bluuebunny/crossref_metadata_2025 huggingface dataset:
Epidural versus Subpleural Analgesia for Pulmonary Resections: A Comparison of Morbidities
Authors: Engelhardt Kathryn E. , Starnes Sandra L. , Hanseman Dennis J. , Guitron Julian
Published: June 2020

There are several methods to mitigate the pain that results from thoracic surgery. All of them may be associated with complications. We analyzed the morbidities associated with epidural and subpleural catheter analgesia in patients undergoing pulmonary resections for lung cancer. We conducted a retrospective review of our prospective lung cancer outcomes database for all patients undergoing lobectomy for lung cancer through a thoracotomy or thoracoscopy. All patients had either an epidural or subpleural catheter placed for pain control. One hundred twenty-nine patients met the inclusion criteria. Patients were stratified based on age and pain management technique and the 30-day outcomes were examined. Ninety-three patients had epidural catheters placed and 36 received subpleural catheters. Baseline demographics were similar except for two variables; the subpleural catheter group had a larger proportion of thoracoscopic surgery and more pack-years smoked. Patients in the epidural group were more likely to experience postoperative pruritus and had longer intensive care unit stays but were less likely to use a patient-controlled anesthesia pump. Patients in the subpleural group were more likely to develop intestinal complications. When a subset analysis was done by age (younger than 70 vs 70 years or older), there were no significant differences in postoperative outcomes in the older group. The younger cohort had more pruritus and longer intensive care unit stays in the epidural group. The differences between subpleural and epidural catheters are minimal across all ages and nonexistent for geriatric patients. Thus, the choice of pain management should be determined by individual patient characteristics and risk factors rather than based on age alone.
Watchful Waiting for Ventral Hernias: A Longitudinal Study
Authors: Bellows Charles F. , Robinson Celia , Fitzgibbons Robert J. , Webber Larry S. , Berger David H.
Published: June 2020

Ventral hernias are a common clinical problem. Immediate repair is recommended for most ventral hernias despite significant recurrence rates. This practice may be related to a lack of understanding of the natural history of ventral hernias. The purpose of this study was to determine the natural history of ventral hernias and to determine if watchful waiting is an acceptable and safe option. Forty-one patients with ventral hernias were enrolled in a longitudinal cohort study of watchful waiting. Primary outcomes were functional impairment resulting from hernia disease as measured by the Activities Assessment Scale (AAS) and changes from baseline to two years in the physical and mental component score of the SF-36 Health Survey. Secondary outcomes included complications such as incarceration. Mixed-effects model for repeated measures and Student's t tests were used to evaluate scale performance. The mean age of enrollees was 64 years, and the mean hernia size was 239 cm2. Eleven patients were lost to follow-up, and seven patients died of other causes. All remaining patients were followed for two years. There was one incarceration during the follow-up period. There was no deterioration in the AAS score (baseline vs 24 months = 28 vs 25, P = 0.60). There was deterioration of the physical functioning dimension of the SF-36 (baseline vs 24 months = 40 vs 32, P < 0.01), but the mental functioning dimension was improved (45 vs 51; P = 0.01). Watchful waiting was a safe option for patients in this study with ventral hernias.
Ligaments of the Rectum: Anatomical and Surgical Considerations
Authors: Charran Ordessia , Muhleman Mitchel , Shah Sameer , Tubbs R. Shane , Loukas Marios
Published: June 2020

The ligaments of the rectum have been the subject of controversy for decades. Not only have their contents and components been a source of contention, but also the very existence of these ligaments has been called into question. This article explores the anatomical features of these ligaments with implications for surgical treatment of rectal prolapse, rectal cancer, and resection of the rectum and mesorectum. A theory about the evolution of the lateral rectal ligaments and the mesorectum in humans and higher mammals is also presented.
Predictors of Hospital Discharge to an Extended Care Facility after Major General Thoracic Surgery
Authors: Walters Dustin M. , Nagji Alykhan S. , Stukenborg George J. , Peluso Melissa R. , Taylor Matthew D. , Kozower Benjamin D. , Lau Christine L. , Jones David R.
Published: June 2020

Failure to anticipate the need to discharge patients to rehabilitation centers and skilled nursing facilities results in expensive delays in the discharge of patients after surgery. Early identification of patients at high risk for discharge to these extended care facilities could mitigate these delays and expenditures. The purpose of this study was to identify preoperative patient factors associated with discharge to extended care facilities after major general thoracic surgery. Discharge records were identified for all patients undergoing major general thoracic surgery admitted to a university hospital between January 2006 and May 2009 who had a stay of longer than one day. The following risk factors were selected a priori based on clinical judgment: age, preoperative albumin, pre-operative Zubrod score, history of peripheral vascular disease, and use of home oxygen. Multiple logistic regression analysis was used to estimate the statistical significance and magnitude of risk associated with each predictor of patient discharge to extended care facilities. Of the 1646 patients identified, 68 (4.1%) were discharged to extended care facilities. Hospital length of stay was on average six days longer for patients discharged to these facilities than for patients discharged home ( P < 0.0001). Multivariate analysis demonstrated that advanced age, lower preoperative albumin, and increased preoperative Zubrod score were statistically significant predictors of discharge to extended care facilities. Age, preoperative nutritional status, and functional status are strong predictors of patient discharge to extended care facilities. Early identification of these patients may improve patient discharge planning and reduce hospital length of stay after major thoracic surgery.
Perioperative Morbidity and Mortality after Noncardiac Surgery in Young Adults with Congenital or Early Acquired Heart Disease: A Retrospective Cohort Analysis of the National Surgical Quality Improvement Program Database
Authors: Maxwell Bryan G. , Wong Jim K. , Lobato Robert L.
Published: June 2020

An increasing number of patients with congenital heart disease survive to adulthood. Expert opinion suggests that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. Using the National Surgical Quality Improvement Program database, we identified a cohort of patients aged 18 to 39 years with prior heart surgery who underwent noncardiac surgery between 2005 and 2010. A comparison cohort with no prior cardiovascular surgery was matched on age, sex, race/ethnicity, operation year, American Society of Anesthesiologists physical status, and Current Procedural Terminology code. A study cohort consisting of 1191 patients was compared with a cohort of 5127 patients. Baseline dyspnea, inpatient status at the time of surgery, and a prior operation within 30 days were more common in the study cohort. Postoperative outcomes were less favorable in the study cohort. Observed rates of death, peri-operative cardiac arrest, myocardial infarction, stroke, respiratory complications, renal failure, sepsis, venous thromboembolism, perioperative transfusion, and reoperation were significantly higher in the study cohort ( P < 0.01 for all). Mean postoperative length of stay was greater in the study cohort (5.8 vs 3.6 days, P < 0.01). Compared with a matched control cohort, young adult patients with a history of prior cardiac surgery experienced significantly greater perioperative morbidity and mortality after noncardiac surgery. A history of prior cardiac surgery represents a marker of substantial perioperative risk in this young population that is not accounted for by the matched variables. These results suggest that adult patients with congenital heart disease are at risk for adverse outcomes and support the need for further registry-based investigations.
Short Bowel Syndrome after Laparoscopic Procedures
Authors: McBride Corrigan L. , Oleynikov Dmitry , Sudan Debra , Thompson Jon S.
Published: June 2020

Short bowel syndrome (SBS) is a potential postoperative complication after intra-abdominal procedures. Whether the laparoscopic approach is as likely to result in SBS or the causative mechanisms are similar to open procedures is unknown. Our aim was to evaluate potential mechanisms of SBS after laparoscopic procedures. The records of 175 adult patients developing SBS as a postoperative complication were reviewed. One hundred forty-seven patients had open procedures and 28 laparoscopic. Colectomy (39%), hysterectomy (11%), and appendectomy (11%) were the most common open procedures. SBS followed laparoscopic gastric bypass (46%) and cholecystectomy (32%) most frequently. The mechanisms of SBS were different: adhesive obstruction (57 vs 22%, P < 0.05) was more common in the open group, whereas volvulus (18 vs 46%, P < 0.05) was more common after laparoscopy. Overall, ischemia (25 vs 32%) was similar but significantly more laparoscopic patients had postoperative hypoperfusion (32 vs 67%, P < 0.05). Eleven of the 13 laparoscopic bariatric procedures had internal hernias and volvulus. Of the nine patients undergoing cholecystectomy, four developed ischemia early postoperatively presumably secondary to pneumoperitoneum. SBS is an increasingly recognized complication of laparoscopic procedures. The mechanisms of intestinal injury differ from open procedures with a higher incidence of volvulus and more frequent ischemia from hypoperfusion.
Letting the Sun Set on Small Bowel Obstruction: Can a Simple Risk Score Tell Us When Nonoperative Care is Inappropriate?
Authors: O'Leary Elizabeth A. , Desale Sameer Y. , Yi William S. , Fujita Kari A. , Hynes Conor F. , Chandra Suma K. , Sava Jack A.
Published: June 2020

Controversy remains as to which patients with small bowel obstruction (SBO) need immediate surgery and which may be managed conservatively. This study evaluated the ability of clinical risk factors to predict the failure of nonoperative management of SBO. The electronic medical record was used to identify all patients with SBO over one year. Clinical, laboratory, and imaging data were recorded. Univariate and multivariable analyses were performed to identify risk factors predicting need for surgery. Cox proportional hazards regression was used to identify risk factors that influence need and timing for surgery. Two hundred nineteen consecutive patients were included. Most patients did not have a prior history of SBO (75%), radiation therapy (92%), or cancer (70%). The majority had undergone previous abdominal or pelvic surgery (82%). Thirty-five per cent of patients ultimately underwent laparotomy. Univariate analysis showed that persistent abdominal pain, abdominal distention, nausea and vomiting, guarding, obstipation, elevated white blood cell count, fever present 48 hours after hospitalization, and high-grade obstruction on computed tomography (CT) scan were significant predictors of the need for surgery. Multivariable analysis revealed that persistent abdominal pain or distention (hazard ratio [HR], 3.04; P = 0.013), both persistent abdominal pain and distention (HR, 4.96; P < 0.001), fever at 48 hours (HR, 3.66; P = 0.038), and CT-determined high-grade obstruction (HR, 3.45; P = 0.017) independently predicted the need for surgery. Eighty-five per cent of patients with none of these four significant risk factors were successfully managed nonoperatively. Conversely, 92 per cent of patients with three or more risk factors required laparotomy. This analysis revealed four readily evaluable clinical parameters that may be used to predict the need for surgery in patients presenting with SBO: persistent abdominal pain, abdominal distention, fever at 48 hours, and CT findings of high-grade obstruction. These factors were combined into a predictive model that may of use in predicting failure of nonoperative SBO management. Early operation in these patients should decrease length of stay and diagnostic costs.
Withdrawal of Care in a Trauma Intensive Care Unit: The Impact on Mortality Rate
Authors: Weireter Leonard J. , Collins Jay N. , Britt Rebecca C. , Novosel T. J. , Britt L. D.
Published: June 2020

Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (6 18.5) years old and neurologic injury was responsible in 63 per cent (6 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (6 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.
Concurrent Surgical Patient Safety Indicator Evaluation Results in More Accurate Reporting and Reimbursement
Authors: Duane Therese M. , Ramanathan Rajesh , Leavell Patrick , Mays Catherine , Harvey Dale
Published: June 2020

We sought to determine whether concurrent (before discharge) Agency for Healthcare Research and Quality patient safety indicator evaluation would result in a more expeditious review, accurate reporting, and improved reimbursement. We compared the period of preconcurrent (preC) coding (January 2012 to June 2012) with the period after concurrent coding (postC) began (July 2012 to December 2012) for total billing errors. There were 276 records reviewed in the preC versus 424 in the postC time periods. Overall coding errors were 225 (81.5%) preC versus 365 (86.1%) postC ( P = nonsignificant), whereas documentation errors were present in 26 (9.4%) preC versus 40 (9.4%) postC ( P = nonsignificant). Total charges were $3,782,024 preC and $2,011,144 postC. Recodes requiring rebilling were 21 (7.6%) preC for a total of $213,723 rebilled versus four (0.9%) postC for a total of $31,327 rebilled ( P < 0.0001). Time from service to review was 98.7 preC versus 52.3 postC days ( P < 0.0001). Time from service until rebill submitted averaged 100.8 preC versus 54.0 postC days ( P = 0.06). Concurrent review allows for more accurate reporting because recodes are completed before discharge. Billing delays prolong time to reimbursement and results in loss of revenue.
Moped Collisions among Patients with Revoked Drivers’ Licenses are a Significant Public Health Problem: A Retrospective Cohort Study
Authors: Braun Benjamin M. , Gries Lynn M. , Hildreth Amy N. , Miller Anna N.
Published: June 2020

Many states do not require a license to operate a moped, defined as a motor vehicle with less than 50-cc engine displacement. These vehicles may therefore serve as a mode of transportation for those who are driving without a license and who may have a history of prior high-risk behavior. We hypothesized that those involved in moped collisions were more likely to have previous convictions for driving while intoxicated (DWI) and other non-DWI offenses than those on conventional motorcycles. At a Level I trauma center, we queried the trauma registry from January 2005 to October 2010 for admissions after motorcycle or moped collisions. Classification of mechanism of injury was verified through chart review. Corrections databases from our state were then reviewed for previous convictions for DWI and other offenses. One thousand seventy-three patients over the study period were involved in motorcycle or moped collisions; 94 were from another state. Of the patients identified from our state, 249 had moped collisions and 730 had motorcycle collisions. Forty-nine per cent (121) of moped drivers had a history of DWI versus only 8 per cent (56) of motorcycle drivers ( P ≤ 0.05). Sixty-four per cent (161) of moped drivers were previously convicted of a crime versus 20 per cent (146) of those on motorcycles ( P ≤ 0.05). Moped drivers were significantly more likely to have a prior conviction of DWI as well as prior convictions of other crimes, establishing a pattern of disregard for the law. The use of these vehicles without a license likely presents a risk to public safety. Legislation to require licensing before moped operation should be considered.
KRAS and PIK3CA Mutation Frequencies in Patient-derived Xenograft Models of Pancreatic and Colorectal Cancer Are Reflective of Patient Tumors and Stable Across Passages
Authors: Tignanelli Christopher J. , Loeza Silvia G. Herrera , Yeh Jen Jen
Published: June 2020

One obstacle in the translation of advances in cancer research into the clinic is a deficiency of adequate preclinical models that recapitulate human disease. Patient-derived xenograft (PDX) models are established by engrafting patient tumor tissue into mice and are advantageous because they capture tumor heterogeneity. One concern with these models is that selective pressure could lead to mutational drift and thus be an inaccurate reflection of patient tumors. Therefore, we evaluated if mutational frequency in PDX models is reflective of patient populations and if crucial mutations are stable across passages. We examined KRAS and PIK3CA gene mutations from pancreatic ductal adenocarcinoma (PDAC) (n = 30) and colorectal cancer (CRC) (n = 37) PDXs for as many as eight passages. DNA was isolated from tumors and target sequences were amplified by polymerase chain reaction. KRAS codons 12/13 and PIK3CA codons 542/545/1047 were examined using pyrosequencing. Twenty-three of 30 (77%) PDAC PDXs had KRAS mutations and one of 30 (3%) had PIK3CA mutations. Fifteen of 37 (41%) CRC PDXs had KRAS mutations and three of 37 (8%) had PIK3CA mutations. Mutations were 100 per cent preserved across passages. We found that the frequency of KRAS (77%) and PIK3CA (3%) mutations in PDAC PDX was similar to frequencies in patient tumors (71 to 100% KRAS, 0 to 11% PIK3CA). Similarly, KRAS (41%) and PIK3CA (8%) mutations in CRC PDX closely paralleled patient tumors (35 to 51% KRAS, 12 to 21% PIK3CA). The accurate mirroring and stability of genetic changes in PDX models compared with patient tumors suggest that these models are good preclinical surrogates for patient tumors.
Procalcitonin Elevation Suggests a Septic Source
Authors: Friend Kara E. , Burgess Jessica N. , Britt Rebecca C. , Collins Jay N. , Weireter Leonard N. , Novosel Timothy J. , Britt L. D.
Published: June 2020

Procalcitonin is used as a marker for sepsis but there is little known about the correlation of the procalcitonin elevation with the causative organism in sepsis. All patients aged 18 to 80 years who were admitted to the surgery service from June 2010 to May 2012 and who had a procalcitonin drawn were evaluated. Culture data were reviewed to determine the causative organism. Infections analyzed included pneumonia, urinary tract infection (UTI), bloodstream infection, and Clostridium difficile. Other parameters assessed included reason for admission, body mass index, pressor use, antibiotic duration, and disposition. Two hundred thirty-two patient records were reviewed. Patients without a known infection/source of sepsis had a mean procalcitonin of 3.95. Those with pneumonia had a procalcitonin of 20.59 ( P = 0.03). Those with a UTI had a mean procalcitonin of 66.84 ( P = 0.0005). Patients with a bloodstream infection had a mean procalcitonin of 33.30 ( P = 0.003). Those with C. difficile had a procalcitonin of 47.20 ( P = 0.004). When broken down by causative organisms, those with Gram-positive sepsis had a procalcitonin of 23.10 ( P = 0.02) compared with those with Gram-negative sepsis at 32.75 ( P = 0.02). Those with fungal infections had a procalcitonin of 42.90 ( P = 0.001). These data suggest that procalcitonin elevation can help guide treatment by indicating likely causative organism and infection type. These data may provide a good marker for initiation of antifungal therapy.
Aspirin Increases the Risk of Venous Thromboembolism in Surgical Patients
Authors: Barmparas Galinos , Jain Monica , Mehrzadi Devorah , Melo Nicolas , Chung Rex , Bloom Matthew , Ley Eric J. , Margulies Daniel R.
Published: June 2020

The risk of venous thromboembolism (VTE) for patients taking an antiplatelet agent is largely unknown. This study aimed to investigate the association between antiplatelet agent use before admission with the risk of in-hospital VTE in surgical intensive care unit (ICU) patients. A retrospective review of all patients admitted to the surgical ICU at a Level I trauma center over 30 months was performed. Patients who underwent diagnostic imaging for VTE were selected. Patients were divided based on whether or not antiplatelet agents were used before admission (APTA vs NAPTA). The primary outcome was VTE occurrence. A forward logistic regression model was used to identify factors independently associated with the primary outcome. During the study period, 461 (24%) patients met inclusion criteria: 70 (15%) APTA and 391 (85%) NAPTA. After adjusting for confounding factors, APTA patients were at a significantly higher risk for developing VTE (59 vs 40%; adjusted odds ratio, 1.8; 95% confidence interval, 1.0 to 3.0; adjusted P = 0.04). Whether or not antiplatelet agents were resumed during the hospital stay and the day on which they were resumed did not affect VTE risk. In conclusion, surgical ICU patients receiving antiplatelet agents before admission are at a significantly higher risk for development of VTE.
Duodenal Adenocarcinoma: Why the Extreme Rarity of Duodenal Bulb Primary Tumors?
Authors: Goldner Bryan , Stabile Bruce E.
Published: June 2020

Adenocarcinoma of the small bowel accounts for only one per cent of all gastrointestinal malignancies. Duodenal adenocarcinoma accounts for half of all small bowel adenocarcinomas. The duodenum is divided into four segments: D1 (proximal horizontal 5 cm beginning with the 3-cm duodenal bulb), D2 (descending), D3 (distal horizontal), and D4 (ascending). The most common location of duodenal adenocarcinomas is the ampullary region of D2. Based on observational experience, our hypothesis was that primary adenocarcinomas arising from the mucosa of the duodenal bulb are extremely rare or possibly nonexistent. Our institutional cancer registry provided a list of patients for the years 1990 through 2012 who had small bowel cancers. Only those patients with primary adenocarcinomas of the duodenal mucosa were reviewed. Ampullary cancers arising from bile duct mucosa were specifically excluded. Medical records were abstracted to obtain patient age, sex, race, anatomic location of the tumor, disease stage (as per American Joint Committee on Cancer 7th edition staging guidelines), operation performed, and current vital status. A total of 30 patients with primary duodenal adenocarcinomas were identified. The mean age was 58 years and 17 (57%) patients were male. The tumor locations were: D2 in 26 (87%), D3 in two (7%), and D4 in two (7%). No tumors arose from D1. The patients presented with the following stages of disease: Stage 0 is in three (10%), Stage I in three (10%), Stage II in five (17%), Stage III in 15 (50%), and Stage IV in four (13%). These findings combined with a diligent review of 724 reported cases in the English language literature yielded only five clearly defined cases of adenocarcinoma arising from the mucosa of the duodenal bulb. Although a 1991 published multicenter tumor registry series of 128 localized duodenal adenocarcinomas reported 29 D1 tumors, no anatomic distinction was made between duodenal bulb and more distal D1 tumors. Earlier reports used nonanatomic divisions of the duodenum or a simple breakdown into supra-ampullary, periampullary, and infra-ampullary portions. These data beg the question as to why primary duodenal bulb adenocarcinomas are so exceedingly rare. The obvious implication is that the duodenal bulb mucosa may be physiologically, immunologically, or otherwise uniquely privileged to virtually escape oncogenic transformation. The scientific challenge and opportunity is to explore and understand the important phenomena responsible for this finding.
Incidence of Intracranial Hemorrhage and Outcomes after Ground-level Falls in Geriatric Trauma Patients Taking Preinjury Anticoagulants and Antiplatelet Agents
Authors: Reddy Subhash , Sharma Rohit , Grotts Jonathan , Ferrigno Lisa , Kaminski Stephen
Published: June 2020

Antiplatelet and anticoagulant medication increases the risk of intracranial hemorrhage (ICH) after a fall in geriatric patients. We sought to determine whether there were differences in ICH rates and outcomes based on type of anticoagulant or antiplatelet agent after a ground-level fall (GLF). Our institutional trauma registry was used to identify patients 65 years old or older after a GLF while taking warfarin, clopidogrel, or aspirin over a 2-year period. Rates and types of ICH and patient outcomes were evaluated. Of 562 patients who met inclusion and exclusion criteria, 218 (38.8%) were on warfarin, 95 (16.9%) were on clopidogrel, and 249 (44.3%) were on aspirin. Overall ICH frequency was 15 per cent with no difference in ICH rate, type of ICH, need for craniotomy, mortality, or intensive care unit or hospital length of stay between groups. Patients with ICH were more likely to present with abnormal Glasgow Coma Score, history of hypertension, and/or loss of consciousness.
Management of Patients with Evisceration after Abdominal Stab Wounds
Authors: Nicholson Kristina , Inaba Kenji , Skiada Dimitra , Okoye Obi , Lam Lydia , Grabo Daniel , Benjamin Elizabeth , Demetriades Demetrios
Published: June 2020

In the era of nonoperative management of abdominal stab wounds, the optimal management of patients with evisceration remains unclear. Furthermore, the role of imaging in guiding management of these patients has not been defined. Patients admitted to a Level I trauma center (2005 to 2012) with evisceration after an abdominal stab wound were retrospectively identified. Demographics, admission vital signs, topography and contents of evisceration, Glasgow Coma Score, indications for exploration, and imaging and operative reports were abstracted. Clinical outcomes measured were: injuries identified on exploration, hospital length of stay, and mortality. Descriptive analysis was performed. Ninety-three patients with evisceration were identified. Ninety-two (98.9%) were male and 60 (64.5%) were Hispanic. Mean age was 31.9 ± 13 years. Forty-seven (50.5%) had evisceration of the omentum, 41 (44.1%) had evisceration of abdominal organs, and two (2.2%) had both. Seventy-four (80.4%) had positive laparotomies. Ten (10.8%) underwent computed tomography (CT) preoperatively. Sixty per cent of CT findings were congruent with operative findings. CT did not impact clinical management. In conclusion, the rate of intra-abdominal injury in patients with evisceration remains high. Even in the age of nonoperative management, evisceration continues to be an indication for immediate laparotomy. The diagnostic yield of CT is low and CT should not impact management of these patients.
Rhabdomyolysis in Obese Trauma Patients
Authors: Chan Joshua L. , Imai Taryne , Barmparas Galinos , Lee Jonathan B. , Lamb Alex W. , Melo Nicolas , Margulies Daniel , Ley Eric J.
Published: June 2020

Patients sustaining traumatic injuries are at risk for development of rhabdomyolysis. The effect of obesity on this risk is unknown. This study attempted to characterize the role of obesity in the development of rhabdomyolysis after trauma. This was a retrospective review of all trauma patients with creatine kinase (CK) levels admitted to the surgical intensive care unit (SICU) at a Level I trauma center from February 2011 until July 2013. Patients were divided based on their body mass index (BMI): overweight/obese group with BMI 25 kg/m2 or greater and nonoverweight/obese group with BMI less than 25 kg/m2. Primary outcome was CK greater than 10,000 U/L. During the 30-month study period, 198 trauma patients with available CK levels were admitted to the SICU. The majority (27.8%) of patients were involved in a motor vehicle collision. There were 96 patients (48.4%) with BMI 25 kg/m2 or greater and 102 (51.5%) with BMI less than 25 kg/m2. There was no difference in creatinine levels between the two groups (1.5 ± 1.2 mg/dL vs 1.5 ± 1.4 mg/dL, P = 0.83). BMI 25 kg/m2 or greater was independently associated with the development of CK greater than 10,000 U/L (14.6 vs 4.9%; adjusted odds ratio, 3.03; P = 0.04). Patients with BMI 25 kg/m2 or greater are at a significantly higher risk for rhabdomyolysis after trauma. Aggressive CK level monitoring to prevent rhabdomyolysis in this population is strongly encouraged.
Statement on Surgical Preresidency Preparatory Courses
Authors: Cogbill Thomas H.
Published: June 2020

The leadership of the surgical community is actively engaged in improving the preparation of incoming residents to assume responsibility and accountability for key elements of care and stewardship. To better prepare for this transition, it is essential that all matriculants to surgery residency successfully complete a preparatory course of blended learning that specifically addresses essential components of quality care and patient safety before the start of their training. A national multidimensional curriculum, along with objective assessment tools, has been developed to accelerate readiness, responsibility, and accountability during the transition from medical school to surgery residency. We strongly endorse this effort and encourage medical schools to adopt this or a similar program. We stand ready to assist medical schools and medical students in implementation of this important initiative.
Octogenarians: Noncompliance with Breast Cancer Treatment Recommendations
Authors: Strader Lindsaya , Helmer Stephen D. , Yates Christine L. , Tenofsky Patty L.
Published: June 2020

Recent research suggests that women older than 70 years of age with early breast cancer who choose lumpectomy may forgo radiation if they take antihormonal medication. However, many elderly patients choose to forgo both radiation and hormonal therapy. This study assessed treatment compliance in elderly patients with breast cancer. A retrospective review was conducted of patients with new-onset breast cancer older than 70 years of age. Patients were stratified by age (70 to 79 vs 80 years or older) and surgical procedure (lumpectomy vs mastectomy). Ninety-seven patients were included; 47 were aged 70 to 79 years, whereas 50 were aged 80 years or older. Treatment recommendations were similar between age groups; however, patients aged 80 years or older were more often noncompliant with recommendations for surgery (14.9 vs 0.0%, P = 0.012), radiation therapy (64.0 vs 16.0%, P = 0.001), and hormonal therapy (53.3 vs 22.6%, P = 0.013). When stratified according to surgical procedure, women aged 80 years or older receiving lumpectomy were overall more noncompliant (50.0 vs 14.8%, P = 0.014) than younger women. Women older than 80 years of age who elected for lumpectomy treatment were significantly less likely to receive standard recommendations of adjuvant hormonal or radiation therapy. The reasons for this vary and it is unknown whether this impacts their local recurrence or survival rate.
Treatment Strategies for Primary Hyperparathyroidism: What is the Cost?
Authors: Aliabadi-Wahle Shaghayegh , Kelly Tracy L. , Rozenfeld Yelena , Carlisle James R. , Naeole Lihau K. , Negreanu Francesca A. , Schuman Earl , Hammill Chet W.
Published: June 2020

Primary hyperparathyroidism (HPT) contributes to the onset of many chronic conditions. Although parathyroidectomy is the only definitive treatment, observation remains a valid option. Over a 3-year span, a major health plan was queried for HPT and benign parathyroid neoplasm. Patients with secondary and tertiary HPT, Stage III to V kidney disease, and prior renal transplant were excluded. Patients were divided into: observation (Group 1), parathyroidectomy during the study period (Group 2), and parathyroidectomy before the study group (Group 3), and were compared with a control group of 27,092 adult members without HPT using analysis of variance. The 3-year mean total allowed expenditure for Group One (n = 559), Group Two (n = 93), and Group Three (n = 48) were $21,267, $37,043, and $14,702, respectively. Groups One and Two had significantly higher use than the nonparathyroid group ( P < 0.0001), whereas that of Group Three was comparable. Group Two had the highest cost, whereas Group Three had a significantly lower cost than Group One ( P 0.0001). Primary hyperparathyroidism is associated with a higher use of healthcare resources. Patients observed incurred a higher allowed expenditure than those with prior parathyroidectomy. Surgical treatment may represent a cost-effective strategy for treatment of hyperparathyroidism, although more comprehensive studies are needed to confirm these findings.
Niels Thorkild Rovsing: The Surgeon behind the Sign
Authors: Hognason Kormakur , Swan Kenneth G.
Published: June 2020

Niels Thorkild Rovsing (1862 to 1927) was a Danish surgeon. His eponyms include the Rovsing sign of acute appendicitis, the Rovsing syndrome (abdominal pain in a horseshoe kidney), the Rovsing operation I (for polycystic kidney), and the Rovsing operation II (to separate a fused “horseshoe” kidney). He received his M.D. degree in 1885 and his Ph.D. in 1889 from Copenhagen University. Rovsing practiced surgery from 1892 to 1902 at the Queen Louise Children's Hospital and the Red Cross Hospital, both located in Copenhagen. He became Professor of Surgery in 1899 and Director of Surgery at the Royal Frederiks Hospital in 1904. Rovsing earned international recognition for his innovative urological surgery. Together with his colleague, Eilert A. Tscherning, Rovsing founded the Danish Surgical Society (Dansk Kirurgisk Selskap) in 1908. His advocacy for antisepsis and Listerism advanced his notoriety and exemplified his medical leadership. His clarion call for a modern hospital led to the construction of the Copenhagen University Hospital (Rigshospitalet) that opened in 1910. Rovsing was an Honorary Member of the Edinburgh Medico-Chirurgical Society and the Association of Surgeons of Great Britain and Ireland. Rovsing served briefly as Denmark's Minister of Education in 1920. He died in 1927 from cardiac failure and laryngeal cancer.
Gastroesophageal Reflux Disease-related Symptom Assessment in Subjects with Malignant Dysphagia Receiving Esophageal Stents
Authors: North D. Alan , Schlegel Melissa , Martin Robert C. G.
Published: June 2020

Concerns remain over the ability to stent across of the lower esophageal sphincter (LES) for esophageal adenocarcinoma and the effects of gastroesophageal (GE) reflux. Thus, the aim of this study was to demonstrate minimal quality-of-life (QOL) side effects in patients undergoing esophageal stenting across the LES. An Institutional Review Board–approved prospective clinical trial evaluated the results of the Gastrointestinal Symptom questionnaire that includes a validated GE reflux disease (GERD) assessment (GERD-HRQL) and a dysphagia assessment. Consecutive patients were enrolled in this clinical trial, with 81 per cent male, 19 per cent female, median age of 62 years, with adenocarcinoma of the GE junction as their diagnosis. The median dysphagia score was 3 (only liquids can be tolerated) prestent and was improved to a median score of 0 (ability to eat all foods) poststent ( P = 0.01). The median GERD score was 0 (none) prestent and did not change with a median score of 0 (none) poststent ( P = 0.2). All GERD-related questions were unchanged prestent and poststent in all categories, specifically: frequency of GERD, time of day of reflux, pain behind breastbone, and pain medications. There was also no difference in regurgitation frequency (median prestent 1 vs poststent 0, P = 0.08), texture (prestent 2 [semisolid] vs poststent 1 [liquid]). There was only a statistical change in the ability to belch (prestent 0 [no ability] to poststent 1 [ability]), P = 0.02) and the ability to vomit. Esophageal stenting across the GE junction for dysphagia relief in esophageal malignancies does not adversely effect a patient's QOL in regard to reflux-related symptoms.
Article Commentary: Medullary Thyroid Cancer: An Update for Surgeons
Authors: Azar Faris K. , Lee Stephanie L. , Rosen Jennifer E.
Published: June 2020

Medullary thyroid carcinoma is uncommon but accounts for approximately 4 to 5 per cent of all thyroid cancers. Although most cases are sporadic, close to one-fourth of cases result from germline mutations in the RET proto-oncogene. These mutations are clinically important because they predict the earliest age of medullary thyroid cancer diagnosis and clinical aggressiveness, which guide individualized management. This review covers the presentation, diagnosis, workup, current management, and future directions of the management of medullary thyroid carcinoma. Today's chance for cure depends on early and appropriate surgical resection. Further investigation of the cellular signaling pathways shown to be essential for the growth and spread of medullary thyroid carcinoma remains an active field with hope for providing targeted systemic therapy for patients with progressive disease.
Usefulness of Lung Biopsy in Pediatric Pulmonary Conditions
Authors: Lamoshi Abdulraouf Y. , Nakayama Don K.
Published: June 2020

Lung biopsy, performed as a diagnostic procedure in children with pulmonary disease to guide treatment, may not provide a diagnosis or change therapy. We therefore reviewed our experience with the procedure to determine its use. We reviewed all children undergoing lung biopsy at two large children's hospitals, 2001 to 2010. Lesions were categorized as either diffuse or localized based on final radiological interpretations. Pathological interpretations and subsequent treatment regimens were reviewed for specificity of diagnoses and any changes in therapy. Of 99 patients, there were 14 diffuse and 85 localized pulmonary lesions. Biopsy confirmed the radiological diagnosis in 29 (29%), 71 per cent (70) receiving a new histopathological diagnosis, or a definitive one from a range or radiological possibilities, both diffuse (10 of 14) and diffuse lesions (60 of 85, both 71%). Forty-five per cent (44 of 99) had sufficient clinical data to ascertain treatment before and after biopsy. A significant change in treatment occurred in only 16 per cent (seven of 44) without a significant difference between diffuse (33% [three of nine]) and localized (11% [four of 35]) lesions ( P = 0.38). Twenty-five per cent (25 of 99) of patients undergoing lung biopsy died. Lung biopsy is performed for conditions with a high mortality rate. The procedure yields a definitive diagnosis in the majority of cases but infrequently changes therapy.
Total Body Surface Area Overestimation at Referring Institutions in Children Transferred to a Burn Center
Authors: Swords Douglas S. , Hadley Edmund D. , Swett Katrina R. , Pranikoff Thomas
Published: June 2020

Total body surface area (TBSA) burned is a powerful descriptor of burn severity and influences the volume of resuscitation required in burn patients. The incidence and severity of TBSA overestimation by referring institutions (RIs) in children transferred to a burn center (BC) are unclear. The association between TBSA overestimation and overresuscitation is unknown as is that between TBSA overestimation and outcome. The trauma registry at a BC was queried over 7.25 years for children presenting with burns. TBSA estimate at RIs and BC, total fluid volume given before arrival at a BC, demographic variables, and clinical variables were reviewed. Nearly 20 per cent of children arrived from RIs without TBSA estimation. Nearly 50 per cent were overestimated by 5 per cent or greater TBSA and burn sizes were overestimated by up to 44 per cent TBSA. Average TBSA measured at BC was 9.5 ± 8.3 per cent compared with 15.5 ± 11.8 per cent as measured at RIs ( P < 0.0001). Burns between 10 and 19.9 per cent TBSA were overestimated most often and by the greatest amounts. There was a statistically significant relationship between overestimation of TBSA by 5 per cent or greater and overresuscitation by 10 mL/kg or greater ( P = 0.02). No patient demographic or clinical factors were associated with TBSA overestimation. Education efforts aimed at emergency department physicians regarding the importance of always calculating TBSA as well as the mechanics of TBSA estimation and calculating resuscitation volume are needed. Further studies should evaluate the association of TBSA overestimation by RIs with adverse outcomes and complications in the burned child.
Francis Daniels Moore: One of the Brightest Minds in the Surgical Field
Authors: Low Sara L. , Yeo Charles J. , Cowan Scott W. , Shah Ashesh P.
Published: June 2020

Francis Daniels Moore was a pioneer ahead of his time who made numerous landmark contributions to the field of surgery, including the understanding of metabolic physiology during surgery, liver and kidney transplant, and the famous Study on Surgical Services of the United States (SOSSUS) report of 1975 that served for decades as a guideline for development of surgical residencies. He was the epitome of what a physician should be, a compassionate and dedicated surgeon, innovative scientist, and a medical professional dedicated to quality medical education across all specialties.
Surgeons and Their Tools: A History of Surgical Instruments and Their Innovators. Part IV: Pass Me the Forceps
Authors: El-Sedfy Abraham , Chamberlain Ronald S.
Published: June 2020

This is the fourth of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.
Histological Findings in Resected Bowel of Motility-disordered Patients
Authors: Kidane Biniam , Lam Jennifer , Manji Farouq , Gupta Vaibhav , Chadi Sami A. , Taylor Brian M.
Published: June 2020

Gastrointestinal (GI) motility disorders are prevalent conditions associated with pain and bowel dysfunction. Some motility-disordered patients with intractable symptoms have undergone bowel resection aimed at palliating their symptoms. Our objective was to describe a population of motility-disordered patients with histopathological abnormalities identified in full-thickness surgical biopsies. A retrospective cohort study using prospectively collected clinical data and pathology reports was conducted. All adult patients referred to a tertiary motility clinic from 1996 to 2011 who had bowel resection for motility disorder were consecutively sampled. Fisher's exact test was used. Ninety-seven patients were referred for motility disorder during this time and pathology reports were available for 62 patients (63.9%). Hypertrophy or hyperplasia of the myenteric plexus was reported in 13 patients (21.0%). These patients were predominantly females with constipation-dominant symptoms. They were more likely to have objective evidence of colonic inertia ( P = 0.01) than patients without myenteric plexus hypertrophy/hyperplasia. Consistent histopathologic abnormalities of myenteric plexus hypertrophy/hyperplasia were described in 21 per cent of patients with refractory GI motility disorders referred for surgical management. Our findings contrast with the hypoganglionosis reported in the slow transit constipation literature. Future studies are needed to systematically investigate these novel histologic findings through a follow-up immunohistochemical study of stored bowel specimens.
Appendectomy and Pregnancy: Gestational Age Does Not Affect the Position of the Incision
Authors: de Moya Marc A. , Sideris Antonios C. , Choy Garry , Chang Yuchiao , Landman Wendy B. , Cropano Catrina M. , Cohn Stephen M.
Published: June 2020

The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.
Disease Recurrence Patterns and Analysis of Clinicopathological Prognostic Factors for Recurrence after Resection for Distal Bile Duct Cancer
Authors: Choi Sae Byeol , Han Hyung Joon , Park Pyoung Jae , Kim Wan Bae , Song Tae Jin , Kim Jae Seon , Suh Sung Ock , Choi Sang Yong
Published: June 2020

Surgical resection is the treatment of choice for bile duct cancers. The aim of this study was to investigate disease recurrence patterns and prognostic factors for recurrence of distal bile duct cancers after surgical resection. A retrospective study was performed on 122 patients with distal bile duct cancers who underwent R0 or R1 surgical resection at Korea University Guro Hospital from 1991 to 2010. Sites of initial disease recurrence were classified as locoregional or distant. Univariate and multivariate analyses were performed to investigate the factors affecting recurrence. Of the 122 patients, 80 patients developed recurrence. The disease-free survival rate was 63.1 per cent at one year and 36.4 per cent at three years. The patterns of recurrence at diagnosis were locoregional in 25 patients, locoregional and distant metastasis in 14 patients, and distant metastasis in 41 patients. Multivariate analyses revealed that recurrence pattern, lymph node metastasis, and differentiation are independent prognostic factors affecting disease-free survival. R status (marginal significance) and tumor differentiation were independent prognostic factors associated with locoregional recurrence. Differentiation and lymph node metastasis were independent prognostic factors associated with distant metastasis. The prognosis after recurrence was poor with a 1-year survival rate after recurrence of 26.1 per cent. Adjuvant chemo- or radiation therapy, delivered in patients mainly with R1 resection or with presence of lymph node metastasis, did not demonstrate the survival benefit. Significant factors for recurrence were tumor differentiation and lymph node metastasis. Therefore, close follow-up and adjuvant therapy will be necessary in patients with lymph node metastasis or poorly differentiated tumor.