bluuebunny/crossref_metadata_2025 huggingface dataset:
The Novel Use of Resuscitative Endovascular Balloon Occlusion of the Aorta to Explore a Retroperitoneal Hematoma in a Hemodynamically Unstable Patient
Authors: Rosenthal Martin D. , Raza Ahsan , Markle Stephanie , Croft Chasen A. , Mohr Alicia M. , Smith R. Stephen
Published: June 2020

Balloon occlusion of the aorta was first described by C.W. Hughes in 1954, when it was used as a tamponade device for three wounded soldiers during the Korean War suffering from intra-abdominal hemorrhage. Currently, the device is indicated in trauma patients as a surrogate for resuscitative thoracotomy. Brenner et al. reported a case series describing the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in advanced hemorrhagic shock. Their conclusion was that “it is a feasible method for proximal aortic control.” We describe the novel use of REBOA before retroperitoneal hematoma exploration in a hemodynamically unstable patient. Reported is a 19-year-old blunt trauma victim where REBOA was successfully deployed as a means for proximal arterial control before a Zone 1 retroperitoneal hematoma exploration. The source of the patient's hemorrhagic shock was multifactorial: grade V hepatic injury, retrohepatic inferior vena cava laceration, and right renal vein avulsion with Zone 1 retroperitoneal hematoma. Immediate return of perfusion pressure, as systolic pressures increased from 50 to 150 mm Hg. Hemodynamic improvements were accompanied by decreased transfusion and vasopressor requirements. In addition, the surgeons were able to enter the retroperitoneal hematoma under controlled conditions. REBOA is an attractive new tool to gain proximal aortic control in select patients with hemorrhagic shock. It is less morbid, possibly more efficient, and appears to be more effective than resuscitative thoracotomy. REBOA is certainly feasible for proximal aortic control before retroperitoneal exploration, and should be considered in select patients.
Outcomes of Recreational Activity-Associated Trauma in Elderly Persons on Blood-Thinning Medications
Authors: Deboard Zachary M. , Grotts Jonathan , Ferrigno Lisa
Published: June 2020

With increasing life expectancy, the elderly are participating in recreational activities traditionally pursued by younger persons. Elderly patients have many reasons for worse outcomes after trauma, one of which may be the rising use of anticoagulant and/or antiplatelet medications. This study aimed to determine whether preinjury use of these agents yielded worse outcomes in geriatric patients injured during high-impact recreational activities. The National Trauma Data Bank was reviewed from 2007 to 2010 for patients ≥65 years admitted to Level I or II trauma centers with ICD-9 E-codes for specific mechanisms of injury. These included motorcycles, bicycles, snowmobiles, all-terrain vehicles, equestrian, water and alpine skiing, snowboarding, and others. Patients with preinjury bleeding disorder (BD), including warfarin and clopidogrel use, were compared with controls via a coarsened exact matching analysis. BD patients (294) were compared with 3929 controls. Although increased in BD patients, no significant mortality differences were observed in unmatched or matched analyses. BD patients yielded greater hospital length of stay (5 vs 4 days, P = 0.020) with increased odds of receiving five units or more of blood (7.0% vs 2.1%, odds ratio = 4.7, P < 0.001) and of deep vein thrombosis (7.6% vs 3.8%, odds ratio = 2.1, P = 0.018). Elderly patients with BD, including warfarin or clopidogrel use, do not seem to have significantly increased mortality after injury during specified recreational activities. BD patients had greater hospital length of stay, transfusion requirements, and deep vein thrombosis rates. These findings may inform counseling for those taking such medications as to the potential for adverse outcomes.
Treatment Options for Pilonidal Disease
Authors: Ehrl Denis , Choplain Cornelia , Heidekrueger Paul , Erne Holger C. , Rau Horst-Guenter , Broer P. Niclas
Published: June 2020

Pilonidal disease can be treated medically; however, surgical excision remains the gold standard. Nonetheless, all current surgical approaches are still associated with potential for tissue loss, wound healing disorders, and high rates of recurrence. Aim of this study is to assess the long-term outcomes of the minimal-invasive pit-picking operation in comparison to the well-established technique of Karydakis flap-closure. Medical records of all patients undergoing either Karydakis flap-closure or the pit-picking operation for pilonidal disease at our department were reviewed retrospectively. A total of 101 patients were treated either by excision and Karydakis flap-closure (n = 62) or by the pit-picking operation (n = 39). Mean follow-up time was 65.5 (range: 38–101) months, including data collection using a standardized questionnaire. Analysis of the outcomes revealed no significant differences between the Karydakis flap-closure- and the pit-picking groups; however, the latter was associated with faster recovery, no need for hospitalization and overall low complication rates. In summary, the main advantages of the pit-picking operation lie in its’ outpatient character, the simplicity of the procedure, low complication rates, short recovery time, and predictably good results.
Emergency Cholecystectomy for Patients on Antiplatelet Therapy
Authors: Akahoshi Keiichi , Ochiai Takanori , Takaoka Ayumi , Kitamura Takuya , Ban Daisuke , Kudo Atsushi , Tanaka Shinji , Tanabe Minoru
Published: June 2020

The use of antiplatelet therapy (APT) and/or anticoagulant therapy (ACT) continues to increase due to the aging population. Because the management of patients with acute cholecystitis receiving APT/ACTis still unclear, surgeons are sometimes faced with the difficult decision to delay surgery. We aimed to analyze characteristics and surgical risks of patients who underwent emergency cholecystectomy for acute cholecystitis without discontinuing APT. We conducted a retrospective review of 113 patients between 2006 and 2014. Treatment outcomes among 13 patients who underwent cholecystectomy without discontinuing APT (the cAPT group), 11 patients who discontinued APT and ACT (the D group), and 89 patients who did not receive preoperative APT and/or ACT (the No APT group) were compared. There were no significant differences in intraoperative blood loss, conversion to open surgery, and bleeding-related complications. However, the incidence of intraoperative blood transfusion was higher in the cAPT group (P = 0.04). They presented with severe local inflammation; thus, it was difficult to stop bleeding from the gallbladder bed. Hemostatic tools for liver surgery were used to control bleeding. Emergency cholecystectomy was tolerable for patients with acute cholecystitis while continuing APT. However, in case of severe local inflammation, there is a greater risk for massive hemorrhage.
Can Tumor Biology Predict Occult Multifocal Disease in Breast Cancer Patients?
Authors: Chagpar Anees B. , Cicek Ali F. , Harigopal Malini
Published: June 2020

The SHAVE trial is a prospective trial in which 235 women with stage 0 to 3 disease undergoing partial mastectomy were randomized intraoperatively to either have cavity shave's (CSMs) taken at the time of initial surgery or not. In this study, 9 of the 76 patients (11.8%) with initially negative margins randomized to the “shave” group had occult cancers found in the CSM. Seven of these patients had sufficient primary tumor tissue available for further analysis. These patients were age and stage matched in a 1:2 ratio to other patients in the trial who had no further disease found in their CSM. A tissue microarray was created, stained for E-cadherin, MUC1, and beta-catenin, and evaluated by two independent pathologists (blinded to outcome). There were no significant differences between cases and controls in terms of median invasive tumor size, ductal carcinoma in situ size, volume of initial resection, and volume of CSM. Further, no differences were noted between cases and controls for median (staining intensity x per cent of cells staining) for each marker. Hence, although nearly 12 per cent of breast cancer patients with negative margins will have occult disease, this could not be predicted by primary tumor markers in this study.
Successful Incorporation of Performance Based Payments for Trauma Center Readiness Costs into the Georgia Trauma System
Authors:   Members of the Georgia Research Institute for Trauma (Grit), Ashley Dennis W. , Nicholas Jeffrey M. , Dente Christopher J. , Johns Tracy J. , Garlow Laura E. , Solomon Gina , Abston Dena , Ferdinand Colville H.
Published: June 2020

As quality and outcomes have moved to the fore front of medicine in this era of healthcare reform, a state trauma system Performance Based Payments (PBP) program has been incorporated into trauma center readiness funding. The purpose of this study was to evaluate the impact of a PBP on trauma center revenue. From 2010 to 2016, a percentage of readiness costs funding to trauma centers was placed in a PBP and withheld until the PBP criteria were completed. To introduce the concept, only three performance criteria and 10 per cent of readiness costs funding were tied to PBP in 2010. The PBP has evolved over the last several years to now include specific criteria by level of designation with an increase to 50 per cent of readiness costs funding being tied to PBP criteria. Final PBP distribution to trauma centers was based on the number of performance criteria completed. During 2016, the PBP criteria for Level I and II trauma centers included participation in official state meetings/conference calls, required attendance to American College of Surgeons state chapter meetings, Trauma Quality Improvement Program, registry reports, and surgeon participation in Peer Review Committee and trauma alert response times. Over the seven-year study period, $36,261,469 was available for readiness funds with $11,534,512 eligible for the PBP. Only $636,383 (6%) was withheld from trauma centers. A performance-based program was successfully incorporated into trauma center readiness funding, supporting state performance measures without adversely affecting the trauma center revenue. Future PBP criteria may be aligned to designation standards and clinical quality performance metrics.
Outcomes of Unroofing with Limited Excision and Structured Postoperative Care for Pilonidal Disease
Authors: Tavangari Farees Ricky , Lee Jennifer Amy , Garza David , Tejirian Talar
Published: June 2020

Despite a wide variety of surgical techniques to treat chronic pilonidal disease, high rates of recurrence are common. The current study analyzes the outcome of unroofing with limited excision combined with structured postoperative wound care for pilonidal disease. We performed a retrospective review of all patients who were treated with this technique over a seven year period. Ninety-four patients aged 11 to 63 (mean age 26) received this treatment for pilonidal disease. Eighty-nine patients were treated for primary pilonidal disease and five were treated for recurrent disease after procedures such as flaps. There were 66 males (70%) and 28 females (30%). The operation was performed by unroofing the entire pilonidal sinus along with its pits and area of chronic abscess cavity. All granulation tissue was removed and the base of the sinus was completely cauterized. No wide local excisions were performed. The cavity was packed with dry gauze and the dressing was changed twice daily. Patients were seen postoperatively on a weekly basis in clinic. The area was shaved; the cavity was cleaned and often treated with silver nitrate. In the event of premature skin closure starting to form, unroofing was easily performed in the office. The median time to achieve complete healing was 53 days requiring, on average, seven visits. With a mean follow-up of 40 months, there were two recurrences (2.1%) and reoperation for two (2.1%) inappropriately healing wounds. This study demonstrates that unroofing with limited excision and structured postoperative care for pilonidal disease is a safe and effective treatment approach with a very low recurrence and complication rate.
The Dangers of Equivocal FAST in Trauma Resuscitation
Authors: Kleinman John , Strumwasser Aaron , Rosen David , Hardin Jeremy , Inaba Kenji , Demetriades Demetrios
Published: June 2020

Equivocal focused abdominal sonography for trauma (FAST) examinations confound decision-making for trauma surgeons. We sought to determine whether the equivocal FAST (defined as any nonconcordant result) has a deleterious effect on trauma outcomes. A 2-year review (2014–2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST results were compared. Outcomes included resuscitation time (h), ventilation days (d), hospital length of stay (HLOS-d), ICU length-of-stay, and survival (%). In addition, skill level of the sonographer was stratified by novice (postgraduate year (PGY) years 1–3) or expert skill levels (PGY-4/fellow or attending). A total of 1,027 patients were included. Compared with concordant FAST examinations, equivocal FASTs were associated with increased HLOS (14.1 vs 10.6, P = 0.05), higher mortality (9.8 vs 3.7%, P = 0.02), decreased positive predictive value in the right upper quadrant (RUQ) (55 vs 79%, P = 0.02) and left upper quadrant (LUQ) (50 vs 83%, P < 0.01) and significantly decreased specificity in the thoracic (83 vs 98%), RUQ (80 vs 98%), LUQ (86 vs 99%), and pelvic (88 vs 98%) windows (P < 0.01 for all). A trend of greater positive predictive value in the thoracic window (100 vs 81%, P = 0.09) among PGY-4/fellow and attending providers compared with PGY levels 1–3 was observed. Equivocal FASTs portend worse outcomes than concordant FASTs because of high false-negative rates, specifically in the thoracic region and the upper quadrants. Lower thresholds for intervention are recommended.
Optimizing the Management of Abnormal Liver Function Tests after Orthotopic Liver Transplant: A Systems-Based Analysis of Health Care Utilization
Authors: Russell Tara A. , Angarita Stephanie A. K. , Showen Amy , Agopian Vatche , Busuttil Ronald W. , Kaldas Fady M.
Published: June 2020

Elevated liver function tests (eLFTs) are a major cause of unplanned readmissions (UR) after orthotopic liver transplantation. Diagnostic workup for eLFTs requires multiple invasive and noninvasive procedures, often done in the inpatient setting to expedite diagnosis, yet consequently resulting in increased costs. In this study, we evaluated eLFT readmissions at a single institution with respect to resource utilization. From 3/2013 to 12/2015, 388 patients underwent orthotopic liver transplantation, resulting in 463 UR totaling 5833 bed days; 87 (18.8%) UR and 929 (15.9%) bed days were for eLFTs. During eLFT-UR all patients underwent repeat laboratory testing, 75 (86.2%) liver ultrasound, 66 (75.8%) liver biopsy, and 17 (19.5%) endoscopic retrograde cholangiopancreatography. Discharge diagnoses were acute cellular rejection (40.2%), transaminitis not otherwise specified (17.2%), biliary complications (16.1%), recurrent hepatitis (11.5%), vascular complications (5.8%), viral hepatitis (5.8%), and steatohepatitis (3.5%). The greatest bed-day utilization was secondary to acute cellular rejection (60.8%) and biliary complications (13.7%). More than 35 per cent of eLFT-UR were due to transaminitis not otherwise specified, steatohepatitis, recurrent or viral hepatitis, none of which necessitate inpatient treatment. In addition, >25 per cent of eLFT-UR bed days were attributed to diagnostic workup. Identifying patients who can undergo expedited outpatient workup and require only outpatient management will result in significantly decreased readmissions, bed days, and hospital costs.
Outcomes of Soft Tissue Reconstruction for Traumatic Lower Extremity Fractures with Compromised Vascularity
Authors: Badash Ido , Burtt Karen E. , Leland Hyuma A. , Gould Daniel J. , Rounds Alexis D. , Azadgoli Beina , Patel Ketan M. , Carey Joseph N.
Published: June 2020

Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries. A retrospective review of 158 lower extremities with traumatic fractures, including 26 extremities with arterial injuries, was performed to determine the effects of vascular compromise on flap survival, successful limb salvage and complication rates. Patients with arterial injuries had a larger average flap surface area (255.1 vs 144.6 cm2, P = 0.02) and a greater number of operations (4.7 vs 3.8, P = 0.01) than patients without vascular compromise. Patients presenting with vascular injury were also more likely to require fasciotomy [odds ratio (OR): 6.5, confidence interval (CI): 2.3–18.2] and to have a nerve deficit (OR: 16.6, CI: 3.9–70.0), fracture of the distal third of the leg (OR: 2.9, CI: 1.15–7.1) and intracranial hemorrhage (OR: 3.84, CI: 1.1–12.9). After soft tissue reconstruction, patients with arterial injuries had a higher rate of amputation (OR: 8.5, CI: 1.3–53.6) and flap failure requiring a return to the operating room (OR: 4.5, CI: 1.5–13.2). Arterial injury did not correlate with infection or overall complication rate. In conclusion, arterial injuries resulted in significant complications for patients with lower extremity fractures requiring flap coverage, although limb salvage was still effective in most cases.
Hypoalbuminemia and Clinical Outcomes: What is the Mechanism behind the Relationship?
Authors: Kim Sunghye , McClave Stephen A. , Martindale Robert G. , Miller Keith R. , Hurt Ryan T.
Published: June 2020

Albumin has a number of important physiologic functions, which include maintaining oncotic pressure, transporting various agents (fatty acids, bile acids, cholesterol, metal ions, and drugs), scavenging free oxygen radicals, acting as an antioxidant, and exerting an antiplatelet effect. Hypoalbuminemia in adults, defined by an intravascular albumin level of <3.5 g/dL, is associated with poor postoperative outcomes in patients undergoing surgical intervention. Although the relationship of hypoalbuminemia and poor surgical outcome has been known for many years, the pathophysiology behind the relationship is unclear. Three theoretical constructs might explain this relationship. First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor postoperative outcomes. Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor postoperative outcomes. Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization. While surgeons may use albumin levels on admission for their prognostic value, they should avoid therapeutic strategies whose main endpoint is correction of this abnormality.
Continuing Trauma: The Unmet Needs of Trauma Patients in the Postacute Care Setting
Authors: Fakhry Samir M. , Ferguson Pamela L. , Olsen Jama L. , Haughney Jennifer J. , Resnick Heidi S. , Ruggiero Kenneth J.
Published: June 2020

Trauma care has traditionally focused on prehospital and hospital settings, yet many injured patients report emotional distress in the postacute care setting, which is known to impair recovery. The objective of this study was to assess postdischarge emotional recovery and communication preferences. An observational cohort of 100 adult patients from our Level 1 Trauma Center was surveyed one to two months postdischarge. Among those employed preinjury, 44 per cent had not returned to work. Nearly half screened positive for emotional issues (posttraumatic stress disorder, depression, and/or psychological distress); of these, only 35 per cent considered getting professional help and only 10 per cent received help. The barrier most cited (58%) was cost; 42 per cent did not know how or where to get help. Most participants responded “no” or “I don't know” when asked if they had received information about coping with negative emotions after injury and how to seek help from a doctor to address these emotions. Two-thirds preferred to receive such information via phone call from a health care provider or by text. Eighty-nine per cent owned a cellphone. Our trauma systems are failing to provide comprehensive care or look at the ultimate outcomes of our patients, yet modern technology could provide needed resources to patients in novel ways.
The Sonographic Subcentimeter Malignant Thyroid Nodule: What Does It Stand for?
Authors: Marrero Annette Pascual , Gracia Alvaro , Méndez William
Published: June 2020

Thyroid cancer management has moved to less extensive surgery in lesions with favorable criteria. Our study evaluated if the sonographic (US) size of thyroid nodules is a reliable criterion to determine the extent of surgery in patients with papillary thyroid carcinoma (PTC). A retrospective study was performed to evaluate thyroid nodules measuring <10 mm in the preop sonogram with a permanent pathology of PTC. Patients were subdivided into two groups based on the US size: A (1–5 mm) and B (6–10 mm). Statistical correlations were made for the presence of the following unfavorable criteria: multifocality, capsular invasion, angio/lymphatic invasion, extrathyroidal invasion, and presence of metastases. A total of 1901 thyroidectomies were performed: 722 (38%) for PTC. 182 (25%) patients met the inclusion criteria. There were 30 patients in Group A (1–5 mm) and 152 patients in Group B (6–10 mm). Five (17%) patients in Group A and 53 (35%) patients in Group B presented unfavorable criteria ( P < 0.005). Malignant thyroid nodules with the US size of <5 mm can in theory be candidates for partial thyroidectomy, but 17 per cent of them might still need further surgical intervention. Lesions with the US size of 6 to 10 mm still have a moderate risk of presenting unfavorable pathological criteria.
Trauma Surgeons Save Lives—Scribes Save Trauma Surgeons!
Authors: Golob Joseph F. , Como John J. , Claridge Jeffrey A.
Published: June 2020

With the advent of the electronic medical record, the documentation burden of the trauma surgeon has become overwhelming. To help, our trauma division added scribes to the rounding team. We hypothesized that scribe utilization would improve our documentation efficiency and offer a financial benefit to the institution. A review of trauma surgeon documentation and billing was performed at a Level I trauma center over two time periods: January to May 2014 (no scribes) and January to May 2015 (scribes). The number of notes written by trauma surgeons was obtained, as were documentation charges. Documentation efficiency was determined by noting both the hour of the day in which inpatient progress notes were written and the number of notes written after patient discharge. In the 2014 period, a total of 9726 notes were written by trauma attendings. In the 2015 period, 10,933 were written. Despite having 407 fewer trauma patient-days in the 2015 period, the group wrote 343 notes/week versus 298 notes/week ( P = 0.008). More inpatient progress notes were written earlier in the working day and fewer were written in the evening. Fewer notes were written after patient discharge (12.7 vs 8.4%). A total of 1,664 hours of scribe time were used over the 5-month period, generating an expense of $32,787. The additional notes generated by scribes resulted in $191,394 in charges. Conservatively, assuming a 20 per cent charge reimbursement, the cost of the scribes was covered. The addition of scribes to the daily trauma rounding team improved note efficiency and increased charge capture at our center.
The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review
Authors: Stroh Gregory R. , Dong Fanglong , Ablah Elizabeth , Ward Jeanette G. , Haan James M.
Published: June 2020

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.
Laparoscopic Heller Myotomy for Achalasia Technical Aspects
Authors: Schlottmann Francisco , Allaix Marco E. , Patti Marco G.
Published: June 2020

Esophageal achalasia is a primary esophageal motility disorder defined by the lack of esophageal peristalsis, and by a lower esophageal sphincter that fails to relax in response to swallowing. Patients’ symptoms include dysphagia, regurgitation, aspiration, heartburn, and chest pain. Achalasia is a chronic condition without cure, and treatment options are aimed at providing symptomatic relief, improving esophageal emptying, and preventing the development of megaesophagus. Presently, a laparoscopic Heller myotomy with a partial fundoplication is considered the best treatment modality. A properly executed operation is key for the success of a laparoscopic Heller myotomy.
Early Urinary Dysfunction after Laparoscopic Rectal Cancer Surgery: Does Surgeons’ Learning Curve Matter?
Authors: Zhao Yong , Hou Xiao-Ling , Ding Jian-Hua , Zhao Ke , Xu Xiao , Dong Guang-Long
Published: June 2020

Poor early urinary outcomes after laparoscopy were reported in studies comparing laparoscopic versus open rectal cancer surgery. One possible explanation was that these studies might include a number of patients on the laparoscopic surgeons’ learning curve. This study aims to evaluate whether the learning curve of laparoscopic rectal cancer surgery influences early postoperative urinary dysfunction. Between September 2009 and December 2014, 208 consecutive patients undergoing laparoscopic rectal resection for rectal cancer were enrolled in the present study. All the clinical data were obtained from a prospectively compiled database. The primary outcomes were the incidences of postoperative urinary retention (POUR) and major urinary dysfunction requiring long-term urinary catheterization. POUR and major urinary dysfunction rate were 20.2 per cent (42/208) and 4.3 per cent (9/208), respectively. The learning curve analysis for operative time using the moving average method showed stabilization at 80 cases. Surgeon experience was divided into two periods: learning curve period (1–80 cases) and experienced period (81–208 cases). Multivariate analysis showed that older age (OR = 3.250, P = 0.006) and learning curve (OR = 2.241, P = 0.024) were independent risk factors for POUR. Learning curve was not significantly associated with increased rates of major urinary dysfunction (OR = 3.378, P = 0.092). Learning curve is a significant risk factor for increased rate of POUR after laparoscopic rectal cancer surgery. Technical training may be key to shorten the learning curve and limit its impact on the postoperative urinary complications.
Management of Esophageal Perforation: 28-Year Experience in a Major Referral Center
Authors: Puertavicente Ana , JimÉNez Pablo Priego , López María Ángeles Cornejo , Nisa Francisca GarcÍA-Moreno , Velasco Gloria RodrÍGuez , Álvarez Julio Galindo , Martínez Eduardo Lobo
Published: June 2020

Esophageal perforation constitutes a surgical emergency. Despite its gravity, no single strategy has been described as sufficient to deal with most situations to date. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease. A retrospective clinical review of all patients treated for esophageal perforation at Ramón y Cajal Hospital between January 1987 and December 2015 was performed (n = 57). Iatrogenic injury was the most frequent cause of esophageal perforation (n = 32). Abdominal esophagus was the main location (23 patients; 40.4%). Eight patients (14%) were managed with antibiotics and parenteral nutrition. In seven patients (12.3%), an endoscopic stent was implanted. Surgical therapy was performed in 38 patients (66.7%). Morbidity and 90-day mortality rates were 61.4 and 28 per cent, respectively. Five patients were reoperated (8.8%). Median hospital stay was 23.5 days. The mortality rate was higher among patients with spontaneous and tumoral perforation (54.5 and 100%; P = 0.009), delayed diagnosis (>24 hours; P = 0.0001), and abdominal/thoracic location (37.5%; P = 0.05). No statistical differences were found between surgical and conservative/endoscopic management (31% vs 20%; P = 0.205) although hospital staying was longer in surgical group (36.30 days vs 15.63 days; P = 0.029). Esophageal perforation was associated with high morbidity and mortality rates. Global outcomes depend on etiology, site of perforation, and delay in diagnosis. An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.
The Branching Pattern of the Inferior Pancreaticoduodenal Artery in Patients with a Replaced Right Hepatic Artery
Authors: Tomimaru Yoshito , Tanaka Kaishu , Noguchi Kozo , Morita Shunji , Imamura Hiroshi , Dono Keizo
Published: June 2020

Understanding the anatomy of the inferior pancreaticoduodenal artery (IPDA) is important in patients undergoing pancreaticoduodenectomy, especially in an artery-first approach, resulting in some studies focusing on IPDA anatomy. However, the studies have covered only cases without variation in hepatic arterial anatomy, a common arterial variant, suggesting the necessity of the investigation of IPDA anatomy in cases with the variant. Using images of multidetector row computed tomography, cases with replaced right hepatic artery (rRHA) were picked out among 714 patients undergoing multidetector row computed tomography for determining arteries of the pancreatic head at our institution. IPDA branching pattern was investigated in the rRHA cases. Three-dimensional reconstruction was performed to visually understand the branching pattern in representative cases. rRHA was identified in 139 cases (19.5%); rRHA originating from the superior mesenteric artery (SMA) (type 1; 74.1%), celiac axis (type 2; 18.0%), and others (type 3; 7.9%). IPDA branching pattern was categorized; IPDA originated from SMA (type A), posterior and anterior IPDA originated from rRHA and SMA, respectively (type B), or IPDA originated from rRHA (type C). Of type 1 cases, 69, 23, and 11 cases showed type A, B, and C pattern, respectively. Of type 2 cases, 16 and 9 cases showed type A and B, respectively. All 11 type 3 cases showed type C. IPDA branching pattern was determined in the rRHA cases. This would help identification of rRHA cases where the artery-first approach is technically less feasible at pancreaticoduodenectomy (type 1-B, 1-C, and 2-B).
A Prospective, Comparative Evaluation on Totally Implantable Venous Access Devices by External Jugular Vein versus Cephalic Vein Cutdown
Authors: Iorio Olga , Gazzanelli Sergio , D'ermo Giuseppe , Pezzolla Angela , Gurrado Angela , Testini Mario , Toma Giorgio De , Cavallaro Giuseppe
Published: June 2020

The request for totally implantable venous access devices (TIVADs) has rapidly grown up through the last decades. TIVADs are implanted by direct vein puncture or by surgical approach with vein cutdown. The authors present a comparative prospective study evaluating external jugular vein (EJV) and cephalic vein cutdown techniques. Two hundred and fifteen patients were consecutively submitted to TIVAD implantation to perform chemotherapy. Patients were divided in two groups, depending on the implantation technique. Group A patients (106) underwent implantation via EJV cutdown and group B (109) patients underwent implantation by cephalic vein cut-down. The following variables were investigated: operating time, need for conversion to other approaches, complications, and intraoperative and postoperative pain. In Group A patients, the success rate of the procedure was 100 per cent, whereas in 11 patients (10.1%) of Group B, a modification of the initial approach was needed. Mean operative time was 23.9 ± 9.2 minutes in Group A and 35.4 ± 11.9 in Group B, and this was statistically significant (P < 0.05). Complication rates at 30 days were similar. Considering intraoperative pain, a difference was found between the two groups because the mean value of pain in Group Awas lower than that in Group B (4.13 ± 0.3 vs 5.22 ± 1.24), even if not significant. External jugular vein cutdown approach is quick and safe and allows a very high success rate with very low risk of complications. For these reasons, this approach could be considered as a first choice in TIVAD placement.
Bone Autograft Coupled with Locking Plates Repairs Symptomatic Rib Fracture Nonunions
Authors: Hernandez Matthew C. , Reisenauer Janani S. , Aho Johnathon M. , Zeb Muhammad , Thiels Cornelius A. , Cross William W. , Schiller Henry J. , Kim Brian D.
Published: June 2020

Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010–2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (66.1) months. A median of 3 [1–3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.
Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma
Authors: Aksakal Nihat , Agcaoglu Orhan , Sahbaz Nuri Alper , Albuz Ozgur , Saracoglu Ayten , Yavru Aysen , Barbaros Umut , Erbil Yesim
Published: June 2020

Pheochromocytoma is an uncommon catecholamine-secreting tumor in which resection is often associated with hemodynamic instability (HI). In this study, we aim to clarify the factors affecting surgical HI in patients who underwent surgery with the diagnosis of pheochromocytoma. All patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 and 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. A total of 37 patients were included in this study. Patient demographics, operative time, tumor size, period of medical treatment until surgery, catecholamine levels in urine, and HI patterns were analyzed. There were 23 (62%) male and 14 (38%) female patients. Hemodynamic instability occurred in 13 (35%) patients. Overall, HI was higher in patients with tumor size <6 cm (P < 0.02); moreover, urine catecholamine levels were detected significantly higher than a cutoff value of 2000 mg/24 hours in hemodynamically instable group. In this study, tumor diameter of <6 cm and urine catecholamine levels >2000 mg/24 hours were associated with HI. Preoperative management is essential for preventing hypertensive crisis and HI before or during surgery.
Comparison of Treatment Outcomes of Endoscopic Stenting and Laparoscopic Gastrojejunostomy for Malignant Gastric Outlet Obstruction
Authors: Leiyuan Shuai , Jianli Xu , Zhengzhong Zhao , Guangyan Ji , Dailiang Zhu
Published: June 2020

To compare the clinic outcomes of endoscopic stenting and laparoscopic gastrojejunostomy (LGJ) for patients with malignant gastric outlet obstruction (GOO). We retrospectively reviewed 63 patients with malignant GOO that underwent endoscopic stenting [Stent Group (SG), n = 29] or LGJ [Laparoscopic Group (LG), n = 34]. Then, we evaluated the medical effects, postoperative hospital stay, and hospitalization expenses in both groups. Compared to LG, SG has a shorter operation time [SG: (41.1 ± 9.3) minutes vs LG: (137.4 ± 21.7) minutes, P = 0.000], less intra-operative blood loss [(23.7 ± 9.0) mL vs (121.1 ± 24.3) mL, P = 0.000], relatively lower hospitalization expenses [(2272.7 ± 413.9) $ vs (5182.4 ± 517.3) $, P = 0.000]. Besides, the median intake time was significantly shorter in the SG than that in the LG [(0.9 ± 0.3) days vs (4.1 ± 0.6) days, P = 0.000]. However, there were no significant differences between SG with LG in surgical success rate (100 vs 100%, P = 1.000), length of hospital stay [(6.1 ± 3.3) days vs (10.9 ± 4.7) days, P = 0.422], recurrent obstructive rate (37.9 vs 26.5%, P = 0.949) and median survivals [(141.4 ± 81.4) days vs (122.7 ± 88.8) days, P = 0.879]. Endoscopic stenting and LGJ are both relatively safe and effective treatments for patients with malignant GOO. But we suggest that endoscopic stenting should be considered first in patients with malignant GOO because it has many advantages over LGJ.
Early Enteral Nutrition is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients
Authors: Haac Bryce , Henry Sharon , Diaz Jose , Scalea Thomas , Stein Deborah
Published: June 2020

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chisquared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.
Splenic Bed Laparoscopic Splenectomy Approach for Massive Splenomegaly Secondary to Portal Hypertension and Liver Cirrhosis
Authors: Tian Guangjin , Li Deyu , Yu Haibo , Dong Yadong , Xue Huanzhou
Published: June 2020

This study was performed to evaluate the feasibility of the splenic bed laparoscopic splenectomy approach (SBLS) for massive splenomegaly (≥30 cm) in patients with hypersplenism secondary to portal hypertension and liver cirrhosis. Patients who underwent laparoscopic splenectomy (LS) from January 2012 to December 2016 were retrospectively reviewed. We performed LS in 83 patients with massive splenomegaly (≥30 cm) secondary to portal hypertension and liver cirrhosis. Of these patients, 37 underwent the SBLS and 46 underwent anterior LS (ALS). Five patients in the ALS group and none in the SBLS group underwent conversion to open surgery. The operation time, intraoperative blood loss volume, transfusion volume, frequency of transfusion, hemorrhage of short gastric vessels, conversion rate, postoperative hospital stay, and incidence of pancreatic fistula were all significantly lower in the SBLS than ALS group (all P < 0.05). No death or postoperative bleeding occurred in the two groups, and there were no significant differences in age, gender, spleen size, hemoglobin level, platelet count, prothrombin time, Child-Pugh class, hypoproteinemia, or ascites (all P > 0.05). The SBLS is more feasible and effective than ALS in patients with massive splenomegaly (≥30 cm) secondary to portal hypertension and liver cirrhosis.
Follicular Carcinoma Masquerading as a Hot Nodule in a Pediatric Patient
Authors: Benzon M. , Katabi Nora , Boucai Laura , Shaha Ashok
Published: June 2020

Autonomous functioning thyroid nodules (AFTNs) are generally considered to be benign entities, with malignancy found in about 1 per cent considered to be rare in the general population. Because of this low rate, fine needle aspiration is generally not recommended, and these lesions are most often treated with radioactive iodine, medication, or surgery. However, AFTNs are exceedingly rare in the pediatric population and the optimal treatment is not defined. We present a 14-year-old female patient with an AFTN treated with surgical resection and found to contain a follicular carcinoma with capsular invasion.
Antibiotic Irrigation of the Surgical Site Decreases Incidence of Surgical Site Infection after Open Ventral Hernia Repair
Authors: Fatula Lily Knight , Nelson Allison , Abbad Hamza , Ewing J. Alex , Hancock Ben H. , Cobb William S. , Carbonell Alfredo M. , Warren Jeremy A.
Published: June 2020

Surgical site infections (SSI) are common complications after open ventral hernia repair (OVHR), potentially requiring further intervention. Antibiotic lavage before abdominal closure has been shown to lower the incidence in intra-abdominal and soft tissue SSI. A retrospective review of OVHR was performed with mesh at Greenville Health System Hernia Center between 2008 and 2017. Patients were divided into three groups, receiving no antibiotic irrigation (Grp 1, n = 260), gentamicin alone (Grp 2, n = 263), or gentamicin 1 clindamycin (G 1 C) irrigation (Grp 3, n = 299). Differences in categorical variables among the three groups were tested using chi-squared or Fischer's exact test (for n < 5). Analysis of continuous variables was performed using analysis of variance or Kruskal-Wallis test for differences in length of stay. Logistic regression was performed using all clinically relevant variables to determine the effects of irrigation on SSI. Incidence of surgical site occurrence was significantly lower after G 1 C irrigation (Grp 1, 28.1%; Grp 2, 35.4%; Grp 3, 19.7%; P < 0.001). Incidence of SSI was significantly lower after G 1 C irrigation, but not G alone (Grp 1, 16.5%; Grp 2, 15.2%; and Grp 3, 5.4%; P < 0.001). Multivariate logistic regression demonstrated significantly increased SSI with contaminated wounds (OR 2.96; 95% confidence interval (CI) 1.39–6.21), dirty wounds (OR 3.84; 95% CI 1.49–9.69), and chronic obstructive pulmonary disease (OR 3.70; 95% CI 2.16–6.38), as expected. Use of G 1 C was an independent predictor of decreased SSI (OR 0.33; 95% CI 0.16–0.67). Irrigation with a combined G 1 C antibiotic irrigation significantly reduces the incidence of surgical site infection after OVHR with mesh.
The Effect of Insurance and Race on Breast Cancer Tumor Biology and Short-Term Outcomes
Authors: Samiian Laila , Sharma Priya , Botty Van Den Bruele Astrid , Smotherman Carmen , Vincent Mia , Crandall Marie
Published: June 2020

To determine whether low-income status as demonstrated by insurance type has any association with aggressive tumor biology and breast cancer outcomes. Retrospective review of 535 women with new diagnosis of breast cancer from January 2009 to March 2013 was performed. There was no significant association between race and stage at diagnosis. Women with Medicaid/Charity coverage were diagnosed at more advanced stages, more likely to have triple-negative breast cancer (TNBC), and had longer time to treatment. Rate of TNBC was higher in black women and younger patients. There was no significant difference in breast cancer recurrence or survival by race, insurance type, age, or tumor biology. In multivariable analysis, only black race (P = 0.003) and Medicaid/Charity Insurance (P = 0.0008) were the most significant predictors of TNBC. Presentation of aggressive tumor biology and advanced stage is strongly associated with socio-economic factors as reflected by Medicaid funding and lack of insurance.