bluuebunny/crossref_metadata_2025 huggingface dataset:
Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches
Authors: Ramacciato Giovanni , Nigri Giuseppe R. , Petrucciani Niccolò , Di Santo Vincenzo , Piccoli Michaela , Buniva Paolo , Valabrega Stefano , D'Angelo Francesco , Aurello Paolo , Mercantini Paolo , Del Gaudio Massimo , Melotti Gianluigi
Published: June 2020

Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.
Cervical Spinal Cord Injury Associated with Near-Drowning Does Not Increase Pneumonia Risk or Mortality
Authors: Butler Thomas , Shin Susanna , Collins Jay , Britt Rebecca C. , Reed Scott F. , Weireter Leonard J. , Britt L. D.
Published: June 2020

Body surfing accidents (BSA) can cause cervical spinal cord injuries (CSCIs) that are associated with near-drowning (ND). The submersion injury from a ND can result in aspiration and predispose to pulmonary complications. We predicted a worse outcome (particularly the development of pneumonia) in patients with CSCIs associated with ND. A retrospective review was performed of patients who were treated at Eastern Virginia Medical School for a CSCI resulting from a blunt mechanism. Data collected included basic demographic data, data regarding injury and in-hospital outcomes, and discharge data, including discharge disposition. Statistics were performed using χ2 and Student t test. In 2003 to 2008, 141 patients were treated for CSCIs with inclusion criteria. Thirty patients (21%) had an associated ND (BSA) and 111 patients (79%) did not (BLT). The cohorts were similar in mean age (BSA, 45 years; BLT, 50 years; P = 0.16) and male gender distribution (BSA, 93%; BLT, 79%; P = 0.13). The cohorts were similar in injury severity using Injury Severity Score (BSA, 22; BLT, 24; P = 0.65). The cohorts were similar in rates of developing pneumonia (BSA, 3%; BLT, 12%; P = 0.31). The rate of infection was significantly higher in the cohort without an associated near-drowning (BSA, 10%; BLT, 32%; P = 0.033). The mean intensive care unit stay (BSA, 3.5 days; BLT, 11.3 days; P = 0.057) and the rate of mortality were similar (BSA, 10%; BLT, 10% P = 0.99). Those patients with an associated ND had a shorter hospital stay (BSA, 5.7 days; BLT, 22.2 days; P = 0.007) and a better chance of being discharged home (BSA, 57%; BLT, 27%; P = 0.004). CSCIs after a BSA do better than their counterparts without an associated ND. CSCIs associated with ND appear to be isolated injuries with minimal pulmonary involvement despite submersion injuries.
Combined Side-to-End Anastomosis with Temporary End Colostomy for the Management of Selected Left-Sided Colonic Emergencies
Authors: Safioleas Michael , Stamatakos Michael , Safioleas Panayoitis , Safioleas Konstantinos , Sakorafas George H.
Published: June 2020

Management of surgical emergencies of the left colon commonly requires excision of the colonic segment bearing the lesion, creation of an end colostomy, and closure of the rectosigmoid stump. Closure of the end stoma may be technically challenging. During this study, we used a new surgical technique involving the creation of an end-to-side anastomosis of the rectosigmoid stump to the base of the proximal colonic segment in association with an end colostomy. During a 15-year period, 23 patients were offered this type of surgery. Mortality was zero. Complications were observed in seven patients (morbidity, 7/23). Mean hospitalization time was 12.3 days. Closure of the colostomy was performed approximately 1 month after initial surgery and was easily performed using a mechanical stapler, either intraperitoneally or even extraperitoneally. No complications were observed after closure of the colostomy. The described technique is a useful alternative for the management of selected patients with left-sided colonic surgical emergencies. Its main advantage is that it greatly facilitates colostomy closure, which is performed earlier compared with the colostomy closure after a typical Hartmann's procedure.
Ultrasound Detection of Pneumothorax Compared with Chest X-Ray and Computed Tomography Scan
Authors: Nagarsheth Khanjan , Kurek Stanley
Published: June 2020

Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.
Minimally Invasive Parathyroid Surgery, The Norman 20% Rule: Is It Valid?
Authors: Quillo Amy R. , Bumpous Jeffery M. , Goldstein Richard E. , Fleming Muffin M. , Ccrp  , Flynn Michael B.
Published: June 2020

The 20 per cent rule proposed by Norman established a guideline using radioactivity in the minimally invasive radioguided parathyroidectomy (MIRP) technique to localize and confirm removal of an abnormal parathyroid gland in patients with primary hyperparathyroidism. If radioactivity in the resected gland was at least 20 per cent of excision site/background radioactivity, the 20 per cent rule was satisfied. Patients meeting these criteria underwent unilateral MIRP without intraoperative parathyroid hormone assay or intraoperative frozen section. The study aim was to independently evaluate the 20 per cent rule in MIRP patients with primary hyperparathyroidism. Using the University of Louisville Parathyroid Database from January 1, 1999 to December 31, 2007, 216 MIRP patients with complete radioguided and postoperative management data were identified. The average percentage of ex vivo parathyroid gland radioactivity compared with excision site/background radioactivity was 107 per cent with a range from 14 to 388 per cent. For 99 per cent (196/198) radioactivity recorded from the excised gland was at least 20 per cent of radioactivity recorded from the excision site. Normocalcemia was documented in 98.5 per cent (195/198) at 12 month follow-up. Our data supports the 20 per cent rule in that in 99 per cent of MIRP patients the resected gland radioactivity was at least 20 per cent of excision site radioactivity allowing localization and confirmation of an overactive gland without intraoperative parathyroid hormone monitoring or tissue analysis.
Article Commentary: Aberrant Hepatic Arterial Anatomy and the Whipple Procedure: Lessons Learned
Authors: Chamberlain Ronald S. , El-Sedfy Abraham , Rajkumar Dhiraj
Published: June 2020

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.
Benefits of Laparoscopy: Does the Disease Condition that Indicated Colectomy Matter?
Authors: De Campos-Lobato Luiz Felipe , Alves-Ferreira Patricia Cristina , Geisler Daniel P. , Kiran Ravi P.
Published: June 2020

The benefits of laparoscopic (LC) over open colectomy (OC) have been well characterized for a variety of conditions. Whether the relative benefits of LC differ for different conditions has not been previously investigated. The aim of this study was to identify whether there are differences in benefits of LC for colon cancer (CC), Crohn's disease (CD), and diverticular disease (DD). Data of patients with CC, CD, and DD undergoing elective colectomy from January 2000 to December 2007 were identified from departmental databases. Patients with CC, CD, and DD undergoing LC were matched 1:1 for diagnosis, gender, body mass index, surgical procedure, American Society of Anesthesiologists scale, and date of surgery to patients undergoing OC. TNM stage was also matched for patients with CC. Two hundred eighty-nine patients undergoing LC (CC, 93; CD, 140; DD, 56) were matched 1:1 to 289 patients undergoing OC. Median age was 49 years (range, 14 to 91 years) in LC and 52 years (range, 14 to 98 years) in OC ( P = 0.35). All other matched criteria were also similar in both groups. The conversion rate to OC was 13 per cent (n = 36). Patients undergoing LC had significantly shorter lengths of stay (LOS) (3 days [range, 1 to 70 days] vs 6 days [range, 1 to 37 days], P < 0.001) and lower estimated blood loss (EBL) (100 mL [range, 10 to 1750 mL] vs 200 mL [range, 10 to 1700 mL], P < 0.001). Median operative time was similar in both groups (LC: 145 minutes [range, 35 to 431 minutes] vs OC: 135 minutes [range, 23 to 485 minutes], P = 0.54). The conversion rate was lower for DD (2%) when compared with CC (18.9%) and CD (13.4%). Improvement in EBL with LC was least pronounced in patients with CD and most pronounced in patients with DD ( P interaction < 0.001). In the LC group, patients with DD presented less postoperative complications ( P = 0.009). LC results in reduced LOS and EBL with similar complications rates when compared with OC. The benefits of LC are more pronounced in DD when compared with CD and CC.
Seatbelt Triad: Severe Abdominal Wall Disruption, Hollow Viscus Injury, and Major Vascular Injury
Authors: Kulvatunyou Narong , Albrecht Roxie M. , Bender Jeffrey S. , Friese Randy S. , Joseph Bellal , Latifi Rifat , O'Keefe Terrance , Wynn Julie L. , Rhee Peter M.
Published: June 2020

The triad of seatbelt-related severe abdominal wall disruption, hollow viscus injury, and distal abdominal aortic injury after a motor vehicle collision is uncommon. We present a small case series involving those three clinical features with the goal of preventing a future missed diagnosis of the distal abdominal aortic injury in particular.
Feasibility of Pancreaticoduodenectomy in a Nonuniversity Tertiary Care Center: What Are the Key Elements of Success?
Authors: Khithani Amit , Christian Derick , Lowe Kevin , Saad A. Joe , Linder Jeffrey D. , Tarnasky Paul , Jeyarajah D. Rohan
Published: June 2020

It is advocated that a favorable outcome for pancreaticoduodenectomy (PD) is related to a high volume at university centers. This article examines the specific elements that allow an equivalent outcome from PD in a nonuniversity tertiary care center (NUTCC). The study was performed to: 1) evaluate the outcome of PDs done at a NUTCC; 2) study the components of the process that are required to attain success in a NUTCC; and 3) provide a new look at the volume-outcome relationships in complex surgeries in a novel nonuniversity setting. Medical records of patients who underwent PD by a single surgeon between September 2005 and August 2008 at a high-volume NUTCC were analyzed. The records were reviewed with respect to preoperative and postoperative data, 30-day mortality, morbidity, and histopathology data. A total of 122 patients underwent PD. The mean age was 68.2 years. Jaundice was the most common presenting symptom in 57 per cent (69 patients). Thirty-nine patients (32%) underwent a pylorus-preserving PD. The mean operative time was 237 minutes. The mean estimated blood loss was 480 mL. The mean length hospital stay was 13 days. Thirty-day mortality was 3.2 per cent (four patients) and overall morbidity was 49 per cent. The key factors in developing a team dedicated to the care of the patient undergoing PD are discussed. A center of excellence can be developed in a NUTCC resulting in outcomes that meet and indeed may exceed nationally reported benchmarks. The key elements to success include a team approach to the patient undergoing PD.
Clinicopathological Risk Factors for Recurrence within One Year after Initial Hepatectomy for Hepatocellular Carcinoma
Authors: Hayashi Michihiro , Shimizu Tetsunosuke , Hirokawa Fumitoshi , Inoue Yoshihiro , Komeda Koji , Asakuma Mitsuhiro , Miyamoto Yoshiharu , Takeshita Atsushi , Shibayama Yuro , Tanigawa Nobuhiko
Published: June 2020

Hepatocellular carcinoma (HCC) shows a high rate of recurrence after hepatectomy; predictive factors for early recurrence would help determine optimal therapeutic and management strategies. Among 163 patients with HCC undergoing hepatectomy with curative intent, 46 patients developed recurrence within 1 year. Clinicopathological data were retrospectively analyzed to identify predictive parameters for early recurrence. Survival rates in cases of recurrence within 1 year were worse than those of no recurrence within 1 year or recurrence after 1 year. Protein induced by vitamin K absence/antagonist II (PIVKA-II) greater than 150, positive fucosylated alpha-fetoprotein (L3-AFP), and deviancy from Milan criteria (MC) on preoperative imaging were associated with high risk of early recurrence and total number of these three risk factors predicted the survival. With multivariate analysis, 1) preoperatively, positive factors of two or more among three items of PIVKA-II, L3-AFP, and deviancy from MC; 2) and postoperatively, pathological cancer spread (microscopic vascular invasion and/or intrahepatic metastasis) both represented risks for early recurrence. A combination of three preoperative factors, PIVKA-II, L3-AFP, and MC status, in conjunction with the postoperative factor of cancer spread status represents a significant indicator for recurrence within 1 year. Improving the prognosis of patients with HCC would depend on how to adequately treat those at high risk of early recurrence.
Laparoscopic Approach to Adrenalectomy: Review of Perioperative Outcomes in a Single Center
Authors: Nguyen Phuong H. , Keller Jennifer E. , Novitsky Yuri W. , Heniford B. Todd , Kercher Kent W.
Published: June 2020

Laparoscopic expertise increases the volume of adrenalectomies at referral centers. We report our 10-year experience with laparoscopic adrenalectomy. All laparoscopic adrenalectomies at a single institution were prospectively recorded in a surgical outcomes database. Patient demographics, operative/perioperative outcomes, and adrenal pathology were reviewed retrospectively. From March 1999 through July 2009, 154 laparoscopic adrenalectomies were performed in 150 patients. Average patient age was 49.9 years (range 15-82); mean body mass index was 31.1 kg/m2 (range 17-56). Pathologic diagnoses included hyperaldosteronism (n = 69), nonfunctional adenoma (n = 28), pheochromocytoma (n = 23), hypercortisolism (n = 14), malignancy (primary n = 3, metastasis n = 9), and cyst (n = 4). Seventy-three per cent (n = 110) occurred on the left, 23 per cent (n = 35) on the right, 2.6 per cent (n = 4) bilateral, and 0.6 per cent (n = 1) as extra-adrenal. The average tumor measured 3.6 cm (range 0.4-12). The average operative time was 156 minutes (range 62-409), the mean estimated blood loss was 60 mL (range 10–100), and mean American Society of Anesthesiologists score was 2.6 (range 1-4). Three operations (0.2%) were converted to open. Three patients (0.2%) experienced perioperative complications (respiratory failure, urinary tract infection, line sepsis, and readmission within 30 days). The average length of stay was 3.4 days (range 1–14) and mean follow-up was 96.9 days (5-2567). No wound-related complications or deaths occurred. Pathologic diagnosis was not associated with a particular side or development of a complication ( P > 0.5). Patients with pheochromocytomas had the longest operative times, highest estimated blood loss, and highest American Society of Anesthesiologists scores (218.2 minutes, 128 mL, 3.0; P < 0.004). Laparoscopic adrenalectomy is safe and effective. Removal of pheochromocytomas is more challenging and may be more appropriate for referral to a specialized center for optimal outcomes.
Lymph Nodes Ratio Is Associated with the Survival of Colorectal Cancer Patients with Peritoneal Carcinomatosis
Authors: Matsuda Kenji , Hotta Tsukasa , Takifuji Katsunari , Kobayashi Yasuhito , Tsuji Takeshi , Nagai Yugo , Horiuchi Tetsuya , Yamaue Hiroki
Published: June 2020

The purpose of this study was to clarify the prognostic factors in patients with peritoneal carcinomatosis from colorectal origin, especially focusing on lymph node status. Between 1998 and 2007, 126 patients who underwent surgical treatment for primary colorectal cancer with peritoneal carcinomatosis were retrospectively assessed concerning prognostic factors. To estimate survival, we formulated a scoring system by numbers of independent poor prognostic factors. According to a multivariate analysis, extent of peritoneal carcinomatosis (hazard ratio, 1.93; 95% confidence interval, 1.19-3.13; P = 0.008) and lymph node ratio (hazard ratio, 1.87; 95% confidence interval, 1.05-3.33; P = 0.034) were found to be independent poor prognostic factors for survival. Furthermore, we demonstrated that score formulated by the number of these criteria was highly predictive of survival ( P < 0.001). The 5-year survival rate for patients with score 0 (having no criteria), score 1 (having one criterion), and score 2 (having two criteria) were 25.1 per cent, 6.2 per cent, and 0 per cent, respectively. Lymph node ratio is an important prognostic factor in addition to the extent of peritoneal carcinomatosis after resection of primary colorectal carcinoma. Patients without these criteria have a favorable outcome, and therefore should be considered for further aggressive surgery and intraperitoneal chemotherapy.
Incidence, Risk Factors, and Outcomes for Atrial Arrhythmias in Trauma Patients
Authors: Hadjizacharia Pantelis , O'Keeffe Terence , Brown Carlos V.R. , Inaba Kenji , Salim Ali , Chan Linda S. , Demetriades Demetrios , Rhee Peter
Published: June 2020

The purpose of this study is to determine the incidence, risk factors, and outcomes after the development of an atrial arrhythmia (AA) in trauma patients admitted to the Intensive Care Unit (ICU). We performed a retrospective study of more than 7 years of trauma patients admitted to the ICU at an urban, academic Level I trauma center. Patients with AA, defined as atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia, were compared with patients without AA. Groups were compared by univariate and multivariate analysis. Three thousand, four hundred and ninety-nine trauma patients were admitted to the ICU during the study period and 210 (6%) developed an AA. AA patients were more likely to sustain blunt trauma, were older, more often female, more severely injured, and sustained more head injuries. The only independent risk factor for developing an AA was age > 55 years (odds ratio = 4.6, P < 0.01). Mortality was higher in the AA group (33% vs 14%, P < 0.01) and AA was an independent risk factor for mortality (odds ratio = 1.7, P = 0.01). Twenty-eight per cent (n = 59) of AA patients received beta-blockers in the postinjury period, and these patients had lower mortality (22% vs 37%, P = 0.04). AA occurs in 6 per cent of trauma patients admitted to the ICU. Developing an AA is an independent risk factor for mortality after trauma. Beta-blocker therapy was associated with decreased mortality in trauma patients with AA.
Thoracic Surgery in Octogenarians CVTSA/Inova Fairfax Hospital Experience, 1990 to 2009
Authors: Kiernan Paul D. , Khandhar Sandeep J. , Fortes Daniel L. C. , Schmidt Keilla , Sheridan Michael J. , Hetrick Vivian
Published: June 2020

With an increasing proportion of U.S. individuals 80 years of age or older, the authors examined their surgical experience with octogenarians undergoing major, curative-intent thoracic surgery. Between January 1, 1990, and September 1, 2009, 102 octogenarians underwent curative-intent resection for nonsmall cell carcinoma of the lung (NSCCL), esophageal carcinoma (EC), or related surgery for thoracic esophageal perforation (EP). Analysis and reporting followed the guidelines of the Nationwide Inpatient Sample database study (1994 to 2003). Eighty-six patients underwent curative-intent resection for NSCCL, 12 for EC, and four for surgery for EP. Hospital and 30-day mortalities were 0 per cent. Overall 1-, 2-, and 5-year survival rates were: 78, 58, and 32 per cent. Within the NSCCL cohort, minimally invasive exposures (video-assisted thoracic surgery [VATS] and video thoracoscopy [VT]) were associated with fewer and shorter duration of air leaks, leading to shorter length of stay. Since we began using minimally invasive exposure for NSCCL in 2007, the percentage of octogenarians discharged within 5 days of surgery has increased from 35.5 to 66.7 per cent ( P = 0.01), and the percentage of patients discharged within 3 days of surgery has increased from 8.1 to 33.3 per cent ( P = 0.006). Of 24 patients undergoing surgery for NSCCL since 2007, 18 (75%) underwent minimally invasive (VATS or VT) exposures, of which 15 patients (83.3%) were discharged home within 5 days and eight (44.4%) within 3 days of their procedure. Excellent, short- and longer-term results can be achieved in elderly patients if risks, exposures, and resections are appropriately matched to patient performance.
Management of Full-Thickness Duodenal Laceration in the Damage Control Era: Evolution to Primary Repair Without Diversion or Decompression
Authors: Mayberry John , Fabricant Loic , Anton Amy , Ham Bruce , Schreiber Martin , Mullins Richard
Published: June 2020

The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications (DRC). We conducted a retrospective review of all patients with full-thickness DL surviving more than 72 hours in the years 1989 to 2009. Forty-one patients with a median duodenal organ injury scale of 3 and a mean abdominal trauma index (ATI) of 45 ± 24 underwent laparotomy. Twenty-five patients (61%) were treated with DC and 16 (39%) with fascial closure (FC). Although the ATI of the patients treated with DC was greater than the ATI of the patients treated with FC (56 ± 23 vs 28 ± 17, P < 0.001), DRCs were equivalent (two vs three, nonsignificant). Twenty-one patients were treated in the first decade and 20 in the second decade. Between the first and second decades, there were trends toward an increased use of DC (52 to 70%, nonsignificant) and a decreased use of DDE (52 to 35%, nonsignificant) with a significant reduction in DRC (5 vs 0, P = 0.04). Among the 18 patients (44%) who underwent DDE procedures there were 2 DRCs (11%) related to DDE. Among the 23 patients who did not have DDE, there were three DRCs (13%), including two obstructions, one partial and one complete. When DC is used after DL, DDE may be unnecessary. Diversion is recommended, however, when the duodenum is at risk for obstruction after primary repair.
Early-Onset Coronary Artery Disease after Pediatric Kidney Transplantation: Implicating the Angiogenesis Inhibitor, Endostatin
Authors: Iqbal Corey W. , Dean Patrick G. , Ishitani Michael B.
Published: June 2020

Pediatric kidney transplant recipients have a higher rate of coronary artery disease (CAD) as adults. The angiogenesis inhibitor, endostatin, has been implicated in the development of atherosclerosis. Endostatin levels will vary between adult patients who received a kidney transplant as a child. We conducted a study in young adult patients who had undergone pediatric kidney (n = 12) or liver transplantation (n = 8). Coronary arterial calcification was measured using electron beam CT. Values were compared with age-matched control subjects from an epidemiologic database. Serum endostatin levels were measured using enzyme-linked immunosorbent assay. Risk factors for atherosclerosis were assessed. Kidney transplant recipients had a higher rate of CAD compared with liver transplant recipients (33 vs 0%, P = 0.03). Mean (± standard error of mean) serum endostatin levels were higher in kidney transplant recipients compared with liver transplant recipients (26 ± 7 vs 14 ± 3 ng/mL, P = 0.04) and control subjects (26 ± 7 vs 11 ± 1 ng/ mL, P = 0.01). Pediatric kidney transplantation is associated with a higher rate of adult-onset CAD compared with liver transplantation. Endostatin levels were greater in kidney transplant recipients compared with liver transplant recipients and healthy control subjects. Endostatin may play a role in the development of atherosclerosis after kidney transplantation and may serve as a biomarker for atherosclerotic disease.
Breath Analysis by Mass Spectrometry: A New Tool for Breast Cancer Detection?
Authors: Patterson Sharla Gayle , Bayer Charlene W. , Hendry Robert J. , Sellers Nancy , Lee Kichun Sky , Vidakovic Brani , Mizaikoff Boris , Gabram-Mendola Sheryl G.A.
Published: June 2020

Breath analysis has received attention as a noninvasive diagnostic tool with increasing research into its potential usefulness. We are investigating the utility of the analysis of breath volatile organic compounds (VOCs) as an effective modality for breast cancer (BC) detection and monitoring by collecting breath samples with a simple portable device to determine whether BC patients have breath VOCs distinct from those in healthy volunteers. We prospectively enrolled 20 healthy volunteers and 20 newly diagnosed stage II-IV BC patients. The study subjects deeply exhaled into a commercially available Teflon/valved breath sampler equipped with a rapid passive diffusive sampler five times at 5-minute intervals trapping alveolar breath VOCs. The exhaled breath samples were analyzed by thermal desorption/gas chromatography/mass spectrometry monitoring 383 VOCs in the breath of both populations. Our results indicate that aggregate low-dimensional summaries and compound quantities result in specific patterns that can confirm BC. We found a definite clustering of the presence of BC from cancer-free points. Overall sensitivity was 72 per cent and specificity was 64 per cent resulting in a correct classification rate of approximately 77 per cent. Our data show promising evidence that BC patients can be differentiated from healthy volunteers through distinct breath VOCs.
An Alternative Technique for Immediate Breast Reconstruction
Authors: Komenaka Ian K. , Maffi Terry R. , Davis Karole M. , Klemens Anne E. , Bouton Marcia E. , Pennington Robert E.
Published: June 2020

Immediate reconstruction has demonstrated superior cosmesis compared with delayed reconstruction, however, unexpected final pathology may necessitate post mastectomy radiation. We describe an alternative technique for immediate breast reconstruction. Twelve patients underwent 14 skin-sparing mastectomies from July 2006 to December 2009. The skin-sparing mastectomies and sentinel node biopsies were performed through a periareolar incision. At the completion of the operation the incision was closed in a transverse fashion. No simultaneous reconstruction was performed. No drains were placed. After 3 days seroma developed, which maintained the integrity of the skin envelope and appearance of a breast. Nine patients (75%) had a contraindication to breast conservation. All patients were clinically node negative and 67 per cent were clinical stage 0. The majority (75%) experienced an adverse change from clinical stage to final pathologic stage. Four patients (33%) required postmastectomy radiation. The mean time from oncologic procedure to initial reconstruction procedure was 14 days. Two patients (17%) developed postoperative infections. This technique allows immediate reconstruction and avoids the fear of adverse final pathology indicating radiation to the reconstructed breast. In addition, it provides flexibility in scheduling for the surgeons and allows the patient to maintain the appearance of the breast.
Transanal Endoscopic Microsurgery for T1 and T2 Rectal Cancers: A Meta–Analysis and Meta-Regression Analysis of Outcomes
Authors: Sgourakis George , Lanitis Sophocles , Gockel Ines , Kontovounisios Christos , Karaliotas Charilaos , Tsiftsi Katerina , Tsiamis Achilleas , Karaliotas Constantine C.
Published: June 2020

The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24,95% confidence interval (CI) 0.07–0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection (SR) group compared with TEM (OR = 0.46, 95% CI 0.24-0.88). The number of patients with positive margins were less in the SR group (OR = 6.49, 95% CI 1.49-24.91), which was associated with lower local recurrence (OR = 4.92,95% CI 1.81-13.41) and overall recurrence rate (OR = 2.03, 95% CI 1.15-3.57). No survival advantage was observed in favor of either procedure. TEM had lower rate of positive margins and longer disease-free survival when compared with transanal excision (TAE). TEM seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence. No survival advantage was observed in favor of either procedure. Unfavorable tumor preoperative histology does not seem to influence the selection between TEM and SR. TEM is more effective than TAE in obtaining negative surgical margins and shows a greater disease-free survival.
General Surgery at Rural Tennessee Hospitals: A Survey of Rural Tennessee Hospital Administrators
Authors: Cofer Joseph B. , Petros Tommy J. , Burkholder Hans C. , Clarke P. Chris
Published: June 2020

Rural communities face an impending surgical workforce crisis. The purpose of this study is to describe perceptions of rural Tennessee hospital administrators regarding the importance of surgical services to their hospitals. In collaboration with the Tennessee Hospital Association, we developed and administered a 13-item survey based on a recently published national survey to 80 rural Tennessee hospitals in August 2008. A total of 29 responses were received for an overall 36.3 per cent response rate. Over 44 per cent of rural surgeons were older than 50 years of age, and 27.6 per cent of hospitals reported they would lose at least one surgeon in the next 2 years. The responding hospitals reported losing 10.4 per cent of their surgical workforce in the preceding 2 years. Over 53 per cent were actively recruiting a general surgeon with an average time to recruit a surgeon of 11.8 months. Ninety-seven per cent stated that having a surgical program was very important to their financial viability with the mean and median reported revenue generated by a single general surgeon being $1.8 million and $1.4 million, respectively. Almost 11 per cent of the hospitals stated they would have to close if they lost surgical services. Although rural Tennessee hospitals face similar difficulties to national rural hospitals with regard to retaining and hiring surgeons, slightly more Tennessee hospitals (54 vs 36%) were actively attempting to recruit a general surgeon. The shortage of general surgeons is a threat to the accessibility of comprehensive hospital-based care for rural Tennesseans.
Appendicitis, Is it an Emergency?
Authors: Udgiri Navalkishor , Curras Ernesto , Kella Venkata K. , Nagpal Kamal , Cosgrove John
Published: June 2020

Prompt appendectomy has always been a standard of care because of the risk of progression in pathology. This time honored practice has been recently challenged by studies, suggesting that appendicitis can be operated on electively. The aim of this study is to examine whether delayed intervention in acute appendicitis is safe by correlating the interval from presentation to operation with the operative and postoperative complications. Retrospective review of patients who underwent appendectomy for acute appendicitis in 2009 was done. The following parameters were recorded: demographics, duration from presentation to evaluation by emergency room attending, performing CT scan, surgical consult, and operation. The pathology, post operative complications, and length of stay were also recorded. Patients were divided into two groups: incision time < 10 hours (early group) and incision time > 10 hours (delayed group). The end points chosen for comparison were: 1) laparoscopic to open conversion rate, 2) complications, 3) readmissions, and 4) length of stay. Number of cases totaled 201, with 76 in the < 10 hours group and 125 in the > 10 hours group. The male to female ratio for the < 10 hours group was 54:22 and for the > 10 hours group was 59:66 ( P < 0.001). Length of stay for the early group was 75.52 hours and for the delayed group, 89.15 hours ( P = 0.04). There was one intra-abdominal abscess in the early group and 10 in the delayed group ( P = 0.04). The early group had 0.2 (2.6%) open conversions, and the delayed group had five (4.1%) conversions ( P = 0.58). There were six (4.8%) readmissions in the delayed group and none in the early group ( P = 0.05). Our study reveals that the complication rate, length of stay, and readmissions are more in the delayed group. Conversion rate was more in the delayed group, but the difference was not significant. We conclude that early surgical intervention is beneficial in acute appendicitis.
Surgical Skin Markers Impair Human Saphenous Vein Graft Smooth Muscle and Endothelial Function
Authors: Eagle Susan , Brophy Colleen M. , Komalavilas Padmini , Hocking Kyle , Putumbaka Gowthami , Osgood Michael , Sexton Kevin , Leacche Marzia , Cheung-Flynn Joyce
Published: June 2020

Marking human saphenous vein graft (HSV) with a surgical skin marker to prevent twisting on implantation is a common practice in peripheral and coronary artery bypass procedures. This study is designed to examine the effects of surgical skin markers on the HSV smooth muscle and endothelial functional responses. De-identified HSV remnants were collected during peripheral and coronary artery bypass procedures. Physiologic responses of the HSV were measured using a muscle bath. Veins that were marked with surgical skin markers intraoperatively generated significantly less contractile force to depolarizing KC1 (110 mM) and receptor-mediated contractile agonists than unmarked HSV, suggesting that surgical skin markers impaired HSV smooth muscle contractility. To directly access the effects of chemical components in the surgical skin markers, unmarked HSV was exposed to isopropyl alcohol (a solvent commonly used in surgical skin markers) or methylene blue (a dye). Smooth muscle contractility was significantly reduced by isopropyl alcohol and methylene blue. Endothelial-dependent relaxation to carbachol was significantly reduced after exposure to surgical skin markers. Our data demonstrated that marking HSV with surgical skin markers reduces smooth muscle and endothelial functional viability.
Incisionless Laparoscopic Total Proctocolectomy with Ileal J-Pouch Anal Anastomosis
Authors: Abarca Francisco , Cologne Kyle G. , Francescatti Amanda , Brand Marc I. , Saclarides Theodore J.
Published: June 2020

Minimally invasive surgery continues to evolve. Recent innovations have included single-incision access, robotic technology, and natural orifice dissection and/or specimen extraction. Many argue that there is minimal patient benefit to these advanced techniques. We report 39 patients undergoing laparoscopic ileal J-pouch anal anastomosis surgery, 17 of whom did not have a separate specimen extraction incision (Group 1). The specimen for this group was extracted through the circular incision made for the ileostomy; the pouch was constructed extracorporeally and returned to the abdomen through the stoma site. For the remaining 22 patients, a suprapubic Pfannenstiel incision was made (Group 2). No hand-assistance was used for either group. Group 1 showed a 45-minute reduction in operative time, a 1-day reduction in hospital stay, and a reduction in complications. Although these differences are modest, it shows that minimally invasive surgery is an evolving process. Small modifications may translate into significant advantages.
Predictors and Outcomes of Prolonged Ventilation after Coronary Artery Bypass Graft Surgery
Authors: Christian Kevin , Engel Amy M. , Smith J. Michael
Published: June 2020

This study investigated and compared the risk factors and outcomes of patients undergoing coronary artery bypass graft surgery with and without the occurrence of prolonged mechanical ventilation. Data in a cardiac surgery database were examined retrospectively. Data selected included any isolated coronary artery bypass graft surgery performed by the surgical group from August 2005 to June 2009. The resulting cohort included a total of 2933 patients which was comprised of 116 patients with a ventilation time of greater than 72 hours (prolonged ventilation) and 2817 patients with a ventilation time of 72 hours or less (no prolonged ventilation). Patients with a prolonged ventilation time were matched (1:3 ratio) to patients not requiring a prolonged ventilation time by year of surgery resulting in our study cohort of 464 patients. To generate the unadjusted risks of each factor, χ2 and t test analysis were performed. Logistic regression analysis was then used to investigate the adjusted risk between cases and controls and each of the significant variables. χ2 and t tests were conducted comparing cases and controls with the outcome variables. Patients undergoing coronary artery bypass graft that experienced a prolonged ventilation time (cases) were more likely female, had a New York Hospital Association functional class of III or IV, and had a longer perfusion time. There was no significant difference between cases and controls with diabetes, chronic obstructive pulmonary disease, left ventricular ejection fraction, or body mass index while controlling for all significant risk factors. Careful patient selection and preparation during preoperative evaluation may help identify patients at risk for prolonged mechanical ventilation and thus help prevent the added morbidity and mortality associated with it.
Regression Does Not Predict Nodal Metastasis or Survival in Patients with Cutaneous Melanoma
Authors: Burton Alison L. , Gilbert Juliana , Farmer Russell W. , Stromberg Arnold J. , Hagendoorn Lee , Ross Merrick I. , Martin Robert C. G. , Mcmasters Kelly M. , Scoggins Charles R. , Callender Glenda G.
Published: June 2020

Controversy exists regarding the prognostic implications of regression in patients with cutaneous melanoma. Some consider regression to be an indication for sentinel lymph node (SLN) biopsy because regression may result in underestimation of the true Breslow thickness. Other data support regression as a favorable prognostic indicator, representing immune system recognition of the primary tumor. This analysis was performed to determine whether regression predicts nodal metastasis, disease-free survival (DFS), or overall survival (OS). Post hoc analysis was performed of a multicenter prospective randomized trial that included patients aged 18 to 70 years with cutaneous melanomas 1 mm or greater Breslow thickness. All patients underwent SLN biopsy; those with tumor-positive SLN underwent completion lymphadenectomy. Kaplan-Meier analysis of survival, univariate analysis, and multivariate analysis were performed. A total of 2220 patients (261 with regression; 1959 without regression) were included in this analysis with a median follow-up of 68 months. Patients with regression were more likely to be male, older than 50 years old, and have lower median Breslow thickness, superficial spreading histologic subtype, and a non-extremity anatomic location ( P < 0.05 in all cases). Regression was not significantly associated with Clark level, ulceration, lymphovascular invasion, number of SLNs removed, or SLN metastasis. On multivariate analysis, factors independently predictive of DFS included Breslow thickness, ulceration, and SLN status ( P < 0.05 in all cases); the same factors along with age, gender, and anatomic tumor location were significantly associated with OS ( P < 0.05 in all cases). Regression was not significantly associated with DFS (risk ratio [RR], 0.94; 95% confidence interval [CI], 0.67-1.27; P = 0.68) or OS (RR, 1.01; 95% CI, 0.76-1.32; P = 0.93). These data suggest that regression is not a significant prognostic factor for patients with cutaneous melanoma and should not be used to guide clinical decision-making for such patients.
Blunt Breast Trauma: Is There a Standard of Care?
Authors: Sanders Christopher , Cipolla James , Stehly Christy , Hoey Brian
Published: June 2020

The incidence of female blunt breast trauma (FBBT) is unknown, and there are no established treatment guidelines. The purpose of this study was to establish the incidence of FBBT, define associated injuries, and develop a treatment algorithm. This is a retrospective analysis of FBBT at a Level I trauma center from October 2000 through December 2008. The incidence, mechanism, and severity of injury, associated injuries, therapeutic interventions, and clinical outcomes were evaluated. A total of 14,499 patients were evaluated. Of these, 13,637 were blunt trauma victims and 5,305 were female blunt trauma victims. One hundred and eight (2%) were diagnosed with FBBT. Although the average injury severity score (ISS) was 12.3 for all FBBT patients, 60 per cent of patients had an ISS > 15. Ninety-four per cent were caused by motor vehicle crashes, with the most common injuries being long bone fractures (45%) and rib fractures (44%). One hundred and one (93.5%) of the injuries were simple hematomas managed expectantly; seven patients (6.5%) had expanding hematomas with radiological evidence of active bleeding that ultimately required invasive procedures, with six of them undergoing arteriogram and four successfully embolized. One patient was taken directly to the operating room for surgical ligation of a bleeding vessel. These data represent the largest series of breast injuries ever reported. Because FBBT is a marker for severe associated injuries, our treatment algorithm recommends that women with radiological evidence of active bleeding who are hemodynamically stable be evaluated with a chest arteriogram plus or minus embolization. However, unstable patients with no other source of hemorrhage should undergo definitive urgent operative repair. All other patients should be managed expectantly.
Dynamic Ultrasound and Treadling: Novel Approaches to Assess and Improve Lower Extremity Circulation
Authors: Hope William W. , Griner Devan , Weatherford David , Clancy Thomas V. , Currie Laura L. , Hundley James D.
Published: June 2020

The purpose of this study was to evaluate the safety and efficacy of a novel treatment of peripheral vascular disease through treadling and to report a dynamic vascular ultrasound technique. After informed consent, 17 volunteers were enrolled in the study. Ultrasound was used to measure venous and arterial waveforms at the superficial femoral artery and vein in the subject's right thigh during a 5-minute baseline evaluation (resting), a 10-minute treadling period, and a 5-minute cool down period. Comparisons between flow velocities were made during the three trial periods using a Repeated Measures Mixed Linear Model test with P < 0.05 considered significant. Twenty-six examinations were performed on subjects with an average age of 37 years (range, 25-75 years). Significant increases in maximum and minimum arterial and venous flow velocities during the treadling time compared with the resting and cool down period were observed ( P < 0.0001) with no change in the subjects’ vital signs. We found no significant difference in maximum and minimum arterial and venous flow velocities between the resting and cool down period ( P > 0.05). There were no untoward side effects, and all subjects were able to complete the protocol. Low-resistance treadling is safe and improves venous and arterial flow. Dynamic peripheral ultrasonography is a viable technique to assess flow during treadling. Potential future implications of this study include the evaluation, treatment, and management of lower extremity vascular and chronic diseases and more sensitive peripheral vascular sonography through dynamic ultrasound.