bluuebunny/crossref_metadata_2025 huggingface dataset:
Ileal Intussusception Due to Intestinal Metastases from Primary Malignant Melanoma of the Lung
Authors: Testini Mario , Trabucco Senia , Divenere Beatrice , Piscitelli Domenico
Published: November 2022

Primary malignant melanoma of the lung (PMML) is an uncommon tumor with very few cases reported in the literature that satisfy the required criteria to establish a primary bronchial origin. We report a case of a 44-year-old man with acute abdominal distress and a right pulmonary roentgenographic opacity. A cranial-thoracic-abdominal CT scan confirmed the presence of a pulmonary nodule with bilateral cerebral metastases and marked dilatation of intestinal loops. At laparotomy an ileal intussusception was noted and an ileal resection was done. The resected intestinal segment contained three endoluminal polypoidal formations. Histological and immunohistochemical analyses showed the presence of multiple sites of melanoma. These lesions as well as the brain lesions clearly appeared metastatic. The patient underwent further evaluation to identify a primary site of melanoma; bronchoscopy was performed with biopsy of the pulmonary nodule. Pathology revealed a neoplastic process of fusiform cells, with focal presence of melanic inter- and extracellular pigment. The immunohistochemical analysis confirmed the diagnosis of PMML. We discuss the criteria for diagnosis and histogenesis of PMML along with this unusual presentation.
Chronic Acalculous Biliary Disease: Cholecystokinin Cholescintigraphy is Useful in Formulating Treatment Strategy and Predicting Success after Cholecystectomy
Authors: Poynter Mark T. , Saba Alexander K. , Evans Richard A. , Johnson W. Michael , Hasl David M.
Published: November 2022

Patients with symptoms consistent with biliary colic who do not demonstrate calculi on routine sonography present a diagnostic dilemma for clinicians. For those patients in whom other disease entities have been excluded and in whom the history and physical examination exemplify classic signs and symptoms of biliary disease we show in this study that cholecystokinin cholescintigraphy with calculation of gallbladder ejection fraction is a predictor of pathology as well as subsequent symptom relief after cholecystectomy. The spectrum of pathology that makes up chronic acalculous biliary disease lacks a distinct definition, yet this review shows that cholecystokinin cholescintigraphy offers the surgeon the means to better counsel his or her patient with regard to surgical indications, options, and benefits. We reviewed 26 patients who had no gallstones detectable, had gallbladder ejection fraction <35 per cent, and were status postlaparoscopic cholecystectomy for suspected chronic acalculous biliary disease. Our results show histopathologic evidence of chronic cholecystitis in 100 per cent, and 92 per cent of the patients had improvement of symptoms and satisfaction with the operation to the point that they would undergo the surgery again without reservation.
The Influence of Gender of the Surgeon on Surgical Procedure Preference for Breast Cancer
Authors: Weinberg Elizabeth , Woods Scott , Grannan Kevin , Hendy Mary Pat
Published: November 2022

There are few data in the literature with regard to the influence of surgeon gender and the treatment of breast cancer. In this retrospective review we propose to test the hypothesis that male surgeons are just as likely as female surgeons to provide breast-conservative treatment. From 1990 through 1997 2271 women with breast cancer in Cincinnati, Ohio were operated on by surgeons within the TriHealth Corporation. We compared the performance rate of breast conservation therapy (BCT) with the rate of mastectomy in early-stage breast cancer patients between male and female surgeons. Male surgeons were significantly more likely to provide their patients with breast-conserving treatment than their female colleagues for stages 0 and IIb ( P < 0.05). Although male surgeons performed more BCT than female surgeons for stages I and IIa the difference was not statistically significant. For the three stages combined there was a 30 per cent greater chance of a patient receiving breast-conserving treatment if she went to a male surgeon ( P < 0.05). We conclude that in our institution male surgeons are no more likely to select mastectomy than their female colleagues and there appears to be an increased use of BCT by male surgeons.
Massive Ventral Hernias: Role of Tissue Expansion in Abdominal Wall Restoration following Abdominal Compartment Syndrome
Authors: Admire Anthony A. , Dolich Matthew O. , Sisley Amy C. , Samimi Kian J.
Published: November 2022

Massive ventral hernias may result from a variety of clinical situations. One such clinical situation, a common problem in trauma patients, is abdominal compartment syndrome. Abdominal compartment syndrome frequently results in a massive abdominal defect when primary closure after surgical decompression is not possible. We offer a technique for repairing these massive ventral hernias by first expanding the lateral abdominal wall muscles, fasciae, and skin with tissue expanders and then closing the defect with elements of the “components separation” method. Additionally we present other clinical situations resulting in a massive ventral hernia that were repaired using this technique.
Small Watercraft Injuries in Children
Authors: Beierle Elizabeth A. , Chen Mike K. , Langham Max R. , Kays David W. , Talbert James L.
Published: November 2022

The speed and use of small watercraft have increased dramatically in recent years. We report our experience with pediatric trauma resulting from small watercraft accidents. We conducted a retrospective chart review including all children admitted with injuries sustained in small watercraft accidents. Sixteen children were included; nine were injured in jet ski accidents and seven in accidents involving other craft. Jet ski accidents tended to result in more serious injuries (closed-head injuries, hollow and solid viscus injuries, chest trauma, spinal injuries leading to paralysis, and death) than those sustained in accidents with small boats. Skin and soft-tissue injuries and long-bone fractures were the most frequent injuries following accidents with other small boats. Six of eight children (75%) injured on jet skis required operative interventions. Only three of seven (43%) children in other watercraft accidents required surgery ( P < 0.05 jet ski vs other watercraft). When compared with children injured in accidents involving small boats those involved in jet ski accidents tended to have more serious injuries and require operative intervention more frequently. A high index of suspicion for serious injuries must be maintained when evaluating children with this mechanism of injury.
Blood Transfusions Correlate with Infections in Trauma Patients in a Dose-Dependent Manner
Authors: Claridge Jeffrey A. , Sawyer Robert G. , Schulman Andrew M. , Mclemore Elizabeth C. , Young Jeffrey S.
Published: November 2022

Infections are a common and significant sequela of major traumatic injury. The objective of this study was to evaluate the relationship between infections in trauma patients and the transfusion of packed red blood cells (pRBCs) within the first 48 hours of admission. We hypothesized that transfusions of pRBCs were associated with an increased risk of infection in a dose-dependent manner. All adult patients admitted to the trauma service of a Level I trauma center from November 1996 to December 1999 were studied. Secondary analysis was performed on prospectively collected data. One thousand five hundred ninety-three consecutive patients were studied; of these 12.6 per cent developed at least one infection. The overall transfusion rate was 19.4 per cent. The infection rate in patients who received at least one transfusion was significantly higher ( P < 0.0001) at 33.0 versus 7.6 per cent in patients receiving no pRBCs. Transfusions per patient ranged from 0 to 46 units. There was a clear exponential correlation in patients receiving between 0 and 15 transfusions (R 2 = 0.757). Multivariate logistic regression, which was used to identify risk factors for the development of infection, demonstrated the odds ratio of receiving pRBCs to be 1.084, with a 95 per cent confidence interval of 1.028 to 1.142 ( P = 0.0028). In summary there is a clear dose-dependent correlation between transfusions of pRBCs and the development of infection in trauma patients. Multivariate analysis further demonstrated that pRBCs were an independent risk factor for the development of infections. Although transfusions are frequently indicated, they should be administered appropriately and with no more pRBCs than absolutely necessary.
Leg Revascularization in Patients with Calciphylaxis
Authors: Friedman Steven G.
Published: November 2022

Calciphylaxis is a rare complication in patients undergoing hemodialysis. The pathogenesis and risk factors for this disease are poorly understood, although an association with secondary hyperparathyroidism has been suggested. Only two cases of lower-extremity revascularization of patients with calciphylaxis appear in the literature; this report adds two more.
A New Perspective in Appendicitis: Calculation of Half Time (T1/2) for Perforation
Authors: Redmond J. Mark , Smith Gardner W. , Wilasrusmee Chumpon , Kittur Dilip S.
Published: November 2022

Appendicitis is generally a more serious disease in the elderly than in the young. In the former, perforation is seen commonly leading to the belief that the appendix perforates more readily and rapidly in the elderly. A competing view is that the appendix perforates relatively more frequently in the elderly than in the young. To distinguish between these two views we analyzed 126 cases of acute appendicitis stratified by age group. The time between onset of symptoms and perforation was calculated with a novel method that utilized the biological concept of T1/2 for perforation. Our findings suggest that the rate of perforation in the elderly is not significantly different from that in the young but the frequency of perforation is higher in the elderly. We concluded that appendicitis carries a graver prognosis in the elderly because the frequency of appendiceal perforation is higher in the elderly.
Recurrent Ischemia in a Young Man with the Antiphospholipid Syndrome
Authors: Best Irwin M. , Vansandani Geetanjali , Rust George , Bumpers Harvey L.
Published: November 2022

Recurrent thromboses, cerebral disease, miscarriages, and antiphospholipid antibodies are characteristic of the antiphospholipid syndrome. A 31-year-old man presented with limb ischemic and isolated right ventricular failure. Antiphospholipid syndrome was suspected and limb salvage was accomplished by anticoagulation and tibial- to-plantar artery bypass surgery. However, recurrent ischemic episodes were successfully treated with thrombolytic therapy and anticoagulants. The surgeon should be aware that patients with antiphospholipid antibodies and lupus anticoagulant antibodies have a high propensity for recurrent arterial thromboses and should use multiple therapeutic approaches to effect successful long-term limb salvage.
Assessment of Initial Base Deficit as a Predictor of Outcome: Mechanism of Injury Does Make a Difference
Authors: Tremblay Lorraine N. , Feliciano David V. , Rozyckl Grace S.
Published: November 2022

Initial base deficit in injured patients has been shown to predict the adequacy of resuscitation and outcome. The usefulness of base deficit as a predictor of outcome, however, may be dependent on the mechanism of injury. We conducted a retrospective review of the trauma registry, supplemented by chart review, of all trauma patients treated at a Level I trauma center from January 1995 through July 2001. Data collected included mechanism of injury, base deficit, Injury Severity Score, and outcome. From 1995 through 2001 a total of 3275 patients (23% of trauma admissions) at a mean age of 34 ± 15 years had a base deficit recorded at the time of admission. The patients were 78 per cent male, and the mechanism of injury was blunt trauma in 58.2 per cent. Mortality increased with successive increases in base deficit but was markedly lower for a given base deficit in those patients having sustained stab wounds and/or severe lacerations as compared with those with gunshot wounds or blunt trauma. The value of the base deficit as a predictor of outcome depends upon the mechanism of injury and appears most useful for patients sustaining gunshot wounds or blunt trauma. Future studies in patients with penetrating trauma using base deficit as a predictor of outcome should separate patients with gunshot wounds from those with stab wounds or lacerations.
Management of Fournier's Gangrene: An Eleven Year Retrospective Analysis of Early Recognition, Diagnosis, and Treatment
Authors: Norton Kathryn S. , Johnson Lester W. , Perry Travis , Perry Katina H. , Sehon James K. , Zibari Gazi B.
Published: November 2022

Fournier's gangrene is an infectious necrotizing fasciitis of the perineum and genital regions. It is a synergistic infection caused by a mixture of aerobic and anaerobic organisms. The mortality rate from this infection ranges from 0 to 67 per cent. One of the most important determinants of overall outcome is early recognition and extensive surgical debridement upon initial diagnosis. This is followed by aggressive antibiotic therapy combined with other precautionary and resuscitative measures. Our hypothesis is that early aggressive surgical debridement combined with broad-spectrum antibiotic coverage results in decreased mortality from Fournier gangrene. The objective of this study was to determine our morbidity and mortality as compared with other institutions. This was a retrospective review of 200 charts of patients from 1990 through 2001. The charts reviewed included patients with a diagnosis of male and female genital abscesses, cellulitis, necrotizing fasciitis, and vascular disorders. This resulted in 33 patients who had a final diagnosis of Fournier's gangrene. There were 26 (79%) males and seven (21%) females with a diagnosis of Fournier's gangrene. The patients ranged in age from 30 to 85 years (mean age 51.5). There were a number of predisposing factors that were examined. Thirteen patients (39%) were diabetic, 18 (55%) suffered from hypertension, 18 (55%) were obese, and 18 (55%) were cigarette smokers. Four patients (12%) had no predisposing factors. The treatment consisted of wide surgical debridement which was performed in all 33 patients. Most patients received multiple debridements ranging from one surgery to seven (mean 3.25) per hospital stay. The majority of patients received broad-spectrum antibiotic coverage. Three patients died, which resulted in a mortality rate of 9 per cent. Early recognition and aggressive surgical debridement is the most essential intervention in stopping the rapidly progressing infectious process of Fournier's gangrene. This intervention should be combined with aggressive triple-antibiotic therapy and other precautionary measures for supporting the patient who has the systemic effects of Fournier's gangrene. Our data do not reach statistical significance with regard to the use of triple-antibiotic therapy. However, we believe that it is an important part of the treatment regimen. The combination of aggressive surgical therapy and appropriate antibiotic coverage results in a reduction in mortality.
Utility of Transesophageal Echocardiography in Determining the Source of Arterial Ernbolization
Authors: Mariano Myron C. , Gutierrez Charles J. , Alexander Jason Q. , Roth Fernando , Katz Steven G. , Kohl Roy D.
Published: November 2022

Arterial embolism is frequently the product of a cardiac source. Arterial-arterial embolization and paradoxical embolization also occur. Failure to identify the point of origin may subject the patient to an important incidence of preventable events. Conventional echocardiography is insensitive in identifying a cardiac origin of emboli and is of little use in identifying sources of arterial-arterial emboli. Aortography is invasive and not as sensitive in detecting mobile aortic thrombus, which is a recently reported embolic source. Herein we describe seven cases in which transesophageal echocardiography was uniquely valuable in identifying the source or mechanism of arterial embolization. We performed chart reviews of patients with arterial emboli definitively diagnosed after utilizing transesophageal echocardiography. Four females and three males with a mean age of 68 years were included in the study. Peripheral embolization occurred in four patients, visceral embolization occurred in one patient, and two patients experienced cerebrovascular events. Six patients had transthoracic echocardiography and six patients had aortography. None of these studies identified the source of embolization. All patients were diagnosed with transesophageal echocardiography. Mobile aortic thrombus was the primary embolic source in three patients, paradoxical embolization occurred in two patients, and two patients had a combination of findings including one patient with atrial thrombus. Two patients received operative repair of the aorta and five underwent nonoperative management. There was one mortality in the operative group. The source of arterial emboli remains obscure in some patients. Transesophageal ultrasound can be valuable in identifying the source or mechanism of embolization even when angiography and conventional echocardiography are negative.
Nonfunctioning Islet Cell Carcinoma of the Pancreas: Case Report
Authors: Pearl Jonathan , Elster Eric , Golocovsky Mario
Published: November 2022

Islet cell carcinomas have an incidence of 5 per million per year; 50 per cent of these are nonfunctioning islet cell tumors. The presenting symptoms mimic pancreatic ductal adenocarcinoma. The CT finding of a pancreatic head mass that spares the main duct may distinguish between the two. The treatment of choice is resection. Most nonfunctioning islet cell tumors are not discovered until metastases are present. However, favorable survival rates have been reported in locally advanced tumors that have undergone resection. Liver metastases carry an unfavorable prognosis. Five-year survival over 60 per cent has been reported. Node-negative patients have a median survival of more than 10 years, and node-positive patients who have undergone resection have a median survival of 75 months. Streptozotocin and 5-fluorouracil are used postoperatively in patients with advanced disease. Considering the favorable survival with resection aggressive surgical treatment is mandated in cases of nonfunctioning islet cell tumors.
Primary Treatment of Malignant Pleural Effusions: Video-Assisted Thoracoscopic Surgery Poudrage versus Tube Thoracostomy
Authors: Erickson Kurt V. , Yost Michael , Bynoe Raymond , Almond Carl , Nottingham James
Published: November 2022

The objective of this study is to show that primary treatment of malignant pleural effusions secondary to ovarian carcinoma with video-assisted thoracoscopic surgery (VATS)-assisted talc poudrage (VATS-ATP) results in shorter hospital stays and reduced time with a chest tube than primary treatment with a chest tube and chemical pleurodesis. We conducted a retrospective chart review of all patients with a symptomatic pleural effusion secondary to primary ovarian carcinoma receiving intervention from January 1996 to December 2000. Patients either received tube thoracostomy with pleurodesis (n = 22) or VATS-ATP (n = 12). Of the patients treated with tube thoracostomy 18 per cent (4/21) died in the hospital before pleurodesis, 77 per cent (14/19) had successful pleurodesis, and 22 per cent (4/18) failed pleurodesis requiring VATS-ATP. In the group treated primarily with tube thoracostomy the chest tube was in place 8.36 ± 2.61 days with a hospital stay of 12.64 ± 5.80 days after the procedure. In the group treated with VATS-ATP there was 100 per cent successful pleurodesis. There were no mortalities. There was one prolonged intubation of 3 days and one incomplete lung reexpansion. The chest tube was in place for 4.58 ± 1.78 days and a hospital stay of 7.50 ± 4.12 days postprocedure. Groups treated by tube thoracostomy and VATS were statistically different; P < 0.001 for days with a chest tube and P = 0.011 for hospital days. We conclude that both tube thoracostomy with chemical pleurodesis and VATS-ATP provide adequate treatment of ovarian carcinoma-associated malignant pleural effusions. VATS-ATP provides a shorter duration of chest tube placement and postprocedure hospital stay.
Laparoscopic Treatment of Large True Cysts of the Liver and Spleen is Ineffective
Authors: Ganti Avinash L. , Sardi Armandol , Gordon Joseph
Published: November 2022

True epidermal cysts of the liver and spleen are uncommon and it has been recommended that laparoscopic management is appropriate. Often these cysts are large and centrally located by the time they reach clinical significance thereby making complete excision difficult without major liver resection or splenectomy. Definitive therapy consists of drainage and complete resection of the cyst wall. Three patients presented with upper abdominal pain. Workup revealed large nonparasitic true cysts of the liver (one) and spleen (two). All were initially treated with laparoscopic resection of their cysts with the primary objective being organ preservation. They were followed with periodic ultrasound/CT scanning. The pathology report in all three cases demonstrated benign congenital epithelial cysts and the patients did well postoperatively. Despite meticulous dissection and marsupialization of the cysts all three patients experienced recurrence that necessitated further therapy. We conclude that laparoscopic surgery is inadequate in the management of true cysts of the liver and spleen unless complete removal of all cyst wall can be assured.
Immediate Preoperative Injection of 99m-Tc Sulfur Colloid Is Effective in the Detection of Breast Sentinel Lymph Nodes
Authors: Vargas Hernan I. , Vargas Maria P. , Gonzalez Katherine D. , Burla Melissa , Venegas Rose , Diggles Linda , Mishkin Fred , Klein Stanley R. , Khalkhali Iraj
Published: November 2022

Sentinel lymph node (SLN) biopsy is an accurate technique to determine the metastatic status of lymph nodes. Radionuclide guidance makes the procedure easier and improves the success rate. Coordinating the operating room and nuclear medicine schedules causes delays when same-day radionuclide injection is used. We hypothesized that injection of 99m-Tc sulfur colloid immediately preoperatively is effective in SLN detection. We analyzed a prospective database of 70 patients treated at Harbor-UCLA Medical Center. The first 39 patients underwent completion axillary dissection (Group A) and subdermal injection of sulfur colloid immediately before surgery. A second group of 31 patients (Group B) had intraparenchymal injection immediately before surgery. We used isosulfan blue in all cases. SLNs were identified in 97 per cent of cases. SLNs were radioactive in 94 per cent and blue in 90 per cent. In Group A the accuracy and the positive and negative predictive values of SLN biopsy were 100 per cent. SLN counts per second ranged from 22 to 1700. The mean count per second was 290 ± 281 (mean ± standard deviation). Subdermal and intraparenchymal injections were equally successful (93% vs 92%). In conclusion injection of radiocolloid and isosulfan blue immediately preoperatively is highly successful and accurate in the detection of SLNs in breast cancer. It avoids operating room schedule delays.
Acute Lower Gastroenteric Bleeding Retrospective Analysis (The ALGEBRA Study): An Analysis of the Triage, Management and Outcomes of Patients with Acute Lower Gastrointestinal Bleeding
Authors: Brackman Matthew R. , Gushchin Vadim V. , Smith Lee , Demory Michelle , Kirkpatrick John R. , Stahl Thomas
Published: November 2022

Many algorithms have been developed for patients with acute lower gastrointestinal hemorrhage (ALGIH). Their clinical usefulness is not readily apparent. It is important first to observe patterns in admission, triage, and management to formulate hypotheses as to how outcomes might be affected. We reviewed patient charts with the diagnosis of gastrointestinal hemorrhage from June 1998 to January 2001. Patients with ALGIH were entered into a database. We defined patients as having ALGIH if presentation included melena or hematochezia. Patients with hematemesis, bloody nasogastric aspirate, or occult fecal blood were excluded. Observations were made on 420 patients. Seventy-six per cent of patients were admitted to the medical service. Lower endoscopy was the first diagnostic method in 33 per cent. Medical management comprised 52 per cent of first management strategies. Surgeons used angiography (3% vs 1%) or surgery (25% vs 5%) more than other services. Fourteen per cent of patients managed with endoscopy, 16 per cent medically, 17 per cent with surgery, and 67 per cent with interventional radiology required two or more subsequent packed red blood cell transfusions. Mean admission Acute Physiology and Chronic Health Evaluation II score was 9.2 whereas that for those with mortality was 13.5. We conclude that the construction of a database will allow for formation and testing of hypotheses in managing ALGIH.
Limitations of Technetium 99m Sestamibi Scintigraphic Localization for Primary Hyperparathyroidism Associated with Multiglandular Disease
Authors: Katz Steven C. , Wang Grace J. , Kramer Elissa L. , Roses Daniel F.
Published: November 2022

Successful surgical treatment of primary hyperparathyroidism requires the localization and excision of the parathyroid tissue responsible for excessive parathyroid hormone secretion while ensuring that the patient will have sufficient endogenous parathyroid hormone production to maintain eucalcemia. In selecting patients with primary hyperparathyroidism for unilateral parathyroidectomy the surgeon should be able to diagnose multiglandular disease either preoperatively or intraoperatively. We performed a retrospective review of 123 patients who underwent surgical treatment for primary hyperparathyroidism to determine the potential feasibility of selecting patients for minimally invasive surgery based on preoperative imaging studies. All patients were studied preoperatively with99mtechnetium-sestamibi scintigraphy. High-resolution ultrasonography was performed in 119 of these patients. All patients except one underwent bilateral cervical exploration. A patient with an intrathoracic adenoma was successfully diagnosed by scintigraphy thereby allowing treatment by a limited thoracotomy. One hundred eight patients had solitary adenomas and 15 had multiglandular disease. In none of the patients with bilateral multiglandular disease were all abnormal glands localized preoperatively. Patients in our study with primary hyperparathyroidism and multiglandular disease were underdiagnosed by preoperative imaging. A minimally invasive approach based solely on preoperative imaging studies may result in treatment failure in patients with multiglandular involvement.
Prospective Evaluation of Criteria for the Nonoperative Management of Blunt Splenic Trauma
Authors: Meguid Ahmed A. , Bair Holly A. , Howells Greg A. , Bendick Phillip J. , Kerr Hugh H. , Villalba Mario R.
Published: November 2022

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.
Correlation of Revised Trauma Score and Injury Severity Score (TRISS) Predicted Probability of Survival with Peer-Reviewed Determination of Trauma Deaths
Authors: Shanti Christina M. , Tyburski James G. , Rishell Kathryn B. , Wilson Robert F. , Lozen Yvonne , Seibert Cathy , Steffes Christopher , Carlin Arthur M.
Published: November 2022

Trauma deaths at our institution are evaluated by a multidisciplinary trauma committee. The purpose of this study was to evaluate preventable trauma deaths (PRDs) as determined by our review committee and correlate them with the Revised Trauma Score and Injury Severity Score (TRISS) probability of survival (PS). A total of 10,002 patients were identified. The PS was calculated using the TRISS method. The Z scores were calculated and the predicted number of deaths was established. The actual number of deaths was compared with the predicted number of deaths. PRDs were compared with the actual and predicted deaths. The Z score was 0.79, which meant we observed more deaths than predicted by TRISS. We had 281 deaths compared with 271 deaths predicted by TRISS. Peer review characterized 45 deaths as preventable. Although we performed well when our outcomes were compared with TRISS predicted outcomes our PRD rate was higher. The higher the PS the more likely the death was found preventable by peer review. We conclude that for our patient population the peer review process is very sensitive and may be more discerning in identifying PRD than TRISS.
Robotic-Assisted Minimally Invasive Transhiatal Esophagectomy
Authors: Horgan Santiago , Berger Robert A. , Elli Enrique F. , Espat N. Joseph
Published: November 2022

Minimally invasive surgery has been increasing in its adaptability to a wide range of procedures. Initially used in general surgery for cholecystectomy its use has now expanded to include Nissen fundoplications, Heller myotomies, donor nephrectomies, and total esophagectomies. Technological advancements have evolved to include robotic systems for performance of complex surgical procedures. We report on our experience of using robotic-assisted technology to perform a transhiatal total esophagectomy.
The Santa Monica Crash: An Urban Multicasualty Event
Authors: Mcgory Marcia , Cryer H. Gill , Chandler Charles , Cohen Marilyn , Hiatt Jonathan R.
Published: November 2022

Mass casualty events provide dramatic challenges for trauma centers and trauma systems. We analyzed the management of victims and assessed the response of the UCLA Healthcare System to the Santa Monica multicasualty event of July 16, 2003, when an elderly man drove his car through a crowded outdoor market and injured 73 people, 10 of whom died (eight at the scene). Of the victims, 26 were treated at UCLA (n = 15) and Santa Monica (n = 11) Medical Centers. Fourteen patients (54%) were female; average age was 41.9 years (range 7 months to 88 years). Fifteen patients were treated in the ER only, and 11 patients required admission. Of the latter, 10 (91%) had multisystem injuries, most commonly musculoskeletal, which occurred in nine patients (82%). Seven patients required immediate operations (orthopedic in six and a pericardial window in one). Three patients required delayed operations (orthopedic and plastic surgery). Most surgical and medical specialties were needed in consultation. Average LOH was 11.8 (range 2–23) days. Mean ISS was 21.2 (range 1–75). There were six complications (three early and three late) and one death from head injury. Seven patients (64%) required rehabilitation. We conclude that mass casualty victims have multisystem injuries of variable severity, which underscores the importance of trauma centers and trauma systems. The large trauma scene and particular need for orthopedic services were notable features of this event.
Thromboprophylaxis Does Not Protect Severely Injured Patients against Pulmonary Embolism
Authors: Velmahos George C. , Toutouzas Konstantinos G. , Brown Carlos , Vassiliu Pantelis , Gkiokas George , Rhee Peter
Published: November 2022

The existing evidence on the effectiveness of thromboprophylaxis after trauma is conflicting. Although prophylaxis with heparin and/or sequential compression devices is practiced widely, many studies failed to document a clear benefit. A recent meta-analysis suggests that prophylaxis does not reduce posttraumatic deep venous thrombosis rates compared to no prophylaxis. The objective of this prospective study is to examine if the use of thromboprophylaxis prevents posttraumatic pulmonary embolism (PE). Sixty-four critically injured patients with clinical evidence of PE were studied by computed tomographic pulmonary angiography and/or conventional pulmonary angiography. PE was diagnosed in 24 (37.5%) patients. Patients with PE were similar to patients without PE with regard to demographics, injury type and severity, operations, and mortality. Thromboprophylaxis was used with equal frequency between PE and no-PE patients (71% vs 80%, P = 0.4). The type of prophylaxis used was similar between patients with PE (17% heparin, 71% sequential compression devices, 17% combination) and patients without PE (32%, 57%, and 10%, respectively; P = 0.16, 0.28, 0.69, respectively). Current methods of posttraumatic thromboprophylaxis may be inadequate. Practices from nontrauma populations have been erroneously extrapolated to the unique trauma population. To reduce the rate of PE after trauma, new methods of thromboprophylaxis should be considered.
Hand-Assisted Laparoscopic Donor Nephrectomy is Safe and Results in Increased Kidney Donation
Authors: Baron Pedro W. , Baldwin D. Duane , Hadley H. Roger , Ojogho O.N. , Ruckle Herbert C. , Concepcion Waldo
Published: November 2022

The impact of hand-assisted laparoscopic donor nephrectomy on kidney allograft function, perioperative complications, and organ supply was evaluated by retrospective analysis of 41 hand-assisted laparoscopic donor nephrectomy patients and their recipients between January and October 2003. Serum creatinine at discharge, length of stay, estimated blood loss, operative time, and perioperative complications were analyzed. The mean values for laparoscopic donors and their recipients were 1.2 ± 0.3 and 1.3 ± 0.8 mg/dL for creatinine, 3.3 ± 0.8 and 6.7 ± 3 days for length of stay, and 110.4 ± 76.9 and 111.6 ± 56 mL for estimated blood loss, respectively. No major complications occurred in the laparoscopic donors. The number of living kidney donors increased by 94% compared to the mean of the previous 4 years following implementation of the laparoscopic program. Hand-assisted laparoscopic donor nephrectomy is safe, results in excellent allograft function, and significantly increases donation.
Endorectal Flap Advancement Repair is an Effective Treatment for Selected Patients with Anorectal Fistulas
Authors: Dixon Matthew , Root Jeffrey , Grant Stuart , Stamos Michael J.
Published: November 2022

Although the majority of anorectal fistulas may be treated with fistulotomy, patients with higher-lying fistulas or women with anterior fistulas in whom simple fistulotomy may threaten continence present a management dilemma. Endorectal flap advancement repair is one potential solution. Chart review was performed of consecutive patients receiving endorectal advancement flaps during a 5-year period (1999–2003). Twenty-nine patients received endorectal advancement flap repair. In 21 (72%) patients, an etiology of the fistula could not be clearly identified, and they were considered to be cryptoglandular in origin. Eight (24%) patients had pathology presumed to be related to prior obstetrical injury. There were 18 (62%) women, and the majority (72%) had anterior fistulas and flaps. Primary success was defined as resolution of symptoms for at least a 3-month period without an additional surgical procedure. If resolution of symptoms after flap placement was achieved after an additional surgical procedure, it was considered a secondary success. Primary success was achieved in 20 (69%) patients, and a secondary success in four (44%) of the remaining nine patients, for a total success of 83 per cent. Anal advancement flaps demonstrate a reasonable success rate when utilized in this group of patients with challenging anorectal fistulas.
Transection of the Base of the Tongue Caused by Penetrating Injury
Authors: Steinig Jeffrey P. , Deloach E. Daniel , Boyd Carl R.
Published: November 2022

Traumatic transection of the base of the tongue can be a life-threatening injury because of blood loss and airway obstruction. Airway control, hemostasis, and meticulous anatomic repair are necessary to prevent speech and airway dysfunction. Laryngeal injuries, when present, require these same principles.
Pudendal Canal: Surgical Anatomy and Clinical Implications
Authors: Shafik Ahmed , Doss Sameh H.
Published: November 2022

The anatomy of the pudendal canal (PC) was studied in 26 cadavers: 10 stillborn and 16 adults (mean age, 48.2 years). Two approaches were used to expose the PC: gluteal and perineal. The PC was an obliquely lying tube with a mean length of 0.8 cm in the stillborn and 1.6 cm in the adult cadavers. It started at a mean distance of 0.8 cm from the ischial spine in the stillborn and of 1.6 cm in the adult cadavers, and ended at a mean distance of 0.7 cm and 2.6 cm, respectively, from the lower border of the symphysis pubis. The PC wall was formed by the splitting of the obturator fascia and not by the lunate fascia. The PC contained the pudendal nerve and vessels embedded in loose areolar tissue. The three branches of the neurovascular bundle arose inside the canal in all but three cadavers. The wall of the PC consisted of collagen and elastic fibers, whereas that of the obturator fascia consisted of collagen only. The PC seems to be structurally adapted to serve certain functions. The criss-cross textile arrangement of collagen fibers in its wall allows the canal to change its shape in response to changes in pudendal vessels that occur during sexual activity. The elastic recoil may not only help to “pump” the blood up the pudendal vein, but also to prevent PC subluxation. The PC may, furthermore, act as a “pulley” for the neurovascular bundle. The pulley action may be disrupted by disordered pelvic floor muscles or defecation. Knowledge of the precise anatomy of the PC is necessary to carry out PC decompression in the treatment of PC syndrome.
Laparoscopic Choledochoduodenostomy
Authors: Gurbuz A. Tayfun , Watson Derek , Fenoglio Michael E.
Published: November 2022

Laparoscopic cholecystectomy has become the gold standard for treatment of patients with symptomatic cholelithiasis. Management of common bile duct stones in the era of laparoscopy is an area of controversy. Although perioperative endoscopic retrograde cholangiography remains as a widely used procedure, experience is accumulating on the exploration of the common bile duct with the laparoscope. A biliary drainage procedure is indicated in selected patients with choledocholithiasis. Initially described by Reidel in 1892, side-to-side choledochoduodenostomy has become a popular biliary-enteric anastomosis technique in the last century. We describe two patients with recurrent choledocholithiasis and biliary obstruction due to benign biliary strictures. Both patients underwent laparoscopic common bile duct exploration and stone extraction. A side-to-side choledochoduodenostomy is then performed laparoscopically as a drainage procedure. Laparoscopic choledochoduodenostomy resulted in resolution of jaundice and relief of biliary obstruction. Laparoscopic choledochoduodenostomy can be an acceptable alternative to the open choledochoduodenostomy. In addition to a tension-free anastomosis and an adequate-sized stoma, intracorporeal suturing and knot-tying skills are also essential to the success of this procedure.
The Absent Role of Prophylactic Antibiotics in Low-Risk Patients Undergoing Laparoscopic Cholecystectomy
Authors: Dobay Kristin J. , Freier Duane T. , Albear Paul
Published: November 2022

A retrospective chart review was done to determine the infection rate and the use of prophylactic antibiotics in consecutive laparoscopic cholecystectomies done in a single community. Incisional infections were discovered in 11 of 566 cases, 10 of whom had received prophylactic antibiotics. The infected patients were significantly older, had longer procedures, and had more comorbidity than the uninfected patients. They were also more likely to have a palpable mass preoperatively and past biliary surgery. A second, prospective study was done to evaluate the efficacy of the use of antibiotic prophylaxis in low-risk patients. Fifty-three patients were randomized into two double-blinded groups. No incisional infections occurred in either group within 30 days postoperatively. This suggests prophylactic antibiotics are not needed to prevent infections for low-risk patients undergoing laparoscopic cholecystectomy.
An Alternative Approach: Antegrade Catheter-directed Thrombolysis in a Case of Phlegmasia Cerulea Dolens
Authors: Centeno R. F. , Nguyen A. H. , Ketterer C. , Stiller G. , Chait A. , Fallahnejad Manucher
Published: November 2022

Phlegmasia cerulea dolens is an uncommon sequela of severe deep venous thrombosis of the lower extremities. Characterized by massive edema, arterial and venous compromise, and threats to limb and life, this clinical entity is a clear indication for thrombolytic therapy. We report an innovative approach to conventional thrombolysis via a lesser saphenous vein cut-down. This simple technique is a safe, reliable alternative to present methods of achieving deep venous access. Hence, it should be considered as an addition to the treatment armamentarium for massive deep venous thrombosis of the lower extremity.
Secure Placement of Continuous Ambulatory Peritoneal Dialysis Catheters under Laparoscopic Assistance
Authors: Wang Jaw-Yuan , Hsieh Jan-Sing , Chen Fang-Ming , Chuan Chieh-Han , Chan Hon-Man , Huang Tsung-Jen
Published: November 2022

Laparoscopic surgical procedures were performed in 18 patients with end-stage renal disease for the placement of a Tenckhoff peritoneal dialysis catheter. Among them, 6 patients had received previous lower abdominal surgical treatment and 3 patients underwent laparoscopic rescue of dysfunctional Tenckhoff catheters. The operating time was between 40 and 80 minutes (median, 50 minutes). After a median follow-up period of 11 months, the short-term results revealed that no significant morbidity was associated with this procedure, and all catheters except two functioned well postoperatively. One of the catheters was not functional because of the patient's death, and the other one was removed because of persistent peritonitis. Laparoscopic secure placement of continuous ambulatory peritoneal dialysis catheters appears to be a simple, safe, and viable procedure, even in patients with previous lower-abdominal operations. The same technique can be used to rescue dysfunctional catheters that are displaced or obstructed by adhesion and omental wrapping, thus increasing catheter longevity.
Laparoscopic Procedures in Pregnancy
Authors: Conron Richard W. , Abbruzzi Kristin , Cochrane Sara Orr , Sarno Albert J. , Cochrane Peter I.
Published: November 2022

As the applications of laparoscopy for general surgical procedures expanded in the 1990s, pregnancy was initially considered a contraindication. Several case reports have suggested the safety of laparoscopy in pregnancy. Previous clinical studies indicate a higher fetal mortality may exist and advised caution. To evaluate the fetal outcome of laparoscopic procedures in pregnant patients at our institution, we retrospectively reviewed the medical records between 1991 and 1997 and identified 21 pregnant patients who underwent either a laparoscopic (n = 12) or open (n = 9) procedure. Appendectomies, cholecystectomies, and diagnostic laparoscopics were performed. Specific variables including age, length of procedure, hospital stay, duration of parenteral analgesic use, gestational age at the time of surgery and delivery, O2 saturation and EtCO2 during surgery, APGAR scores, and birth weights were compared between the two groups. Laparoscopic procedures during pregnancy resulted in shorter hospital stays (34 hours versus 91 hours; P = 0.01), less use of parenteral narcotic analgesics (5 hours versus 29 hours; P = 0.05), and no prolongation of operative times (51 minutes versus 63 minutes; P = 0.20). In addition, laparoscopy was performed at earlier gestational ages (12 weeks versus 29 weeks; P = 0.001). There was one miscarriage 7 days after a laparoscopic cholecystectomy early in the 1st trimester that was not statistically significant. Our experience did not show a higher incidence of fetal loss when comparing laparoscopic to open procedures in pregnant patients.
Surgical Residents and Ultrasound Technician Accuracy and Cost-effectiveness of Ultrasound in Trauma
Authors: Frezza Ermenegildo Eldo , Ferone Terry , Martin Marcel
Published: November 2022

The purpose of this study is 2-fold: 1) to assess the accuracy of the Focused Abdominal Sonogram for Trauma (FAST) as an important evaluative tool for the trauma victim as compared with other objective testing resources (i.e., computerized axial tomography scan); and 2) to analyze the cost-effectiveness of FAST as performed by surgical residents as compared with ultrasound (US) technicians. FAST was performed on 650 trauma victims over a period of 12 months. Testing was completed in a trauma room of the emergency department by an US technician or a trauma surgical resident as determined by the availability of the US technician. Hypotensive patients required two FASTs to be completed for comparison of results. Persistent difficulty interpreting the FAST required the addition of a computerized axial tomography scan to help clarify the results. Statistical analysis was performed using χ2 and analysis of variance. False positive, false negative, and true positive, true negative, along with the accuracy of FAST were calculated as compared with other diagnostic testing. The finding indicated that FAST was both specific (99 per cent) and sensitive (68 per cent) in the sample used. Of the 650 patients receiving FAST, true negative was 95 per cent, true positive was 3 per cent as compared with false negative at 1 per cent, and false positive at 0.5 per cent. US technicians performed 81 per cent of the FASTs with an accuracy of 92 per cent. In comparison, surgical residents had a 92 per cent rate of accuracy in the remaining 19 per cent of the population. The mean accuracy of both was 94 per cent. Furthermore, FAST as performed by resident incurred a single fee of $88 for radiological readings as compared with $274 for an US technician fee plus the radiological reading fee of $88. FAST as performed by surgical residents is more cost-effective than FAST as performed by an US technician.