bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of Conventional Wound Treatment in a Comprehensive Wound Center
Authors: Akopian Gabriel , Nunnery Susan P. , Piangenti Jenny , Rankin Pam , Rinoie Chugo , Lee Elizabeth , Alexander Magdi
Published: June 2020

Conventional wound care is the elementary treatment modality for treating chronic wounds. However, early treatment with topical growth factors may be needed for a subset of chronic wounds that fail to heal with good wound care alone. A prospective nonrandomized case series from a single-community outpatient wound care clinic is presented here in an effort to identify the subset of chronic wounds that may require early adjuvant intervention. There were 378 consecutive patients with 774 chronic wounds of varying etiology. All patients received 4 weeks of conventional wound care, including weekly debridement and twice-daily dressing changes. Wounds not reduced by 50 per cent volume at 4 weeks were nonrandomly treated with human skin equivalent (Apligraf®), platelet-derived wound healing factor, or platelet-derived growth factor isoform BB (becaplermin gel, Regranex®). A total of 601 of 774 (78%) wounds healed regardless of treatment type. The median time to heal for all wounds was 49 days (interquartile range = 26–93). More women than men healed (85% vs 71%, respectively, P < 0.0001). Diabetic wounds were as likely to heal as nondiabetic wounds (78% vs 80%, P = 0.5675). Wounds that did not heal had larger volumes and higher grade compared with wounds that healed (P < 0.0001 for both variables). The data presented here show that the majority of chronic wounds will heal with conventional wound care, regardless of etiology. Large wounds with higher grades are less responsive to conventional wound care and will benefit from topical growth factor treatment early in the treatment course.
Splenic Abscess: An Easily Overlooked Disease?
Authors: Tung Cheng-Cheng , Chen Feng-Chi , Lo Chong-Jeh
Published: June 2020

Splenic abscess is an uncommon but potentially life-threatening disease. Recent advances in radiology have affected the diagnosis and management of this disease entity. The purpose of this study was to review our experience in managing these patients. We retrospectively reviewed the medical records of 51 patients with splenic abscess as seen in a tertiary medical center between 1998 and 2003. We analyzed the demographics, clinical manifestations, etiology, predisposing factors, diagnostic modalities, bacteriologic profile, treatment, and outcome of these patients. The mean age was 59.9 ± 14.2 years (ranging from 21–89 years). The male:female ratio was 29:22. Common symptoms included fever (82%), abdominal pain (71%), and nausea and vomiting (46%). The majority of these patients (83%) had leukocytosis. Thirty-six patients had associated parenchymal liver diseases and 26 patients had diabetes mellitus. Abdominal sonogram or computed tomography was performed to establish the diagnosis. Most cultures from the abscess cavities grew gram-negative enteric bacilli. Patients were treated with antimicrobial therapy only (n = 33), additional percutaneous drainage with a pigtail catheter (n = 11), or splenectomy (n = 7), and the survival rates were 48 per cent, 45 per cent, and 100 per cent, respectively. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy appears to have better treatment outcome than percutaneous drainage or intravenous antibiotics alone.
Biliary-Colonic Fistula: A Case Report and Literature Review
Authors: Munene Gitonga , Graham Jay A. , Holt Richard W. , Johnson Lynt B. , Marshall Harry P.
Published: June 2020

We report the occurrence of common bile duct obstruction and biliary-colonic fistula after open cholecystectomy. Although it is a very unusual complication after cholecystectomy, biliary-colonic fistula should be part of the differential diagnosis for patients presenting with sepsis after open or laparoscopic cholecystectomy. After confirmation and characterization of the injury by endoscopic retrograde cholangiopancreatography and cholangiogram, assessment for undrained collections by computed tomography scan, control of sepsis and coagulopathy, and nutritional support, surgical repair was undertaken. The patient underwent fistula take-down between the common bile duct and the colon at the hepatic flexure, primary closure of the colon enterotomy, and a Roux-en-Y end-to-side hepaticojejunostomy at the confluence of the right and left hepatic ducts. Recovery was uneventful and the patient was doing well at the 6-month follow-up. Surgical repair should be undertaken by surgeons with extensive experience in hepatobiliary reconstruction.
Pancreatic Cancer Presenting with Hematemesis from Directly Invading the Duodenum: Report of an Unusual Manifestation and Review
Authors: Tomita Hiroyuki , Osada Shinji , Matsuo Masayuki , Shimokawa Kuniyasu
Published: June 2020

Pancreatic cancer is a rare cause of gastrointestinal bleeding, and it is extremely rare for hematemesis to be the initial manifestation of invasive pancreatic cancer. We report the case of a 67-year-old man with hematemesis who was found to have invasive pancreatic cancer with a bleeding duodenal ulcer. The patient was not icteric, but repeated sudden hematemesis. An urgent pancreatoduodenectomy was performed with a favorable outcome. Microscopic examination revealed that an adenocarcinoma originating from the pancreatic head extended to the muscularis propria of the duodenum. Furthermore, an exposed vessel and narrow fistula were found. The diagnosis, pathological findings, preoperative events, and postoperative outcome in this unusual case are reviewed.
Sentinel Lymph Node Biopsy for Occult Breast Cancer Detected during Breast Reduction Surgery
Authors: Golshan Mehra , Lesnikoski Beth-Ann , Lester Susan
Published: June 2020

Breast reduction surgery is considered a relative contraindication to a sentinel node biopsy because of the possibility that lymphatics have been interrupted by the procedure. We describe six patients who underwent successful sentinel lymph node biopsy for occult carcinomas detected after breast reduction surgery. A subsequent skin-sparing mastectomy, along with a sentinel lymph node biopsy, was performed. Reconstruction was possible in five of six patients. Sentinel lymph node biopsy should not be considered a contraindication after breast reduction surgery.
Microdissection-Based Allelotyping: A Novel Technique to Determine the Temporal Sequence and Biological Aggressiveness of Colorectal Cancer
Authors: Gamblin T. Clark , Finkelstein Sydney D. , Upsal Neil , Kaye Jonathan D. , Blumberg David
Published: June 2020

Pathologic staging in colorectal adenocarcinoma (CA) is based on the concept that the timing of metastatic tumor spread is directly related to the depth of the primary tumor invasion. To evaluate the temporal sequence of CA metastasis, we performed microdissection mutational profiling at multiple microscopic sites of primary and metastatic CA specimens. Twenty-one cases of CA were selected from fixed-tissue archives. Primary tumors were microdissected at the deepest point of invasion. Comparative mutational profiling for different genomic loci [1p36(CCM = cutaneous malignant melanoma], 3p26(OGGI = 8 oxoguanine DNA glycosylase), 5q23 (APC, MCC = mutated in colorectal cancer), 9p21(p16/CDKN2A = cyclin-dependent kinase 2A), 10q23(PTEN = phosphatase and tensin homolog [mutated in multiple advanced cancers 1]), 12p12(K-ras-2 point mutation), 17p13(TP53), 18q25(DCC= deleted in colorectal cancer) was carried out on each microdissected tissue target using microsatellite loss of heterozygosity determination or DNA sequencing. All primary and metastatic sites of CA manifested acquired mutational change in 18 to 91 per cent of the genomic markers. In 15/21 (71%) cases, metastatic sites lacked a specific allelic loss seen in the corresponding primary tumor, indicating that the metastasis occurred before maximal depth of primary invasion. This was further supported by discordant mutational profiles between primary and secondary tumors, requiring divergent clonal evolution. This is the first report describing the temporal sequence and significance of sequential mutational acquisition in clinical tissue specimens with potential implications for a new molecular pathology approach to classify human cancer.
A Planned Complex Suicide: Need for a High Index of Suspicion
Authors: Parra Michael W. , Lube Matthew W. , Al-Khayat Haitham , Cheatham Michael L.
Published: June 2020

Unusual ways of committing suicide are reported in the medico-legal literature, but few refer to the so-called “planned complex suicide” (PCS).1 PCS, also termed primary combined suicide, is defined as the combination of two or more methods of injury by the suicidal person to prevent failure of a single method of suicide alone. In contrast, in secondary or unplanned complex suicide, the victim uses the second method of suicide only after failure of the first method.2 Combinations of shooting, hanging, burning, and/or poisoning have been used as suicidal methods.3–6 Sometimes the double use of one method such as simultaneous gunshot wound from two firearms or ingestion of two different toxic substances has been reported. This gives the suicidal person a high degree of protection against failure of one of the methods, as both modes of injury are relatively certain.2 This case report demonstrates the importance of the treating physician maintaining a high index of suspicion for the possibility PCS with the aim of avoiding a misdiagnosis that may be fatal.
Laparoscopic Debridement of Recurrent Pancreatic Abscesses in the Hostile Abdomen
Authors: Haan James M. , Scalea Thomas M.
Published: June 2020

Recurrent necrotizing pancreatitis in the frozen or hostile abdomen remains a challenge. Percutaneous drainage is useful in these cases but often fails if there is significant pancreatic necrosis. We describe a technique for laparoscopic drainage of necrotic pancreas. The preexisting percutaneous drainage tract was sequentially dilated and a working thoracoscope was placed via a Hasson cannula. A pulsatile irrigation system was used to open the cavity for visualization and to wash away obvious necrotic debris. Working sequentially using the irrigation jet flow for debridement and visualization, we opened the entire tract and debrided a majority of the necrotic tissue. A large drainage tube was placed to allow the egress of any residual infection. Three patients to date have been treated with the above technique with no intraoperative complications. All three patients did well initially postoperatively and had adequate drainage. One patient developed a delayed pancreatic pseudocyst. Laparoscopic debridement via percutaneous drainage tract is a useful technique in the hostile abdomen.
Use of Sentinel Node Mapping for Cancer of the Colon: ‘To Map or Not to Map’
Authors: Thomas Kristen A. , Lechner Jonathan , Shen Perry , Waters Gregory S. , Geisinger Kim R. , Levine Edward A.
Published: June 2020

Sentinel lymph node (SLN) mapping has become a cornerstone of oncologic surgery because it is a proven method for identifying nodal disease in melanoma and breast cancer. In addition, it can ameliorate the surgical morbidity secondary to lymphadenectomy. However, experience with SLN mapping for carcinoma of the colon and other visceral malignancies is limited. This study represents an update to our initial pilot experience with SLN mapping for carcinoma of the colon. Consenting patients over the age of 18 diagnosed with adenocarcinoma of the colon were included in this study. At the time of operation, 1 to 2 mL of isosulfan blue was injected with a 25-gauge needle into the subserosa at 4 sites around the edge of the palpable tumor. The SLN was identified visually and excised followed by a standard lymphadenectomy and surgical resection. SLNs were evaluated by standard hematoxylin and eosin (H&E) evaluation as well as immunohistochemical (IHC) techniques for carcinoembryonic antigen and cytokeratin if the H&E was negative. Sixty-nine patients underwent SLN mapping. A SLN was identified in 93 per cent (64 of 69) of patients. Nodal metastases were identified in 38 per cent (26 of 69) of patients overall. In 5 patients, the only positive node identified was the SLN, 2 of which were positive by IHC criteria alone. Therefore, 3 per cent (2 of 69) of patients were upstaged by SLN mapping. This technique was 100 per cent specific while being 46 per cent sensitive. Fourteen patients had false-negative SLNs. Metastasis to regional lymph nodes remains the key prognostic factor for colon cancer. SLN mapping is feasible for colon cancer and can identify a subset of patients who could benefit from adjuvant chemotherapy. Although SLN mapping did not alter the surgical management of colon cancer, it does make possible a more focused and cost-effective pathologic evaluation of nodal disease. We do not suggest routine utilization of SLN mapping for colon cancer, but we believe that the data supports proceeding with a national trial.
Does Obesity Predict Functional Outcome in the Dysvascular Amputee?
Authors: Kalbaugh Corey A. , Taylor Spence M. , Kalbaugh Brooke A. , Halliday Matthew , Daniel Grace , Cass Anna L. , Blackhurst Dawn W. , Cull David L. , Langan Eugene M. , Carsten Christopher G. , York John W. , Snyder Bruce A. , Youkey Jerry R.
Published: June 2020

Limited information is available concerning the effects of obesity on the functional outcomes of patients requiring major lower limb amputation because of peripheral arterial disease (PAD). The purpose of this study was to examine the predictive ability of body mass index (BMI) to determine functional outcome in the dysvascular amputee. To do this, 434 consecutive patients (mean age, 65.8 ± 13.3, 59% male, 71.4% diabetic) undergoing major limb amputation (225 below-knee amputation, 27 through-knee amputation, 132 above-knee amputation, and 50 bilateral) as a complication of PAD from January 1998 through May 2004 were analyzed according to preoperative BMI. BMI was classified according to the four-group Center for Disease Control system: underweight, 0 to 18.4 kg/m2; normal, 18.5 to 24.9 kg/m2; overweight, 25 to 29.9 kg/m2; and obese, ≥30 kg/m2. Outcome parameters measured included prosthetic usage, maintenance of ambulation, survival, and maintenance of independent living status. The χ2 test for association was used to examine prosthesis wear. Kaplan-Meier curves were constructed to assess maintenance of ambulation, survival, and maintenance of independent living status. Multivariate analysis using the multiple logistic regression model and a Cox proportional hazards model were used to predict variables independently associated with prosthetic use and ambulation, survival, and independence, respectively. Overall prosthetic usage and 36-month ambulation, survival, and independent living status for the entire cohort was 48.6 per cent, 42.8 per cent, 48.1 per cent, 72.3 per cent, and for patients with normal BMI was 41.5 per cent, 37.4 per cent, 45.6 per cent, and 69.5 per cent, respectively. There was no statistically significant difference in outcomes for overweight patients (59.2%, 50.7%, 52.5%, and 75%) or obese patients (51.8%, 46.2%, 49.7%, and 75%) when compared with normal patients. Although there were significantly poorer outcomes for underweight patients for the parameters of prosthetic usage when compared with the remaining cohort (25%, P = 0.001) and maintenance of ambulation when compared with overweight patients (20.8%, P = 0.026), multivariate analysis adjusting for medical comorbidities and level of amputation showed that BMI was not a significant independent predictor of failure for any outcome parameter measured. In conclusion, BMI failed to correlate with functional outcome and, specifically, obesity did not predict a poorer prognosis.
Laparoscopic Transgastric Removal of an Eroded Angelchik Prosthesis
Authors: Carbonell Alfredo M. , Maher James W.
Published: June 2020

The Angelchik prosthesis is a silicone gel-filled implant historically placed around the gastroesophageal junction for the treatment of gastroesophageal reflux disease. Herein, we describe the laparoscopic transgastric removal of an Angelchik prosthesis that had eroded through the gastroesophageal junction of a patient 25 years after its placement. Under direct laparoscopic and endoscopic guidance, laparoscopic trocars were placed transabdominally, directly into the gastric lumen. Using 2-mm instrumentation, the prosthesis was transected, endoscopically snared, and removed perorally. The patient was discharged after a 3-day hospital stay. This is the first published description of a laparoscopic, transgastric approach to removal of a partially eroded prosthetic device to the stomach.
Celiac Artery Aneurysms: A Case Report and Review of the Literature
Authors: Connell John M. , Han David C.
Published: June 2020

Celiac artery aneurysms (CAA) are uncommon. Most are asymptomatic, but up to 20 per cent will present as surgical emergencies. We present a case of an asymptomatic CAA discovered in a 56-year-old male during evaluation for nephrolithiasis. Only rough estimates of the prevalence of CAA are available, ranging between 0.005 per cent and 0.05 per cent. There appears to be a slight male predominance, and atherosclerotic degeneration is the most common cause. Although most patients are asymptomatic, some will present with vague abdominal pain, nausea, vomiting, or symptoms of mesenteric ischemia. Rupture is a devastating presentation, with reported mortality rates from 35 per cent to 80 per cent. Repair is performed by ligation or reconstruction. Ligation should be considered in an urgent setting, with reconstruction preferred for elective repair. Morbidity and mortality from elective repair should not exceed 5 per cent. Repair of CAA should be undertaken unless major comorbid factors are prohibitive.
Laparoscopic Greater Omentum Harvesting with Split-Thickness Skin Grafting for Sternal Wound Dehiscence
Authors: Barragan Barnard A. , Halldorsson Ari O. , Wachtel Mitchell S. , Frezza Eldo E.
Published: June 2020

Sternal wound dehiscence is a serious complication occasionally requiring soft tissue coverage. The greater omentum typically has been used as a last resort because of the underlying morbidity from a laparotomy. We present a case in which a laparoscopically created omental flap with subsequent split-thickness skin grafting was used to correct a large soft tissue defect that occurred after sternal wound dehiscence developed. A nonambulatory 49-year-old man who underwent coronary artery bypass grafting developed sternal wound dehiscence. Because a large soft tissue defect developed after multiple debridements, soft tissue coverage was required. A laparoscopically harvested omental flap spared this man's upper extremity musculature and provided a soft tissue bed for split-thickness skin grafting. This case helps to establish the role of laparoscopically harvested omentum. If the results suggested by this case are confirmed in a large series, omental flaps should be considered as options of first choice in the management of sternal wound dehiscence.
Risk Factors of Abdominal Surgery in Patients with Collagen Diseases
Authors: Nakashima Hideaki , Karimine Nobuya , Asoh Tsukasa , Ueo Hiroaki , Kohnoe Shunji , Mori Masaki
Published: June 2020

Patients with collagen diseases have been reported to demonstrate a greater risk when undergoing surgical operations. To determine the risk factors in abdominal surgery for patients with collagen diseases, 32 patients with collagen diseases who underwent abdominal surgery were analyzed for their clinical features and surgical results by comparing 26 cases from the favorable prognosis group (Group A) and 6 cases resulting in hospital death (Group B). The analysis revealed that emergent operations tended to result in worse outcomes ( P = 0.011) than elective operations and that cases undergoing operations for collagen disease-related problems, including intestinal perforation and acute pancreatitis, also showed a worse postoperative course than those who underwent operations for problems unrelated to collagen diseases, such as carcinomas and cholelithiasis ( P = 0.0006). The dose of steroids administered at the time of operation was also significantly higher in Group B than in Group A ( P = 0.03). These results suggested that the patients with collagen diseases should be followed periodically not only for the primary disease but also for any potential surgical diseases to identify such diseases at an early stage and to avoid an emergent operation, and that patients treated with high doses of steroids also need intensive care after abdominal surgery.
Gallbladder Management during Laparoscopic Roux-en-Y Gastric Bypass Surgery: Routine Preoperative Screening for Gallstones and Postoperative Prophylactic Medical Treatment are Not Necessary
Authors: Patel Kevin R. , White S.C. , Tejirian Talar , Han Soo H. , Russell Doug , Vira Darshai , Liao Lingchen , Patel Karina B. , Gracia Carlos , Haigh Phillip , Dutson Erik , Mehran Amir
Published: June 2020

In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.
Routine Postoperative Upper Gastroesophageal Imaging is Unnecessary after Laparoscopic Roux-en-Y Gastric Bypass
Authors: Bertucci William , White Stephen , Yadegar John , Patel Kaushal , Han Soo Hwa , Blocker Oliver , Frickel Deborah , Kadell Barbara , Mehran Amir , Gracia Carlos , Dutson Erik
Published: June 2020

Routine early postoperative upper gastroesophageal imaging (UGI) is often used in laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures to confirm anastomotic patency and to exclude leaks. The aim of our study was to assess the usefulness of this practice. From January 2003 to November 2004, 322 LRYGB cases were performed using linear staplers for the gastrojejunostomy and jejuno-jejunostomy anastomoses. As part of our protocol, all patients received a Gastrograffin® (Mallinkrodt, Inc., St Louis, Missouri) UGI on postoperative Day 1. The same radiological techniques were used and the same radiological team reviewed all films. Abnormal films were identified. In addition, patient demographics, time to discharge, and complications were collected and analyzed in a prospective database. There were no anastomotic leaks or obstructions. However, 42 of 322 (13%) studies demonstrated delayed gastric emptying. There were no statistically significant differences between patients with normal and delayed UGI studies. Routine UGI studies did not contribute significantly to patient care, and its routine use was subsequently abandoned.
Number of Lymph Nodes Examined and its Impact on Colorectal Cancer Staging
Authors: Kim Justin , Huynh Richard , Abraham Iype , Kim Eddie , Kumar Ravin R.
Published: June 2020

The status of lymph nodes is the most important prognosticator in colorectal cancer patients. Patients with lymph node involvement have a lower survival rate and are candidates for adjuvant therapy. The purpose of our study was to determine the number of lymph nodes that needs to be examined to accurately detect nodal metastasis. We conducted a retrospective study of 151 patients who underwent colorectal cancer operation at Harbor-UCLA Medical Center. Data from the operative report and pathology report were collected and analyzed. Fourteen (33.3%) patients with five to nine nodes examined had positive nodes. Twenty-six (57.8%) patients with 10 to 14 nodes examined had positive nodes. Patients who had 10 to 14 nodes examined were significantly more likely to have positive lymph nodes (P = 0.03). Patients with advanced T stage had a significantly higher number of positive lymph nodes (78.1% in T4 vs 11.1% in T1, P < 0.0001). Patients with poorly differentiated cancer showed a trend toward a higher positive node rate. Tumor differentiation and T stage seem to correlate with higher nodal metastasis rate. A higher number of lymph nodes examined was associated with a higher nodal metastasis rate. Examination of at least 10 lymph nodes would increase the yield of positive lymph nodes and avoid under-staging of patients with colorectal cancer.
Can a Meta-Analysis Answer the Question: Is Mucosectomy and Handsewn or Double-Stapled Anastomosis Better in Ileal Pouch-Anal Anastomosis?
Authors: Schluender Stefanie J. , Mei Ling , Yang Huiying , Fleshner Phillip R.
Published: June 2020

Although ileal pouch-anal anastomosis (IPAA) is the procedure of choice for polyposis and ulcerative colitis with medically refractory disease or dysplasia, controversy exists concerning whether mucosal preservation with double-stapled (DS) IPAA is superior to mucosectomy and handsewn (HS) IPAA anastomosis for postoperative function. Prospective studies have shown no statistically significant differences. The use of meta-analysis can strengthen statistical power by combining the data from related studies. A meta-analysis was performed to determine whether there was a significant difference in functional and manometric outcome between HS-IPAA and DS-IPAA. Prospective, randomized studies were identified using a literature search. Functional outcome variables included number of normal continence, minor incontinence, nocturnal evacuation, the ability to discriminate flatus from stool, and antidiarrheal medication. Manometric outcomes included postoperative resting and squeeze anal pressures. Four prospective, randomized trials were identified. Of the 184 total patients, the HS-IPAA group included 86 patients (48 men and 38 women) and the DS-IPAA group included 98 patients (49 men and 49 women). There were no significant differences in functional outcome between HS-IPAA and DS-IPAA. In addition, there was no significant difference in sphincter resting and squeeze pressures between the two patient groups. This meta-analysis demonstrates that DS-IPAA offers no advantage in functional or manometric outcome when compared with HS-IPAA.
Axillary Regional Recurrence after Sentinel Lymph Node Biopsy for Breast Cancer
Authors: Rosing David K. , Dauphine Christine E. , Vargas M. Perla , Gonzalez Katherine , Burla Melissa , Kaufmann Paul , Vargas Hernan I.
Published: June 2020

The accuracy of sentinel lymph node biopsy (SLNB) staging in breast cancer has been demonstrated in studies comparing it with axillary dissection. There is a 5 per cent false-negative rate, but this does not always correlate with axillary recurrence. Our purpose was to determine the rate of axillary lymphatic recurrence in breast cancer patients who had a negative SLNB. We conducted a cohort study of breast cancer patients who underwent SLNB between 2001 and 2005. Only patients who had a negative SLNB were included. Patient demographics and tumor factors were reviewed. Outcomes measured were axillary and systemic recurrence and survival. Eighty-nine patients with a mean age of 54.4 ± 9.9 years were included. Eighty-nine per cent of cases had infiltrating ductal carcinoma histology. Mean tumor size was 19 ± 14 mm. Breast conservation surgery was done in 65 cases and mastectomy in 24. A mean of 2.3 ± 2.4 SLN were found. After a median follow-up of 2.15 years, 1 (1%) patient developed a lymphatic recurrence in the axilla. SLNB provides accurate staging of breast cancer. Patients with negative SLNB do not require axillary dissection.
Splenectomy for Trauma Increases the Rate of Early Postoperative Infections
Authors: Wiseman James , Brown Carlos V.R. , Weng Janie , Salim Ali , Rhee Peter , Demetriades Demetrios
Published: June 2020

Little is known what effect splenectomy for trauma has on early postoperative infectious complications. Our aim was to determine if splenectomy increases early postoperative infections in trauma patients undergoing laparotomy. We reviewed all trauma patients undergoing splenectomy from June 2002 through December 2004. Each splenectomy patient was matched to a unique trauma patient who underwent laparotomy without splenectomy based on age, gender, mechanism of injury, injury severity score, and presence of colon or other hollow visceral injury. Outcomes included infectious complications including pneumonia, urinary tract infection, bacteremia, and intra-abdominal abscess, as well as mortality. There were 98 splenectomy patients and 98 controls. The splenectomy patients had more overall infectious complications (45% vs 30%, P = 0.04) trended toward more urinary tract infections (12% vs 5%, P = 0.12), and more often had pneumonia (30% vs 14%, P = 0.02). Additionally, more splenectomy patients developed multiple infections (20% vs 7%, P = 0.01). There was no difference in mortality (11% vs 8%, P = 0.63). Splenectomy is associated with an increase in infectious complications after laparotomy for trauma. More specifically, splenectomy patients more often develop pneumonia and multiple infections. This increase in infections is not associated with increased mortality.
Utility of Plain Film Pelvic Radiographs in Blunt Trauma Patients in the Emergency Department
Authors: Obaid Amal Kamil , Barleben Andrew , Porral Diana , Lush Stephanie , Cinat Marianne
Published: June 2020

The objective of this study was to evaluate the utility and sensitivity of routine pelvic radiographs (PXR) in the initial evaluation of blunt trauma patients. A retrospective review was performed. One hundred seventy-four patients with a pelvic fracture who had computed tomography (CT) and PXR were included (average age, 36.1; average Injury Severity Score, 16.3). Nine (5%) patients died. Five hundred twenty-one fractures were identified on CT. One hundred sixteen (22%) of these fractures were missed by PXR. Eighty-eight (51%) patients were underdiagnosed by PXR alone. The most common fractures missed by PXR were sacral and iliac fractures. Eight patients required angiograms, with four undergoing therapeutic pelvic embolization. Forty-seven (27%) patients were hypotensive or required a transfusion in the emergency department. These patients were more likely to require an angiogram (17% vs 0%, P < 0.0001) and were more likely to require embolization (9% vs 0%, P < 0.001). This study demonstrates that CT scan is highly sensitive in identifying and classifying pelvic fractures. PXR has a sensitivity of only 78 per cent for identification of pelvic fractures in the acute trauma patient. In hemodynamically stable patients who are going to undergo diagnostic CT scan, PXR is of little value. The greatest use of PXR may be as a screening tool in hemodynamically unstable patients and/or those that require transfusion to allow for early notification of the interventional radiology team.
Mesenteric Injuries after Blunt Abdominal Trauma: Delay in Diagnosis and Increased Morbidity
Authors: Shebrain Saad , Zelada Juliette , Lipsky Ari M. , Putnam Brant
Published: June 2020

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.
Evaluation of Bronchoscopic-Assisted Percutaneous Tracheostomy
Authors: Tomsic Jason P. , Connolly Mark C. , Joe Victor C. , Wong David T.
Published: June 2020

The convenience of bedside percutaneous tracheostomy (PT) is growing in popularity. Some centers are placing PTs without the assistance of bronchoscopy. The study objective was to identify operative and perioperative problems with PT placement and to identify potential problems with bronchoscopy-free placement. All operative and perioperative events were prospectively recorded as a performance improvement project at our institution while performing bronchoscopic-assisted bedside PTs. One hundred eighty-three patients underwent PT placement, all with the assistance of a bronchoscope. Although most PT was performed without incident, some of the complications can be severe. The majority of difficulties can be prevented with bronchoscopic assistance. An unexpected procedural difficulty that has not been previously reported is the dilatational difficulty in the younger patient population. Some of these patients required an additional tracheal incision with a scalpel. This may be from a healthy pretracheal fascia and/or musculature.
Transmetatarsal Amputation: Predictors of Healing
Authors: Nguyen Tien H. , Gordon Ian L. , Whalen Delores , Wilson Samuel E.
Published: June 2020

The objective of this study is to determine the predictors of healing after transmetatarsal amputations (TMA) and factors leading to a higher level of amputation. A total of 33 TMA was performed in 31 patients during the 5 years between January 2000 and Jul 2005. All patients were men between the ages of 44 and 82 years (mean, 68 years). The mean follow-up period was 36 months (range, 1–65 months). Twelve (40%) TMA required a subsequent higher level of amputation. Seventeen (57%) TMA were successful. The average time until further proximal amputation after TMA was 3.5 months. Risk factors for subsequent higher amputation by univariate analysis included infrapopliteal arterial occlusion (P < 0.05), tobacco smoking greater than 20 years (P < 0.05), and further TMA debridement (P < 0.05). Upon multivariate analysis, only patients undergoing further TMA debridement were at risk for TMA failure (P = 0.01). The difference in ankle-to-brachial pressure ratio (ABI) between the higher amputation group (ABI = 0.51) and the successful TMA group (ABI = 0.54) was not significant. There were no perioperative deaths after TMA. Five (18%) deaths occurred at a mean of 8.2 months after the TMA. In patients who are walking preoperatively, aggressive TMA is warranted in an attempt to maintain ambulation, recognizing that requirement for further debridement, smoking history, and infrapopliteal occlusion may be predictors of nonhealing and subsequent higher amputation.
Simulation: A Strategy for Success in Quality and Safety in Pay-for-Performance Environments
Authors: Loyd Gary E.
Published: June 2020

Pay-for-Performance appears to be another step in our ever-changing healthcare environment. In most of the white papers, reports, and web pages devoted to improving the quality of healthcare in America, there is a failure to recognize or list medical simulation as a methodology to reduce the costs of implementation and to speed transition to the new order. The Agency for Healthcare Research and Quality is funding research in simulation to improve quality. This article outlines the rationales for using simulation and how simulation can benefit all involved. With a paucity of proof that simulation can deliver in terms of improving the quality of healthcare, the mass of evidence has been from observation and anecdotal tales of medical professionals that simulation is a valid tool. This article correlates the use of simulation in other nonmedical pay-for-performance professions to similar situations in medicine as some other evidence that simulation should be considered a viable option. I conclude by relating the individual strengths of simulation to the six quality initiatives of the Institute of Medicine's second report from the Committee on Quality of Health Care in America. Simulation can work to enhance the assimilation of change with each of these initiatives and help to reduce the costs of doing so. There are limitations to simulation, but used within those limitations, simulation should prove to be a powerful tool.
The Practicing Surgeon as a Member of the Quality–Safety Team
Authors: Vallance Steven R. , Schell Robert H. , Robbins Robert E.
Published: June 2020

The practicing surgeon is a valuable member of the quality–safety team and is often an underutilized data source for quality initiatives. The authors describe how their efforts in Kentucky, during a 10-year period, encouraged surgeons to become leaders in the quality initiative. Their experience began with the establishment of an organization of surgeons devoted to quality health care and cost control. As their efforts expanded and they gained experience, they were well prepared to transition to a regional and national quality initiative as part of a collaborative effort with the Centers for Medicare and Medicaid Services in the 2004 Surgical Care Improvement Project pilot. As a result of this ongoing experience, the authors we have been able to affect the quality of health care and have a positive influence on health care cost. They have demonstrated that surgeons will participate in and lead quality initiatives, and that these efforts foster an environment of cooperation between surgeons and hospitals.
Linking Processes and Outcomes to Improve Surgical Performance: A New Approach to Morbidity and Mortality Peer Review
Authors: Pine Michael , Fry Donald E.
Published: June 2020

Peer review of surgical cases resulting in death or potentially avoidable complications is a longstanding tradition, but intensive reviews of individual cases rarely produces tangible improvements in clinical outcomes. The systematic comparison of care received by patients who experienced adverse outcomes to care received by patients who had uneventful surgical courses is a promising alternative to intensive case review. However, the results of these studies may be misleading because physicians often choose interventions based on their perceptions of patients’ preoperative risks, and higher adverse outcome rates among patients with higher preoperative risk may distort comparisons of alternative interventions. The creation of a control sample by carefully matching each patient who experienced an adverse outcome to a patient who had a similar preoperative risk but did not experience an adverse outcome can overcome this problem and provide excellent insight into how to improve clinical performance most effectively and efficiently. By using currently available electronic data to compute each patient's risk of an adverse outcome, a series of cases with adverse outcomes can be matched to an equal number of controls. Peer review committees can then direct focused data collection and analyses of potentially critical processes of care to determine which, if any, are associated with significantly poorer clinical results. A simulated scenario is analyzed in detail to illustrate the ability of this technique to correctly determine best practices when other approaches fail to do so.
The Effect of Bacterial Contamination on Neointimal Hyperplasia in Vascular Grafts
Authors: Edwards Norma M. , Claridge Jeffrey A. , Shell Dan H. , Handorf Charles R. , Croce Martin A. , Fabian Timothy C.
Published: June 2020

Neointimal hyperplasia (NH) is the most significant contributing factor to long-term vascular graft failure. Inflammation is known to be important in its development; however, the role of bacterial infection is unclear. We examined the effect of contamination with common organisms on the development of NH in expanded polytetrafluoroethylene grafts. Thirty adult pigs were randomized into one of four groups: no infection, contamination with Staphylococcus aureus, mucin-producing Staphylococcus epidermidis, or Pseudomonas aeruginosa. An expanded polytetrafluoroethylene graft (6 mm x 3 cm) was placed as a common iliac artery interposition graft and was inoculated with 1–2 x 108 of the selected organism before closure. Grafts were explanted 6 weeks postoperatively. Microbiologic, histological, and morphometric evaluations were performed. All grafts were patent at the time of euthanasia. The mean areas of NH were 5.45 mm2 in sterile grafts, 8.36 mm2 in S. aureus, 7.63 mm2 in S. epidermidis, and 11.52 mm2 in P. aeruginosa grafts. Comparison of means via analysis of variance showed that P. aeruginosa grafts had significantly higher formation of NH than sterile grafts (P = 0.025). NH production in infected grafts appears to be organism specific and is significantly higher with P. aeruginosa than common Gram-positive organisms. Increased NH from subclinical infection may be a significant factor contributing to late graft failures.
Acellular Dermal Allograft for Ventral Hernia Repair in the Compromised Surgical Field
Authors: Diaz Jose J. , Guy Jeffrey , Berkes Marshall B. , Guillamondegui Oscar , Miller Richard S.
Published: June 2020

A ventral hernia and a contaminated surgical field are a difficult surgical combination. We hypothesize that acellular human dermis (AHD) can be a suitable biological tissue alternative in the repair of a ventral hernia. The study involved a retrospective review of the use of AHD in the repair of ventral hernia from 2001–2004. Inclusion criteria included a ventral hernia repair in a clean-contaminated (CC) or contaminated-dirty (CD) surgical field. The primary outcome of the study was wound infection and mesh removal. Patients were stratified into CC and CD, and management of a wound infection [medically managed (MM) or surgically managed (SM)]. Seventy-five patients met the study criteria. The most common comorbidity was hypertension (45.3%). There was one death in the study (from multiple organ dysfunction syndrome). The overall wound infection rate was 33.3 per cent: 11 MM (14.7%) and 14 SM (18.7%). The average length of stay was 16.7 days (±20.8) with a mean follow-up of 275 (±209) days. Subgroup analysis: CC (n = 64) had 9 wound infections that were MM (14.1%) and 12 wound infections that were SM (18.8%); CD (n = 11) had 2 wound infections that were MM (18.2%) and 2 wound infections that were SM (18.2%). Five of 14 SM (35.7%) wound infections required removal of the mesh. Wound infection in the contaminated surgical field occurred 33.3 per cent of the time. Some (18.7%) of the cases required SM management, and 35.7 per cent of these required removal of the AHD.
Differential Expression of Prognostic Factors and Effect on Survival in Young (≤40) Breast Cancer Patients: A Case-Control Study
Authors: Hartley Michael C. , Mckinley Brian P. , Rogers Emily A. , Kalbaugh Corey A. , Messich H.S. , Blackhurst Dawn W. , Lokey Jonathan S. , Trocha Steven D.
Published: June 2020

The belief that young women develop more aggressive forms of breast cancer than other women is controversial. The purpose of this study was to determine if women 40 years of age and under with breast cancer have more negative prognostic indicators and a higher 5-year mortality than those women over 40 years of age. From January 1998–December 2002, all women with breast cancer were identified from our tumor registry. Women with metastatic disease at presentation were excluded from our study. The women were divided into two groups, women under 40 (cases) and women 40 and over (controls). Seventy-eight cases were identified and matched to 228 controls. These cohorts were matched 3:1 (cases:controls) based on tumor staging. The data collected on each patient included prognostic factors such as tumor size, tumor type, estrogen and progesterone receptors, Her2/neu, and Ki-67. Information on surgical procedure, postoperative therapy, recurrence, and mortality was also gathered. The mean ages for cases and controls were 35 and 59 years, respectively. The rates of modified radical mastectomy were similar in the two groups, but young women were more likely to have breast reconstruction (33.7% vs 9.8%). The rates of breast conservation therapy were actually lower in the group under 40 (32.5% vs 37.6%). Tumors in the 40 and under group were more frequently estrogen receptor negative (33.8% vs 21.9%: P = 0.046) and progesterone receptor negative (50.0% vs 35.5%: P = 0.033). Younger women also experienced a greater prevalence of Ki-67 (P < 0.001) and higher levels of Her2/neu overexpression (P = 0.013). Women over 40 were more likely to receive hormonal therapy (39.7% vs 36.1%). Women over 40 had a lower overall rate of recurrence. A difference in overall survival does exist between these two groups of women, which trends toward significance. The women 40 and under had a lower overall 5-year survival. The reason for this difference remains unclear. Although we demonstrate a higher percentage of younger women with negative biochemical markers, the only factors independently and significantly related to higher mortality were estrogen receptor negativity and tumor stage at presentation.