reviewed with attention paid to colonoscopic perforation and bleeding. Their symptoms, management, and outcome were reviewed. There were 2765 male and 2355 female patients. Ages ranged from 9 to 91 years. A total of 1902 patients (37.1%) had polyps removed. Six patients (0.1%) had colonoscopic perforation. All of them presented with abdominal pain 1 to 4 days after colonoscopic polypectomy. All had subphrenic free air or subcutaneous emphysema on the radiogram. All were treated nonoperatively with nothing by mouth and intravenous fluids and antibiotics in the hospital and recovered uneventfully. Six patients (0.1%) had colonic bleeding that occurred 1 to 14 days after colonoscopic polypectomy. All of them were managed by repeat colonoscopy with injection of epinephrine. All recovered without further bleeding. Therefore, postcolonoscopic perforation and bleeding can be treated nonoperatively. It is safe and cost effective. The mortality and morbidity are very low.
Colonic Histoplasmosis Presenting as Colon Cancer in the Nonimmunocotnpromised Patient: Report of a Case and Review of the Literature
Authors: Lee Jason T. , Dixon Matthew R. , Murrell Zuri , Konyalian Viken , Agbunag Rodolfo , Rostami Sassan , French Samuel , Kumar Ravin R.
Published: November 2022

Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn's disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic antifungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.
Use of Computed Tomography in Diagnosis of Major Postoperative Gastrointestinal Complications of Laparoscopic Roux-en-Y Gastric Bypass Surgery
Authors: Esmailzadeh Houman , Powell Wes , Lourie David
Published: November 2022

Laparoscopic Roux- en-Y gastric bypass (LRYGB) is becoming a frequently performed procedure for the treatment of morbid obesity. It is important for all general surgeons to be able to diagnose correctly and treat its complications. It is the purpose of this study to determine whether computed tomography (CT) is useful in correctly diagnosing these complications. The medical records of all patients that underwent LRYGB between March 2000 and December 2002 (n = 574) at Huntington Memorial Hospital were reviewed. Major abdominal complications defined as anastomotic leaks or small bowel obstruction were noted. Results of CT scans in these patients were reviewed by both a radiologist and an attending surgeon. CT scan findings were then compared to intraoperative findings. Postoperatively, 18 patients were found to have small bowel obstruction/herniation and anastomotic leaks. CT scan correctly diagnosed anastomotic leaks and small bowel obstruction in 71 per cent and 100 per cent of patients, respectively. Complication following LRYGB are rare but potentially life-threatening. CT scans are helpful in predicting the pathology and directing the surgical management of these patients. CT scan findings, however, can be subtle and therefore be missed by those not intimately familiar with post gastric bypass anatomy.
The Optimal Timing of Laparoscopic Cholecystectomy in Mild Gallstone Pancreatitis
Authors: Taylor Edward , Wong Charles
Published: November 2022

The optimal timing of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis is not standardized. Our objective was to determine if patients with mild gallstone pancreatitis (three or fewer Ranson's criteria) can safely proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving. We reviewed the charts of all adults admitted to our institution with gallstone pancreatitis from January 1999 until June 2002 who had LC performed by either surgeon 1 (group 1) or surgeon 2 (group 2). Surgeon 1 preferred to delay surgery until normalization of amylase and complete resolution of abdominal tenderness, whereas surgeon 2 preferred to proceed to LC as soon as serum amylase was decreasing and abdominal tenderness was improving. The two groups were well matched for sex, age, Ranson's criteria, and percentage requiring endoscopic retrograde cholangiopancreatography. Average total hospital stay was 4.7 days in group 1 versus 3.5 days in group 2 ( P = 0.01). There was no statistical difference in complication rate between the two groups (10% in group 1 vs 11% in group 2, P = 0.12). The data suggest that hospital stay can be shortened with no increased complication rate if patients with mild biliary pancreatitis proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving.
Rare Mesenteric Location of Meckel's Diverticulum, A Forgotten Entity: A Case Study aboard USS Kitty Hawk
Authors: Segal Scott D. , Albrecht Dan S. , Belland Kris M.
Published: November 2022

The traditional understanding of Meckel's diverticulum has always emphasized its antimesenteric location, ever since its original description in 1809. We report the finding of an acutely inflamed mass located on the mesenteric aspect of distal ileum, which was discovered during a celiotomy performed aboard a U.S. Navy aircraft carrier. Pathological features of this unusual mass, including focal submucosal abscess formation, proximity to the ileocecal valve, and heterotopic gastric tissue are all characteristic of inflammatory Meckel's diverticulum. The atypical intraoperative finding of a desmoplastic reaction associated with this lesion is discussed within the context of a pertinent differential diagnosis. In addition, both the pathological characteristics and the unusual location of this mass are the basis for a discussion that revisits a 50-year-old surgical controversy regarding Meckel's diverticulum.
Use and Limitations of a Nomogram Predicting the Likelihood of Non-Sentinel Node Involvement after a Positive Sentinel Node Biopsy in Breast Cancer Patients
Authors: Kocsis Lajos , Svébis Mihály , Boross Gábor , Sinkó Mária , Maráz Róbert , Rajtár Mária , Cserni Gábor
Published: November 2022

After a positive sentinel lymph node (SLN) biopsy, some patients may be considered to have a very low risk of non-SLN involvement and could be candidates for axillary sparing. The aim of this study was to validate the nomogram created at the Memorial Sloan-Kettering Cancer Center (MSKCC) for the prediction of non-SLN involvement in an independent set of 140 patients with both positive SLNs and axillary dissection. The predicted proportions of positive non-SLNs were compared with the observed percentages of non-SLN metastasis. Although the SLN metastasis size and tumor size did influence the risk of non-SLN involvement, the correlation between the predicted and observed proportions was weaker for our patients (R: 0.84) than for the patients assessed at the MSKCC (R: 0.97). Differences were noted in the intraoperative assessment and in the final histology of the SLNs (imprints vs frozen sections and more detailed vs less detailed, respectively), and these could partly explain the lower level of the correlation. The nomogram could not be validated and was found to be of only limited use for the prediction of non-SLN involvement in patients operated on under similar, though not fully identical conditions. We therefore warn against the unvalidated use of this prediction tool.
Coexistence of Pregnancy and Cancer
Authors: Jacobs Ira A. , Chang C.K. , Salti George I.
Published: November 2022

The purpose of this study was to review patients with cancer during pregnancy, the effectiveness of the available methods of treatment, and their prognosis. A retrospective chart review was conducted of all women diagnosed with pregnancy-associated cancer between 1974 and 2002 at the University of Illinois at Chicago Medical Center. The demographics, clinical presentation, time and mode of diagnosis, treatment, pregnancy outcome, and maternal survival were noted. The incidence of carcinoma in pregnancy in the series was 0.32/1000 deliveries. The age ranged from 16 to 41 years (mean 30.5 years). No patient underwent a therapeutic abortion, and all patients delivered a healthy infant with no malformations. Metastases developed in three patients with median time of 44 months (range 13–96 months) to presentation of metastases from the time of initial diagnosis. Association of cancer with pregnancy is a rare occurrence. Rates of specific cancers in pregnant and nonpregnant women appear to be equivalent. Pregnant women with cancer are often diagnosed at a later stage compared to their nonpregnant counterparts. Though the cancer may be diagnosed at a more advanced stage, pregnant patients with cancer do not appear to have a more aggressive clinical course.
Hepatoid Carcinoma of the Pancreas
Authors: Hughes Khalista , Kelty Steven , Martin Robert
Published: November 2022

Extrahepatic hepatocellular carcinoma differentiation has been demonstrated in primary malignancies of the stomach. To date, only five cases of hepatocellular differentiation of the pancreas have been reported in the literature. An example of hepatoid carcinoma of the pancreas is reported in this study. A single case of hepatoid carcinoma of the pancreas is presented with long-term follow-up and review of the literature. This rare malignancy of the pancreas represents a hepatocytic transdifferentiation of pancreatic cells to form a combination of both primary ductal adenocarcinoma and hepatocellular differentiation.
Adult Colonic Intussusception Caused by Malignant Tumor of the Transverse Colon
Authors: Lorenzi Marco , Iroatulam Augustine J. N. , Vernillo Remo , Banducci Tania , Mancini Stefano , Tiribocchi Andrea , Ferrari Francesco S. , Mancini Sergio
Published: November 2022

Adult colonic intussusception is rare and often originates from neoplasms. In emergency situations it can be difficult to diagnose. Our aim was to show how the integration of readily available diagnostic means in emergency situations can help in making a correct diagnosis of this disease. A 68-year old male patient presented with vomiting and abdominal pain. The abdomen was distended, with pain to palpation in the left quadrants without a mass. Plain radiographs of the abdomen showed a large amount of gas in the small bowel and in the right and transverse colon. A barium enema demonstrated an endoluminal filling defect in the descending colon. Abdominal ultrasonography revealed the presence of intraperitoneal fluid and thickened left colonic wall at the site of the lesion, with an aspect of a “double ring” consistent with intussusception. A solid formation was also revealed at a point distal to the thickened colonic wall. At emergency laparotomy an approximately 8-cm-long mass was palpable through the left colon. A colostomy was fashioned, and subsequently colonoscopy revealed the presence of a left colon tumor. At the subsequent operation an invagination of the left transverse colon into the descending colon was confirmed. The left transverse and descending colon were resected with high ligation of the left colic artery. Macroscopic examination of the invaginating head showed a vegetating transverse colon neoplasm. We conclude that in emergency settings the association of readily available diagnostic means such as plain abdominal radiography, water soluble contrast enema and ultrasonography may yield reliable information for diagnosing colonic intussusception.
Adenocarcinoma of the Pancreatic Head: A Community Teaching Hospital's Experience from 1982 to 1992
Authors: Falk Jeffrey , Keidan R. , Rigo P.K. , Dmuchowski C.
Published: November 2022

The treatment of adenocarcinoma of the pancreatic head remains variable, with multiple therapeutic options including surgery, biliary stenting, chemotherapy, and radiation therapy. We retrospectively reviewed our experience from 1982 through 1992, which included 160 patients with this diagnosis, evaluating their treatments and outcomes. There were 66 males and 94 females, with a mean age of 70 ± 11 years. Forty patients (25%) had no surgery; of these, 27 had no further treatment, whereas 13 received chemotherapy and/or radiation therapy (CT/RT). Of 120 patients who had surgical exploration, only 19 (16%) were resectable for a potential cure. Eleven of these resected patients had no additional therapy, whereas 8 patients received adjuvant CT/RT. Of the 101 unresectable patients, 62 had no further therapy and 39 received CT/RT. Twenty-two patients (14%) had biliary stents placed, 11 in lieu of surgery, 7 preoperatively, and 4 postoperatively. Perioperative mortality was no different for resectable patients (16%) versus unresectable patients (14%). Overall, 90 patients (56%) had one or more complications related to their disease or treatment, with no differences between groups. Median survivals were as follows: no treatment, 1 month; no surgery with CT/RT, 3.5 months; unresectable with no further treatment, 4 months; unresectable with CT/RT, 8 months; resection with no additonal treatment, 17 months; and resection with CT/RT, 13 months. Patients with resectable disease had a significantly longer survival than patients who had no surgery (P < 0.001) or who were unresectable at exploration (P < 0.001); the addition of CT/RT after resection had no effect on survival (P = 0.8). The addition of CT/RT significantly increased survival for patients who had no surgery (p = .001) and for patients who were explored but were unresectable (p = .002). In conclusion, despite dismal results, surgery remains the mainstay of treatment for adenocarcinoma of the pancreatic head. Although CT/RT did not increase the median survival after resection, it doubled the median survival after noncurative surgery.
Cells Isolated from Adult Human Skeletal Muscle Capable of Differentiating into Multiple Mesodermal Phenotypes
Authors: Williams John T. , Southerland Shiela S. , Souza John , Calcutt Andrew F. , Cartledge Richard G.
Published: November 2022

Wound healing is the response of tissue to injury that results in scar formation. Tissue regeneration would be a more ideal response. Previously, we have isolated a population of cells from avian, rodent, and rabbit skeletal muscle capable of differentiating into multiple mesodermal phenotypes. The present experiments were designed to determine whether a similar population of cells exist in human skeletal muscle. Separate cell preparations from skeletal muscle on an amputated leg of a 75-year-old female and the pectoralis muscle of a 27-year-old male were enzymatically dissociated and cultured to confluence in Eagle's minimal essential medium with 10 per cent preselected horse serum, then trypsinized, filtered, and slowly frozen in 7.5 per cent dimethylsulfoxide to -80° C. The cells were thawed and plated with the same media plus dexamethasone (a nonspecific differentiation agent) at 10–10–-10–6 M concentrations for up to 6 weeks. Immunological and histochemical staining assays were performed. Phenotypes observed included stem cells with typical stellate morphology (control), skeletal myotubes (anti-myosin), smooth muscle (anti-a-actin), bone (von Kossa stain), cartilage (Alcec blue), and fat (Sudan black B). These experiments establish the existence of a population of mesenchymal stem cells in human skeletal muscle capable of differentiating into multiple mesodermal phenotypes. The possibility exists of manipulating the mesenchymal stem cells to achieve appropriate regeneration of mesenchymal tissues in the injured patient.
Abdominal Wall Endotnetriomas: Report of Eight Cases
Authors: Patterson Gregory K. , Winburn Ginger B.
Published: November 2022

Eight cases of abdominal wall endometrioma were encountered in seven patients from February 1994 through April 1996. The age of the patients ranged from 19 to 36 years, with an average age of 32.8 years. Ten abdominal procedures had been performed on these patients before the diagnosis of endometrioma: six cesarean sections, two diagnostic laparoscopics, one total vaginal hysterectomy, and one ventriculoperitoneal shunt. Symptoms occurred from 6 months to 10 years after their previous surgery. Only one patient had a prior diagnosis of endometriosis. The most common presentation was a cyclic painful abdominal mass. The differential diagnosis included endometrioma in four (50%) of the cases. Diagnostic tests used for preoperative evaluation included ultrasound, fine-needle aspiration, and computed tomography. All patients underwent wide local excision. There was one recurrence, requiring re-excision at 22 months postoperatively. The pathogenesis, diagnosis, treatment, and recent literature are discussed.
An Open, Minimally Invasive Approach to the Lumbar Spine
Authors: Dewald Christopher J. , Millikan Keith W. , Hammerberg Kim W. , Doolas Alexander , Dewald Ronald L.
Published: November 2022

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6–10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11–52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5–12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60–330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.
Is Thoracoscopically Aided Pleural Debridement Advantageous in Children?
Authors: Patton R. Michael , Abrams Randel S. , Gauderer Michael W. L.
Published: November 2022

Thoracic empyema encompasses a spectrum of inflammatory manifestations ranging from thin parapneumonic pleural effusion to the formation of a thick, constricting rind. The aim of this study is to determine the applicability of thoracoscopically aided pleural debridement (TAPD) in children with complicated empyema and to assess its possible advantages. In the last 6 years, 26 children (ages 2 months-16 years; median, 7 years; mean, 7 years) were diagnosed with empyema (right, n = 15; left, n = 11). Their charts, radiographs, and follow-up courses were reviewed. All children had typical clinical and radiological findings of empyema; one also had necrotizing pneumonitis. Treatment modalities included antibiotics only (n = 3), antibiotics with tube thoracostomy (n = 11), open thoracotomy (n = 5), and TAPD (n = 7). Children treated with antibiotics alone had an average (avg) length of stay (LOS) of 31 days. Those managed with tube thoracostomy had an avg LOS of 13 days, and those who underwent thoracotomy had an avg LOS of 16 days. The seven children treated with TAPD had an avg LOS of 12 days, and their avg postoperative chest tube use was 6 days. Children with TAPD had considerable less pain and recovered faster. TAPD of empyema is promising for children whose lungs do not expand promptly after tube thoracostomy or who have a persistent loculated empyema.
Infantile Hypertrophic Pyloric Stenosis: Delays in Diagnosis and Overutilization of Imaging Modalities
Authors: Abbas Abbas E. , Weiss Stephen M. , Alvear Domingo T.
Published: November 2022

Infantile Hypertrophic Pyloric Stenosis (IHPS) can usually be diagnosed by the detection of a pyloric olive on examination performed by an experience examiner. In babies with typical symptoms and a palpable olive, no further confirmation of diagnosis is required. We retrospectively reviewed the diagnostic evaluations of 93 consecutive patients with proven IHPS. Many patients who had the diagnosis confirmed on physical examination underwent one or more unnecessary and redundant studies. The performance of these studies was associated with delayed diagnosis and possibly with adverse clinical health problems. An algorithm for management of patients with suspected IHPS is proposed. Prompt examination by an experienced examiner is key to the evaluation of such patients.
Extraperitoneal Rectal Perforation due to Retroflexion Fiberoptic Proctoscopy
Authors: Chu Quyen , Petros James G.
Published: November 2022

The increasing use of retroflexion proctoscopy to evaluate the distal rectum is not without complications. We report a series of three patients who experienced extraperitoneal rectal perforation secondary to retroflexion proctoscopy and discuss our success with conservative management. By evaluating each clinical situation individually and following certain principles, successful outcome can be achieved without surgical intervention. Success depends on several factors: 1) the injury must be below the peritoneal reflection; 2) the patient must have undergone a complete bowel preparation before endoscopy; 3) postinjury, the patient must continue to show no evidence of peritonitis or hemodynamic instability; and 4) the patient must be given nothing by mouth, started on intravenous antibiotics and possibly parenteral nutrition, and closely monitored with serial abdominal examinations. The presence of comorbid conditions does not necessarily diminish the chance that conservative therapy will succeed.
Simple Sutureless Skin Graft Fixation
Authors: Tzarnas Chris D.
Published: November 2022

A simple method to enhance split-thickness skin graft immobilization without sutures is described. The method uses collodion to secure a mesh gauze to the adjacent skin preventing skin graft dislodgment. The technique is rapid and efficient.
Ticarcillin/Clavulanate versus Imipenem/Cilistatin for the Treatment of Infections Associated with Gangrenous and Perforated Appendicitis
Authors: Allo Maria D. , Bennion Robert S. , Kathir Krishna , Thompson Jesse E. , Lentz Melinda , Meute Margaret , Finegold Sydney M.
Published: November 2022

The objective of this study was to compare ticarcillin/clavulanate given at 3.1 g every 6 hours with imipenem/cilistatin given at 500 mg every 6 hours for the treatment of infections associated with gangrenous or perforated appendicitis. One hundred thirty-seven patients were found to have gangrenous or perforated appendicitis and received the study medication for 3 to 5 days in a double-blinded, randomized manner. Clinical success was similar for the two treatment groups, 96.9 and 95.9 per cent in the ticarcillin/clavulanate and imipenem/cilistatin groups, respectively (P = 0.99; 95% confidence interval for the difference was -5.6% to 7.6%). Bacteriologic success at the end of therapy was similar in the two groups, 100 and 98.4 per cent in the ticarcillin/clavulanate and imipenem/cilistatin groups, respectively (P = 0.99; 95% confidence interval for the difference was -1.8% to 4.7%). The occurrence of adverse events related to treatment was similar for the two groups (P = 0.31) and led to study withdrawal for four patients (one with ticarcillin/clavulanate and three with imipenem/cilistatin). Ticarcillin/clavulanate given at 3.1 g every 6 hours is as effective and as safe as imipenem/cilistatin given at 500 mg every 6 hours for treatment of gangrenous or perforated appendicitis.
The Natural History of Extremity Venous Repair Performed for Trauma
Authors: Smith Lou M. , Block Ernest F. J. , Buechter Kennan J. , Draughn David C. , Watson Diana , Hedden William
Published: November 2022

Surgical repair of extremity venous injuries remains controversial. Literature supports both ligation and repair when analyzed for functional recovery. However, few studies review the natural history of venous repair for trauma. Twenty patients were prospectively enrolled in a protocol of immediate repair of major extremity veins. Simple venorraphy and complex reconstructions were performed at the discretion of the operative team. Patients were studied by contrast venogram on postoperative day 3 and 6 weeks after surgery. Patients with occluded repairs at 3 days received a 5-day course of intravenous anticoagulation and were discharged. Overall, patency at 3 days was 55 per cent and increased to 88 per cent at 6 weeks (P < 0.02). Lateral venorraphy and direct reapproximation had higher patency rates than complex repairs at 6 weeks (92% versus 50%; P < 0.05). All veins that were patent at 3 days remained patent (correlation coefficient 1.0). Repair of traumatized extremity veins carries minimal morbidity and has a high rate of early and eventual patency. Long-term anticoagulation in the face of early thrombosis is unnecessary.
Puerperal Ovarian Vein Thrombosis with Extension into the Inferior Vena Cava
Authors: Clarke Christine S. , Harlin Stuart A.
Published: November 2022

The incidence of puerperal ovarian vein thrombosis is estimated to range between 1 in 600 and 1 in 2000 deliveries. The cardinal signs of puerperal ovarian vein thrombosis include fever, leukocytosis, and right lower quadrant abdominal pain, most often in a recently delivered female patient. These patients are classically described as failing to improve with intravenous antibiotic therapy alone; resolution of symptoms and presumptive diagnosis is made on defervescence with the addition of intravenous heparin therapy. Objective diagnostic modalities include venography, ultrasound, laparoscopy, and MRI, although CT remains the gold standard for the identification of this underdiagnosed entity.

We present a case report of a 20-year-old female treated at our facility for puerperal ovarian vein thrombosis. She was transferred to our vascular surgery service after developing the classic signs of puerperal ovarian vein thrombosis and undergoing CT demonstrating ovarian vein thrombosis with extension of free-floating thrombus into her inferior vena cava (IVC). This degree of thrombosis was particularly concerning when one considers the 3 to 33 per cent rate of pulmonary embolism reported in patients with puerperal ovarian vein thrombosis.

Treatment modalities for such extensive degrees of thrombosis are described in the literature and range from hysterectomy and thrombectomy to ligation of the IVC. In our case, we prophylactically placed a suprarenal IVC Greenfield filter to protect against pulmonary embolism and proceeded with the standard regimen of anticoagulation and antibiotics. This treatment approach has been reported only twice previously in the literature, to our knowledge.
The “Seat Belt Mark” Sign: A Call for Increased Vigilance among Physicians Treating Victims of Motor Vehicle Accidents
Authors: Velmahos George C. , Tatevossian Raymond , Demetriades Demetrios
Published: November 2022

The use of seat belts is shown to cause a specific pattern of internal injuries. Skin bruise corresponding to the site of the seat belt is known as the “seat belt mark” (SBM) sign and is associated with a high incidence of significant organ injuries. No study has yet defined the exact incidence of injuries requiring intervention at the presence of this sign. The objective of this study was to find the incidence of surgically correctable injuries in belted car occupants with a SBM sign and to define strategies of early detection and treatment of such injuries. The prospective study included consecutive patients involved in road traffic accidents who were admitted at an academic Level I trauma center. Of 650 car occupants, 410 (63%) were restrained and 77 (12%) had a SBM across the abdomen, chest or neck. The injuries of these 77 patients were compared with the injuries of belted patients without an SBM sign. Of patients with SBMs, 9 per cent had neck bruises, 32 per cent had chest bruises, 40 per cent had abdominal bruises, and 19 per cent had bruises in multiple sites. No significant neck injuries were detected. Three patients were found to have myocardial contusion, and 10 patients had intra-abdominal injuries (predominantly bowel and mesenteric lacerations) requiring laparotomy. There was a near 4-fold increase in thoracic trauma (22.5% versus 6%; P = 0.01) and a near 8-fold increase in intraabdominal trauma (23% versus 3%; P < 0.0001) between the groups of patients with and without SBMs. The presence of the SBM sign should alert the physician to the high likelihood of specific internal injuries. Routine laparotomy or mandatory evaluation by specific diagnostic tests is not justified; rather, a high index of suspicion with a low threshold for appropriate diagnostic evaluation and/or surgical exploration should be maintained for the optimal management of such patients.
Metastasis of Hepatocellular Carcinoma to the Right Colon Manifested by Gastrointestinal Bleeding
Authors: Cosenza Carlos A. , Sher Linda S. , Poletti Bernard J. , Tschirhart Donald , Noguchi Hiroji , Hoffman Allen L. , Lopez Richard R. , Lugo Diana , Rojter Sergio E. , Makowka Leonard
Published: November 2022

An 82-year-old black woman with a history of hepatocellular carcinoma presented with gastrointestinal bleeding. Barium enema and fibrocolonoscopy revealed a 4-cm polypoid mass at the level of the ascending colon with evidence of active bleeding. Biopsies of the lesion proved it to be metastatic hepatocellular carcinoma. Exploratory laparotomy revealed no further dissemination of the tumor, and the patient underwent an ileocolectomy. The serosal side of the colonic lesion was free from tumor, and there was no peritoneal implantation, direct extension, or lymph node involvement. This case represents an extremely rare presentation of metastatic hepatocellular carcinoma.
Perforated Peptic Ulcer following Gastric Bypass for Obesity
Authors: Macgregor Alex M. C. , Pickens N. Earle , Thoburn Eric K.
Published: November 2022

Peptic ulcer in the excluded segment of a gastric bypass performed in the management of morbid obesity has only rarely been reported in the literature. The purpose of this study is to review our experience with the condition in a series of 4300 patients who underwent gastric-restrictive surgery between 1978 and 1997. Eleven patients presented with acute perforation of a peptic ulcer in the excluded gastric segment. Nine ulcers were duodenal, one was gastric, and one patient had both gastric and duodenal perforations. The time between primary gastric-restrictive surgery and ulcer perforation varied from 20 days to 12 years. All patients presented with upper abdominal pain. The classical radiological sign of perforated peptic ulcer, free air under the diaphragm, did not occur in any patient. Nine patients were initially treated by primary closure of the perforation with subsequent definitive ulcer therapy by vagotomy, pyloroplasty, or gastrectomy. One case, initially treated elsewhere, was managed by placement of a Malecot catheter through the duodenal perforation, gastrostomy, and peritoneal drainage. One recent case remains symptom-free on H2 blockers after simple closure. There was no mortality. Six cases were previously reported in the literature with a 33 per cent mortality rate.
Descending Thoracic Aortobifemoral Bypass: An Alternative Approach for Difficult Aortic Revascularization
Authors: Barrett Stephen G. , Bergamini Thomas M. , Richardson J. David
Published: November 2022

Descending thoracic aortobifemoral bypass is an alternative inflow operation in cases in which standard aortobifemoral or axillobifemoral bypass is not an option. We performed descending thoracic aortobifemoral bypass for failed inflow operations in four patients, prior abdominal/pelvic radiation in two patients, poor quality distal aorta (extensive atherosclerotic disease or poor tissue quality) in two patients, and abdominal sepsis in two patients. Eight have had excellent results with patency at a mean follow-up of 38 months. There was no limb loss. One patient died of organ failure, and one patient with hypercoagulability developed a graft clot. A literature review disclosed that a descending thoracic aortobifemoral bypass was reported to have been performed in 203 patients, with most cases reported in the last decade. This procedure was the primary inflow operation in 42 per cent of cases. Indications for the operation included failed aortic grafts (38%), “hostile” abdomen (21%), infected aortic grafts (18%), and other (23%). The patency rate was 95 per cent at 6 months. Few long-term results are known, but the results appear to be durable. Descending thoracic aortobifemoral bypass is a useful operation in highly selected circumstances in which conventional methods of aortic reconstruction are not available.
Malignant Eccrine Spiradenoma: A Previously Unreported Presentation and Review of the Literature
Authors: Beekley Alec C. , Brown Tommy A. , Porter Clifford
Published: November 2022

Malignant eccrine spiradenomas (MESs) are rare rumors arising from previously benign eccrine spiradenomas. A review of the literature reveals only 25 published reports of malignancy arising from eccrine spiradenoma and no prior reports of an MES of the scalp. The tumors have a metastasis rate of >50 per cent in reported cases with high resultant mortality rates. We present the first case report of a single MES of the scalp. Multiple resections were required for local control. Both magnetic resonance imaging and lymphoscintigraphy were used to assess regional spread. A review of the literature follows to include histopathology, diagnosis, and both surgical and adjuvant therapeutic options.
Colostomy Closure: Impact of Preoperative Risk Factors on Morbidity
Authors: Ghorra Salim G. , Rzeczycki Thomas P. , Natarajan Ranjini , Pricolo Victor E.
Published: November 2022

The objective of this study was to stratify patients for colostomy closure into risk categories according to preoperative variables. This was a retrospective case series. Median follow-up was 82 months. A tertiary care academic medical center was the setting for this study. A study sample of 155 consecutive patients who underwent colostomy closure at a single institution between 1985 and 1995 were included in this study. The following preoperative variables were analyzed: indication for colostomy fashioning; age; gender; American Society of Anesthesiology (ASA) class; presence of cardiac, renal, or pulmonary dysfunctions; presence of diabetes mellitus; and immunosuppression. The occurrence of adverse outcome, as evidenced by postoperative morbidity and mortality, was used as the main outcome measure. Complications occurred in 49 patients (31.6%), including a 1.3 per cent mortality. There was a trend of increasing morbidity with increasing ASA class. The single factor that showed a statistically significant increase in morbidity was the presence of diabetes (P = 0.036). Predicted probabilities of complications for patients with ASA HI with renal disease was 31 per cent, increased to 47.9 per cent if cardiac disease was also present and to 77 per cent with the addition of diabetes. The presence of diabetes carries an independent risk factor for adverse outcome in colostomy closure. This study provides information about stratification of postoperative risk based on commonly available preoperative variables. In the majority of cases, colostomy closure seems to carry a very acceptable complication rate. In selected patients with multiple preoperative risk factors, the morbidity becomes significantly higher.
Comparison of Antiadhesive Treatments using an Objective Rat Model
Authors: Buckenmaier Chester C. , Pusateri Anthony E. , Harris Richard A. , Hetz Stephen P.
Published: November 2022

Intraperitoneal adhesions are a significant problem (increased morbidity, mortality, and cost) for patients undergoing abdominal procedures. Although a variety of approaches (e.g., fibrinolytic agents, anti-inflammatory drugs, or barrier/separation methods) have been used with some success in preventing adhesions, a comparison of these different modalities has yet to be performed in a model that objectively measures intraperitoneal adhesion formation. Our objectives were to establish an objective, reproducible model of intraperitoneal adhesion formation and to establish efficacy of different treatment modalities in decreasing the strength and extent of intraperitoneal adhesions. In this two-part study, a rat model establishing an objective measure of both the strength and extent of intraperitoneal adhesions was used to compare different treatment modalities. Fibrinolytic agents [recombinant tissue plasminogen activator (rtPA), streptokinase, and urokinase], anti-inflammatory drugs (dexamethasone and tolmetin sodium), and barrier methods [sodium carboxymethylcellulose (CMC), and sodium hyaluronate] and a control group were compared in the first phase. In the second phase, the two most successful agents (rtPA, CMC) were compared both alone and in combination against a commercially available barrier agent (Seprafilm™) and a control group. In the first phase of the study, rtPA was the only agent that had a statistically significant effect in decreasing the strength of adhesions. CMC was the only agent that demonstrated a decrease in the extent of adhesions, and the difference tended toward significance. In the second phase, the combination of rtPA and CMC showed a significant decrease in both the strength and extent of adhesions when compared with those of the control group. This decrease was also observed in the group treated with Seprafilm™, which showed no difference from the rtPA + CMC group. We conclude that, in this reproducible adhesion model, only the combination of rtPA + CMC and Seprafilm™ significantly reduced both the strength and the extent of intraperitoneal adhesions.
Needle-localized Breast Biopsy for Mammographic Abnormalities: A Community Hospital Experience
Authors: Tran De Q. , Wilkerson Donald K. , Namm Joel , Zeis Margaret A. , Cottone F. John
Published: November 2022

Increased awareness of benefits of early detection of breast cancer has resulted in increased numbers of screening mammographies and breast biopsies for nonpalpable lesions. Tertiary hospital studies have demonstrated positive biopsy rates from abnormal mammographic findings at 18 to 32 per cent. We examined the effectiveness of needle biopsy for nonpalpable radiographic abnormalities in our community hospital. We reviewed 167 records of patients biopsied over a 2-year period. Mammographic assessment, biopsy, and pathological assessment were performed using accepted methods. Malignancy was detected in 34 of 167 biopsies (20%). The biopsy yield rate was highest for mammographic findings of spiculated or stellate masses (75%, P < 0.01). Most biopsies (83%) were performed because of mammographic findings of microcalcifications or circumscribed enlarging masses/nodular developing densities for a positive biopsy yield rate of 16 per cent. Rates were higher in patients with personal (44%) or family history (30%) of breast cancer and in postmenopausal women (30%). These results demonstrate that 1) factors such as age, personal or family history of breast cancer, and certain mammographic features of breast lesions are associated with high biopsy yield rates, and 2) the biopsy yield rate in our community setting is comparable to tertiary hospital experience.
What is the Paradigm: Hospital or Home Health Care for Pressure Ulcers ?
Authors: O'Brien Sean P. , Gahtan Vivian , Wind Sandi , Kerstein Morris D.
Published: November 2022

A home health care (HHC) referral should link the patient in a cost-effective fashion to the physician, home care, and instructions regarding ulcer management. Twenty-one patients (mean age, 74.6 years) had stage III pressure ulcers (<100 cm2) and an involved family member at home. Risk and contributing factors included cardiac disease (n = 9), hypertension (n = 14), end-stage renal disease (n = 7), smoking (n = 11), diabetes (n = 8), chronic brain syndrome (n = 14), cerebrovascular accident (n = 5), and above-the-knee amputation (n = 2). Treatment regimens included standard wound care, pressure relief and, where appropriate, culture-specific antibiotics, as well as a rehabilitation program. Home care progressively decreased the frequency of the nurse HHC and physician office visits. Resolution of the pressure ulcer varied from 6 to 32 weeks. Only two patients had progression of their wound and required hospital readmission. The billable fees included: 1) an office visit, $30.00 (medicare reimbursement, $14.00); 2) the HHC nurse visit, $159.00 (medicare reimbursement, $105.00); 3) supplies, $75.00 to $150.00/week (variable reimbursement); 4) hospitalization, $400.00 to $900.00/day; and 5) a chronic-care bed, $400.00 to $750.00/day. HHC, given a responsible support team and an involved family member, was more socially and financially acceptable than an inpatient facility. Intermittent physician visits with HHC proved safe and reliable, with 90 per cent successfully healing their wounds.