bluuebunny/crossref_metadata_2025 huggingface dataset:
Visceral Artery Aneurysms: Experience in a Tertiary-Care Center
Authors: Hossain Azhar , Reis Ernane D. , Dave Sandeep P. , Kerstein Morris D. , Hollier Larry H.
Published: November 2022

Visceral artery aneurysms (VAAs) often rupture and cause serious morbidity or death. The purpose of this study was to identify conditions associated with VAA in a series of 30 patients treated at our institution from 1988 through 1998. Demographics, types of aneurysms, associated conditions, diagnoses, treatments, and outcomes were recorded and analyzed. Thirty patients (16 men and 14 women) with VAA were identified. The arteries involved were splenic (eight), renal (ten), hepatic (nine), hypogastric (one), celiac (one), and pancreaticoduodenal (one). Five of eight (63%) splenic artery aneurysms occurred in women; however, gender was not a factor in other aneurysmal groups. Splenic artery aneurysm also was associated with cirrhosis in four of the eight (50%) patients. Five of the nine (56%) hepatic artery aneurysms were associated with cirrhosis; two of these were pseudoaneurysms that occurred after liver transplantation. Five of ten (50%) renal artery aneurysms were associated with juxtarenal abdominal aortic aneurysms. Celiac and pancreaticoduodenal aneurysms were associated with gastrointestinal bleeding. Treatments included surgery (19), embolization (eight), and observation alone (three). These data demonstrate that association with other conditions varies according to subgroups of VAA. Despite advances in diagnosis and therapy the heterogeneity of VAA suggests that management must remain individualized.
Talc Pleurodesis: A New Technique
Authors: Ross R.T. , Burnett Clay M.
Published: November 2022

Pleurodesis is a commonly used option in the management of malignant pleural effusion. Although several chemical agents are used talc has only recently been advocated as the sclerosing agent of choice. Talc can be administered via open thoracotomy or tube thoracostomy, but thoracoscopy offers an excellent alternative to these approaches. We describe a new technique of thoracoscopically applied talc pleurodesis that is easy, inexpensive, and reliable.
Clinical Utility of Frozen Section in Sentinel Node Biopsy in Breast Cancer
Authors: Gulec Seza A. , Su Joseph , O'Leary J. Patrick , Stolier Alan
Published: November 2022

One hundred sixty-five breast cancer patients underwent a sentinel lymph node biopsy procedure over a period of 2 years. Sentinel node (SN) could be successfully localized in 157 (95%) of the patients. Complete axillary lymph node dissection was performed only if the frozen section (FS) revealed a positive SN. All SN specimens were further evaluated by hematoxylin and eosin on multiple sections and cytokeratin immunohistochemisty. The patients whose SNs were negative by FS but positive by permanent histopathologic evaluation underwent a delayed axillary lymph node dissection. SN was positive in 41 of 157 (26%) patients. Eighteen (44%) of the 41 patients with SN metastases were diagnosed intraoperatively by FS and underwent a one-stage definitive surgical treatment. The benefit of FS was most notable in patients with T1cand larger lesions.
Stereotactic Breast Biopsy: A Study of First Core Samples
Authors: Kaufman Henry J. , Witherspoon Laura E. , Gwin John L. , Greer Michael S. , Burns R. Phillip
Published: November 2022

Stereotactic core needle biopsy (SCNB) is a sensitive and specific indicator of breast pathology. Commonly the first biopsy core is taken from the center of the lesion in question. Multiple cores are then taken from points peripheral to the central core. The sensitivity and specificity of the central core to diagnose breast disease is unclear. We compared the pathology of the central core biopsy with that of the remaining cores in a prospective study to determine the sensitivity and specificity of the central core to diagnose breast disease. All patients undergoing SCNB for breast lesions in a single surgical office during a 7-month period were eligible for inclusion. One hundred thirty-three patients with first cores from 145 biopsy sites were included. The histologic diagnosis from 117 (81%) of the first cores from these 145 biopsy sites were representative of their respective samples as a whole. Seventy-seven (53%) of the first cores were in complete agreement with the final histologic diagnosis whereas 40 (28%) had minor differences with the histologic diagnosis that had little or no clinical significance. Twenty-eight (19%) central core samples did not agree with the final pathologic diagnosis. Seven of these 28 patients each had a final diagnosis of cancer missed by the central core biopsy. The first core sample had a sensitivity for cancer detection of 79 per cent and specificity 100 per cent. SCNB remains a sensitive and specific identifier of breast pathology. When mammographic evidence of calcifications was the primary indication for SCNB (n = 75) calcification was present in the central core in 51 (68%). In these 51 patients the central core biopsy was in agreement with the final histologic diagnosis in 46 (90%) specimens. Histologic review of the first core sample alone lends no increased benefits and in fact misrepresents the pathology present in a significant number of patients. When analyzed as an independent predictor of breast pathology the first core is a more sensitive indicator than subsequent individual cores, but the most accurate predictor of pathology is examination of the entire group of core samples. This study confirms the need for acquisition of multiple cores from each lesion in question.
Modification of a Choledochoscope for Extraction of Difficult Biliary Stones
Authors: Roth Jeffrey J. , Mann Barry D. , Gerhard Christine , Kerstein Morris D.
Published: November 2022

Cholelithiasis is a common problem in the United States, affecting 10 to 15 per cent of the population. Although only one per cent of these patients have intrahepatic gallstones their discovery intraoperatively may present a technical challenge for the surgeon. This paper describes a simple method for dislodging difficult intrahepatic biliary stones: modification of a rigid choledochoscope to permit use of a biliary Fogarty catheter and Segura basket under direct visualization.
A Rare Case of Primary Group A Streptococcal Peritonitis
Authors: Sanchez Noel C. , Lancaster Brent A.
Published: November 2022

Primary Group A streptococcal peritonitis is a rare clinical entity that is almost always associated with underlying disease. Group A streptococcus commonly causes upper respiratory tract infections and cutaneous infections such as impetigo and erysipelas. However, Group A streptococcus has rarely been associated with gastrointestinal infections. This is a case report describing a previously healthy adult male who developed primary Group A streptococcal peritonitis. Diagnostic laparoscopy resulted in identification of peritonitis without an identifiable intra-abdominal source. Appropriate antibiotic therapy was instituted. Culture of blood, sputum, urine, and urethra were all pathogen free. The patient made a complete recovery and was dismissed from the hospital on oral clindamycin and cephalexin. To the best of our knowledge this report represents the only documented case of primary Group A streptococcal peritonitis in a male patient without any significant past medical history.
Cholecystitis in the Octogenarian: Is Laparoscopic Cholecystectomy the Best Approach?
Authors: Uecker John , Adams Mathis , Skipper Kent , Dunn Ernest
Published: November 2022

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.
Current Assessment of Thromboembolic Disease and Pregnancy
Authors: Armour RenéE , Schwedler Margaret , Kerstein Morris D.
Published: November 2022

This study was undertaken to assess incidence of deep venous thrombosis and pulmonary emboli in an inner-city pregnant population. Thromboembolic disease is believed to occur in 0.05 to 0.1 per cent of all pregnancies. Historically, postpartum thromboembolic disease was more common; decreased hospital stay may shift the thromboembolic disease to the antepartum period. A 5-year retrospective review of 4910 births assessed for incidence of thromboembolic disease, methods of diagnosis and treatment, and risk factors. A total of 4910 deliveries with 3978 transvaginal resulted in 30 episodes of deep venous thrombosis and five pulmonary emboli. All incidences of deep venous thrombosis but one were left-sided; four of five pulmonary emboli were postpartum. Of the epidsodes of deep venous thrombosis 17 per cent were first trimester, 50 per cent second trimester, 27 per cent third trimester, and 6 per cent postpartum. The diagnosis was confirmed by duplex scan in 24 of 30 patients. Heparin was the standard treatment. Deep venous thrombosis in pregnancy is most common in the second trimester; pulmonary emboli remain most common postpartum.
Trauma-Specific Intensive Care Units Can be Cost Effective and Contribute to Reduced Hospital Length of Stay
Authors: Park Christopher A. , Mcgwin Gerald , Smith Donald R. , May Addison K. , Melton Sherry M. , Taylor Allison J. , Rue Loring W.
Published: November 2022

Our hypothesis was that clinical outcomes are improved and cost and hospital length of stay (LOS) reduced as a result of the opening of a closed trauma intensive care unit (ICU). We conducted a cross-sectional study in a university-affiliated Level I trauma center. Our study population comprised trauma patients admitted to the ICU between June 1, 1996 and July 1, 1998 for at least 24 hours and with an Injury Severity Score (ISS) >16 (excluding those with severe brain injury). The main outcome measures were changes in LOS and number of ventilator days, prevalence of complications, changes in patient charges, and hospital costs. Two hundred four patients were included [trauma ICU (TICU) 60, surgical ICU 144]. The two groups were not statistically different in age, ISS, mechanism of injury, infection rate, and mortality; however, the TICU patients had a lower number of ventilator hours (83.1 vs 100.0; P = 0.007), lower ICU LOS (9.4 vs 12.1 days; P = 0.06), and lower total hospital LOS (15.6 vs 22.3 days; P = 0.01). Although this was not of statistical significance TICU patients had lower hospital charges ($125,383 vs $152,994; P = 0.06) and lower cost per case ($42,306 vs $47,548; P = 0.35) for a net savings of $314,520 during the first 6 months of operation of the TICU. This study suggests that improved clinical outcomes and decreases in cost and LOS are directly related to the opening of a closed trauma ICU.
Giant Biliary Cystadenoma: Case Report and Literature Review
Authors: Florman Sander S. , Slakey Douglas P.
Published: November 2022

Biliary cystadenoma is a very rare cystic neoplasm of the liver. This tumor is insidiously progressive and usually presents in white females in their fifth decade. It has a characteristic appearance on ultrasound, computed tomography, and angiography. The exact etiology of these tumors is unknown, but several theories have been proposed. Historically these cystic tumors have been treated by a variety of techniques including aspiration, fenestration, internal drainage, and resection. Previously reported series have confirmed a >90 percent recurrence rate with anything less than complete excision. In addition biliary cystadenoma is a premalignant lesion and only surgical excision can differentiate it from its malignant counterpart, biliary cystadeno-carcinoma.
Clinical Manifestations of Gastrointestinal Granulocytic Sarcoma Requiring Surgical Treatment
Authors: Zhou Wei , Vasquez Julio C. , O'donnell Margaret R. , Paz Benjamin I.
Published: November 2022

Granulocytic sarcoma is a rare extramedullary soft-tissue tumor of granulocytic lineage with an incidence of 3 to 5 per cent in patients with acute myelogenous leukemia. The most common sites of involvement are bone, soft tissue, lymph nodes, and skin. Here we report three unusual cases of granulocytic sarcoma involving the gastrointestinal tract that required surgical intervention.
Local Excision of Rectal Carcinoma
Authors: Chorost Mitchell I. , Petrelli Nicholas J. , McKenna Margo , Kraybill William G. , Rodriguez-Bigas Miguel A.
Published: November 2022

The purpose of this study was to identify the recurrence rate, the salvage rate after recurrence, and the overall survival after local excision of rectal adenocarcinomas. A retrospective medical chart review was performed in 31 consecutive patients with rectal adenocarcinoma who underwent local excision at Roswell Park Cancer Institute from January 1990 through December 1999. After excision nine patients were excluded from further analysis because they were found to have advanced stage on pathologic examination (T2 primary tumors with vascular invasion or T3 tumors). Eight of the nine patients underwent abdominoperineal resection as definitive therapy. In the remaining 22 patients who underwent transanal excision as definitive surgical therapy there were 13 patients with T1 tumors and nine patients with T2 tumors. Overall seven patients (32%) developed local recurrences after local excision. This included four patients with T1 and three patients with T2 primary tumors. All recurrences occurred in the seven patients who did not receive adjuvant chemoradiation. All patients underwent salvage resection of the recurrence. Four patients who underwent salvage resection of the recurrence remain without evidence of disease at a median follow-up of 19.5 months. Local excision without adjuvant therapy has an unacceptably high rate of local recurrence. Although most patients who recur locally are salvaged by radical resection the long-term results after resection remain unknown. The use of adjuvant chemoradiation appears to reduce this high recurrence rate and may eventually become a standard adjunct to local excision of rectal cancer.
Simultaneous Placement of Long-Term Central Venous Catheters and Surgical Debridement for Treatment of Osteomyelitis
Authors: Benak Mark A. , Kent Raleigh B.
Published: November 2022

Nonhealing wounds with underlying osteomyelitis require surgical debridement and a course of intravenous antibiotics usually via long-term venous catheter. Fear of catheter infection resulting from bacteremia or direct cross-contamination has traditionally led to staged procedures. A protocol for simultaneous placement of a long-term central venous catheter (Hickman) for antibiotic therapy and surgical debridement of chronic wounds with osteomyelitis does not result in elevated catheter-related infections. We conducted a prospective consecutive trial at a community-based tertiary-care training hospital. From October 1995 through June 1997 100 consecutive patients received 105 central venous catheters and surgical debridement for treatment of chronic wounds with underlying osteomyelitis at the same operative setting. Four catheters required removal because of infectious complications. There was no correlation between the bacteria cultured from the central venous line or blood cultures and the wound cultures. Combining placement of long-term central venous catheters and surgical debridement of chronic wounds with osteomyelitis at one operative setting results in an acceptably low catheter infection rate.
K-ras Mutational Analysis of Polyclonal Colorectal Cancers Identifies Uniclonal Circulating Tumor Cells
Authors: Thebo Jennifer S. , Senagore Anthony J. , Krygier Susan , Luchtefeld Martin A.
Published: November 2022

The clonal development of colorectal carcinoma resulting from specific mutations in certain oncogenes and/or tumor suppressor genes is a well-accepted model. It is increasingly recognized that a majority of colorectal cancers are polyclonal on the basis of molecular analysis that demonstrates cells with different mutations within a given oncogene or tumor suppressor gene in the same tumor. This polyclonal pattern may occur as a result of either clonal convergence or divergence during the many steps of oncogenesis. Further complicating this picture is the fact that metastatic lesions may arise from only one of the clonal populations within a tumor and thereby present only a partial molecular make-up of the whole tumor. There are few data available that define clonal selection or specificity of circulating tumor cells in patients undergoing curative resection of colorectal carcinoma. The purpose of this paper is to describe the clonal distribution of circulating tumor cells in four patients with multiple K- ras mutations present in the primary lesion. Patients were selected who were known to have polyclonal primary colorectal cancers resected for cure. All patients had multiple mutations present in exon one, codon 12 and/or 13, of the K- ras gene. Blood samples were drawn immediately before surgery and at 2-week to 6-month intervals postoperatively. Epithelial cells were isolated from peripheral blood mononuclear cells using Dynal ImmunobeadsRT coated with antiepithelial antibodies. DNA was extracted from these cells and analyzed for all K- ras mutations present in codons 12 and 13 of the patient's primary tumor using allele-specific polymerase chain reaction followed by Microwell Array Diagonal Gel Electrophoresis. Circulating tumor cells were identified in all four patients. However, in each case of positive circulating cells the only mutation identified was an aspartic acid mutation at codon 13. Once positive the circulating tumor cells persisted in subsequent multiple blood samples. These results provide further strength for the theory of polyclonal progression in primary colorectal cancers, although there may be specific mutational patterns that confer the ability to metastasize. The significance of this persistence of the glycine-to-aspartic acid mutation at codon 13 remains to be defined given that none of these patients has clinical evidence of recurrent cancer at the time of this report.
Blunt Trauma and the Role of Routine Pelvic Radiographs
Authors: Duane Therèse M. , Cole Frederic J. , Weireter Leonard J. , Britt L.D.
Published: November 2022

We evaluated clinical factors that are predictive of pelvic X-ray findings. We sought to identify whether routine pelvic films are necessary in blunt trauma and addressed whether removal of these films would minimize cost. We performed a retrospective chart review of 111 patients without pelvic fractures and 108 with pelvic fractures seen at our Level 1 trauma center between August 1998 and September 1999. We evaluated initial hemodynamics, physical examination findings, laboratory data, and hospital charges. Patients with fractures had higher Injury Severity Scores ( P < 0.001), a higher number of associated injuries ( P < 0.001), and lower blood pressures ( P < 0.001). The back and pelvic examinations were significantly associated with X-ray results ( P < 0.001), and the potential savings with selective radiography was $168,300.00 per year. We believe that clinical factors identified in our study predict the need for pelvic X-ray. Because removal of these films would minimize cost we recommend the elimination of routine pelvic films for the awake and alert blunt trauma patient.
Stress Ulceration Requiring Definitive Surgery after Severe Trauma
Authors: Zarzaur Ben L. , Kudsk Kenneth A. , Carter Katrina , Pritchard F. Elizabeth , Fabian Timothy C. , Croce Martin A. , Minard Gayle
Published: November 2022

Despite antiulcer prophylaxis 19 severely injured patients at our institution developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n = 4) or bleeding (n = 15). A herald bleed (HB) 10.7 ± 1.2 days after admission, 7.2 ± 1.2 days before definitive operative therapy, and requiring 7.1 ± 0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Central nervous system damage was part of the injury pattern in 68 per cent of the patients including spinal cord (42%), severe head injury (16%), or both (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagotomy and pyloroplasty (VP). VA required more time than VP (255 ± 41 vs 158 ± 13 minutes; P = 0.02). One patient (12.5%) rebled after VA versus two (18%) after VP; one patient in each group required reoperation. There was no difference in mortality, length of stay, or intensive care unit stay. A herald bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or head injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not rebleed rates should determine the surgical procedure.
A Mass on Breast Imaging Predicts Coexisting Invasive Carcinoma in Patients with a Core Biopsy Diagnosis of Ductal Carcinoma in Situ
Authors: King Tari A. , Farr Gist H. , Cederbom Gunnar J. , Smetherman Dana H. , Bolton John S. , Stolier Alan J. , Fuhrman George M.
Published: November 2022

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC ( P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.
Bleeding Hepatic Adenoma: Expectant Treatment to Limit the Extent of Liver Resection
Authors: Heeringa Brian , Sardi Armando
Published: November 2022

Hepatic adenomas (HAs) are benign but can present as an acute surgical emergency. The relationship between HA and oral contraceptives (OCs) has been well documented and there have been several reports of tumor regression after the withdrawal of hormonal agents. However, not all HAs regress in this manner; have been reported to remain stable, increase in size, hemorrhage, or rarely, undergo malignant transformation. Given the unpredictable nature of these lesions they are generally treated surgically. In July 1995 a patient with a 6-year history of OC use was admitted with a history of sudden-onset right upper quadrant abdominal pain of 2 days’ duration. The clinical picture and imaging studies led to the diagnosis of a bleeding hepatic adenoma without rupture. She was treated expectantly for a period of 14 months before surgery. This allowed the tumor to significantly decrease in size and thus limit the extent of resection. If the patient presented in this case had undergone surgery at the time of initial diagnosis a right hepatic lobectomy as opposed to a wedge resection would have been required. Treating this patient expectantly significantly decreased the potential morbidity associated with a larger resection.
Merkel Cell Carcinoma: Important Aspects of Diagnosis and Management
Authors: Linjawi Ayman , Jamison W. Bruce , Meterissian Sarkis
Published: November 2022

Merkel cell carcinoma (MCC) is a highly aggressive primary neuroendocrine tumor. It is suggested in the literature that postoperative radiotherapy may decrease local recurrence and improve overall survival. The purpose of this retrospective review was to determine our experience and review the literature on this aggressive malignancy. Charts of ten patients with MCC seen between 1985 and 1997 were reviewed to obtain clinicopathological data. Eight patients were male with a mean age of 72 years (range 49–90). The head and neck was the most common site, affecting 50 per cent of patients. All patients had primary excisions with documented negative margins. Pathological size ranged from 10 to 40 mm. Initial pathological diagnosis was lymphoma in three cases requiring immunohistochemistry for cytokeratin and neuron-specific enolase for definitive diagnosis. Lymphatic invasion was noted in three patients but only one of these patients had clinical lymph node involvement. The mean follow-up was 54 months (range 6–114) with an 80 per cent one-year survival and 30 per cent 2-year survival. Postoperative radiotherapy was administered to five patients. Of these three died with evidence of both local and distant recurrence. This small retrospective review highlights important points in the management of MCC including pathological diagnosis and benefits of adjuvant radiation therapy.
Disseminated Brown Tumors from Hyperparathyroidism Masquerading as Metastatic Cancer: A Complication of Parathyroid Carcinoma
Authors: Gupta Anju , Horattas Mark C. , Moattari Ali Reza , Shorten Scott D.
Published: November 2022

Osteitis fibrosa cystica (brown tumors) can be a skeletal manifestation of advanced hyperparathyroidism, including parathyroid cancer. Severe osteitis fibrosa cystica can mimic metastatic bone diseases especially in patients with a history of cancer. Because the treatment and prognosis of these two problems differ greatly considering hyperparathyroidism in the differential diagnosis of patients found to have osteolytic lesions is critical for the appropriate management of these patients. In this case report we describe a patient with a history of renal cell cancer and presumed osteolytic bone metastases. During prophylactic intramedullary rodding to prevent pathologic fracture of her femur she was found to have a benign lesion related to her previously undiagnosed hyperparathyroidism caused by an underlying parathyroid cancer. A detailed review of this disease and the associated bone changes is also included to underscore the importance of an adequate differential diagnosis as well as optimal management. Patients with hypercalcemia or bony lesions should not automatically be treated palliatively for metastatic disease just because of a past medical history of cancer. Hyperparathyroidism is a readily curable problem if properly diagnosed.
Mucoepidermoid Carcinoma of the Thyroid Gland: A Case Report and Suggested Surgical Approach
Authors: Steele Scott R. , Royer Michael , Brown Tommy A. , Porter Clifford , Azarow Kenneth S.
Published: November 2022

Mucoepidermoid carcinoma (MEC) of the thyroid gland is a rare neoplasm with 40 cases reported in the world literature to date. Controversy surrounds the treatment of this rare neoplasm. It has been described as a low-grade indolent tumor that rarely metastasizes and only recurs locally without morbidity. Suggested treatment has consisted of a lobectomy or subtotal thyroidectomy. We report a case of a 63-year-old woman with a 15-year history of a multinodular goiter with a dominant left lobe nodule. Fine-needle aspiration was inconclusive. The patient opted for a total thyroidectomy. Final pathology yielded a diagnosis of mucoepidermoid carcinoma. We propose that despite its low-grade appearance the morbidity and mortality associated with its ability to locally recur and metastasize justify the need for more aggressive surgical therapy.
Prospective Trial for the Treatment of Malignant Peritoneal Mesothelioma
Authors: Loggie Brian W. , Fleming Ronald A. , Mcquellon Richard P. , Russell Gregory B. , Geisinger Kim R. , Levine Edward A.
Published: November 2022

Malignant peritoneal mesothelioma (MPM) is a rare and often rapidly fatal disease with median survival of 5 to 12 months for untreated cases and 16 months reported after multimodality treatment. We report a prospective clinical treatment study using cytoreductive surgery combined with intraoperative intraperitoneal heated chemotherapy (IPHC) perfusion using mitomycin C for MPM. Twelve patients (11 male with a mean age 51 years) were treated. Seven patients presented with bulky disease and seven with ascites. All underwent exploratory laparotomy with histologically confirmed diagnosis of MPM. Surgical debulking as feasible was performed. Complete gross tumor removal was possible in only one patient. Cytoreduction was followed by a 2-hour closed low-volume IPHC using mitomycin C. One patient died 50 days postoperatively from complications relating to small bowel perforation. Hematologic toxicity of the procedure was minimal. Ascites was controlled in all patients and permanently in 86 per cent of patients presenting with ascites. To date median survival is 34.2 months with median follow-up of 45.2 months. One patient was re-explored for ventral hernia 2 years post-IPHC, had negative peritoneal biopsies, and remains disease-free at 5 years. Given the dismal prognosis associated with MPM the results of treatment with cytoreductive surgery combined with IPHC perfusion are encouraging. The rarity of MPM makes appropriately powered prospective randomized trials unlikely. Therefore, we now offer this approach off protocol; however, further study of this combined modality therapy is warranted.
Benign Anatomical Mistakes: The Thoracic Outlet Syndrome
Authors: Skandalakis John E. , Mirilas Petros
Published: November 2022

The same attribute cannot at the same time belong and not belong to the same subject and in the same respect.
The Effect of Pleural Adhesions on Pediatric Cystic Fibrosis Patients Undergoing Lung Transplantation
Authors: Bremner Ross M. , Woo Marilyn S. , Arroyo Hector , Nigro John J. , Horn Monica V. , Wells Winfield J. , Barr Mark , Starnes Vaughn A.
Published: November 2022

The degree of pleural scarring complicating cystic fibrosis (CF) lung disease is thought to impact on the outcome of adult lung transplantation. This has not been previously studied in the pediatric population. We studied all patients undergoing lung transplantation at Children's Hospital Los Angeles from 1993 through 2000. Operative times, grade of pleural scarring, blood product transfusion requirements, and perioperative mortality were compared for patients with cystic fibrosis (35) versus those without this diagnosis (11). Patients with CF were slightly older (14.7 ± 3.8 vs 10.6 ± 5.6 years; P = 0.01) but had similar weights (34.8 ± 8.7 vs 34.4 ± 12.3 kg). The degree of pleural scarring was greater in the CF group but was only severe in four patients. Scarring did not impact on operative times (237 ± 46 vs 219 ± 39 minutes; P = 0.22) or cardiopulmonary bypass times (127 ± 40 vs 133 ± 49 minutes). Total perioperative blood requirements for the two groups were similar (35.6 ± 14.9 vs 42.8 ± 76.7 cm3/kg; P = 0.82). Pleural scarring in the pediatric CF patients undergoing lung transplantation is only severe in a minority of patients. It does not increase duration of operation nor blood transfusion requirements. CT scanning is consequently unnecessary in the preoperative workup of CF patients being evaluated for transplantation. CF patients undergoing transplantation have perioperative outcomes similar to those of noncystic patients.
Pelvic Desmoid Tumor: Threat to Mother and Fetus
Authors: Firoozmand Eiman , Prager Elliot
Published: November 2022

Desmoid tumors (DTs) are well-recognized extracolonic manifestations of familial adenomatous polyposis. Surgical trauma and hormonal changes during pregnancy have been proposed as etiologic factors. We present a case of a rapidly growing pelvic DT arising from a J-pouch in a 27-year-old pregnant woman status postcolectomy with ileoanal J pouch anastomosis. The tumor interfered with the normal maturation and delivery of the fetus as well as the patient's ability to void or defecate prompting surgical intervention with resection of the tumor and adjacent J pouch at 23 weeks gestation. There are no other reports in the literature of pelvic DT requiring resection during pregnancy. Pelvic DTs in this scenario are potentially fatal to both mother and fetus secondary to uncontrolled bleeding. Surgical intervention should be limited to resection of tumor and when necessary the ileal pouch to minimize bleeding complications.
Surgical Management of Esophageal Perforation: Role of Esophageal Conservation in Delayed Perforation
Authors: Zumbro G. Lionel , Anstadt Mark P. , Mawulawde Kwabena , Bhimji Shabir , Paliotta Marco A. , Pai Ganesh
Published: November 2022

Definitive repair of esophageal perforation is considered the preferred treatment for patients presenting early (<24 hours). However, the optimal management of delayed presentation (>24 hours) has not been well defined. This study examined the management of esophageal perforation and compared the outcomes of early versus delayed presentation. Records of patients admitted with the diagnosis of esophageal perforation were reviewed. Contrast studies were used to confirm the diagnosis in all cases. Patient demographics and outcome were analyzed to determine differences between early and delayed presentation. A total of 22 cases of esophageal perforation were identified (eight early vs 14 delayed presentations). Operative interventions included primary repair (four), reinforced repair (14) either with intercostal muscle or pleural flap, and a complete esophageal resection (one). Debridement and drainage without repair were done in two patients and a proximal intramural tear was treated with antibiotics and observation. Two patients died during hospitalization. All surviving patients had near-normal restoration of esophageal function. Follow-up at 3 years has shown minimal gastrointestinal problems. One patient required repeat esophageal dilatations and two patients underwent antireflux therapy. Esophageal repair should be considered in all cases of nonmalignant esophageal perforation and should not be influenced by the time of presentation.
Venous Claudication in a Child with Thrombophilia
Authors: Best Irwin M. , Bumpers Harvey L.
Published: November 2022

Deep venous thrombosis (DVT) rarely occurs in active children. Its presence usually suggests an inherited or acquired hypercoagulable state. Occasionally mechanical obstruction may be the inciting factor in this process. Initial management usually consists of sequential heparin and warfarin anticoagulation. We present the management of DVT in an adolescent girl with elevated levels of C-reactive protein and lupus anticoagulant. Venous claudication and severe lower-extremity swelling on ambulation complicated her course. After more than 2 weeks of conservative therapy with anticoagulation thrombolytic therapy was instituted. This was terminated early because of mild hematuria. However, follow-up duplex scan at 2 years has shown complete resolution of the iliofemoral thrombosis. Spontaneous DVT in children differ from that in adults in that an underlying etiology can usually be uncovered. These differences are explored.
Valid Informed Consent: A Process, Not a Signature
Authors: English Dan C.
Published: November 2022

Surgeons have dutifully used “consent forms” for most of the last century. But only in the last two decades have we begun to understand the difference between a patient's legalistically signed form and the meaningful process of communicating the reasons for considering surgical or other invasive intervention. Furthermore, we must be reasonably assured that the patient is legally competent, understands the situation and alternatives, and is not coerced (by family or medical professionals) in the decision-making. To accomplish this, time-consuming patient education and negotiation are necessary. To limit this process to a brief agreement that the procedure should be done and the patient is willing (as evidenced by a signature) is to return to paternalism. Little evidence suggests that such signing is valid. Of more importance, patients want and are owed a clear understanding of what is probably ahead including risks and preventive measures to limit complications. This article analyzes the components of “consent,” suggests methods to ensure the validity of the agreement, and proposes that an educated patient benefits greatly by an appropriate process.
Type B Aortic Dissection with Rupture of the Left Common Iliac Artery: A Case Report
Authors: Singh Robert S. , Danikas Dimitrios , Goldenkranz Robert
Published: November 2022

Type B aortic dissection involves the appearance of a false lumen distal to the left subclavian artery and extending distally into the descending thoracic aorta and into the abdominal aorta. Complications of the dissection include rupture of the thoracic aorta, leg ischemia, visceral ischemia, and renal failure. A 37-year-old man presented with complaints of sudden onset of chest pain, left leg pain, and numbness. Examination revealed no femoral, popliteal, or distal pulses with decreased sensory and motor function on the left lower extremity. A CT scan revealed an aortic dissection at the proximal descending aorta extending into the iliac arteries with a left retroperitoneal hematoma at the iliac bifurcation. An MRI confirmed the dissection distal to the left subclavian artery into the iliac artery with a distal occlusion. Exploration revealed rupture of the left iliac artery dissection with arterial occlusion and a contained hematoma. The common iliac artery was ligated and an 8-mm Dacron bypass graft from the right common femoral artery to the left femoral artery was performed. Type B aortic dissection can present as rupture of the common iliac artery. Revascularization of the extremity with a femoral-femoral crossover graft is the recommended procedure in the absence of visceral ischemia. The surgeon should have a keen suspicion of this rare complication and its management.
Stercoral Perforation of the Sigmoid Colon: Report of a Rare Case and Its Possible Association with Nonsteroidal Anti-Inflammatory Drugs
Authors: Patel Vijaykumar G. , Kalakuntla Vikram , Fortson James K. , Weaver William L. , Joel Malcolm D. , Hammami Amir
Published: November 2022

Stercoral perforation of the colon is a rare phenomenon with fewer than 90 cases reported in the literature to date. The pathogenesis of stercoral ulceration is thought to result from ischemic pressure necrosis of the bowel wall caused by a stercoraceous mass. Stercoral perforation in more than 90 per cent of cases involves the sigmoid or rectosigmoid colon with associated fecal mass causing localized mucosal ulceration and bowel wall thinning due to localized pressure effect. We report the case of a 45-year-old woman who presented with a 12-hour history of epigastric pain. Significant comorbidities included systemic lupus erythematosus, sarcoidosis, hypertension, and previous history of congestive heart failure. The patient was also on prednisone and a nonsteroidal anti-inflammatory drug for joint pains. On physical examination the patient had signs of generalized peritonitis. Chest X-ray showed significant free air under the diaphragm. Emergency laparotomy revealed localized perforation over the antimesenteric border of the sigmoid colon with associated stercoral mass at the site of perforation. A segmental resection of the sigmoid colon with end colostomy (Hartmann's procedure) was performed. The patient made an uneventful recovery. Stercoral perforation is often a consequence of chronic constipation; however, there are other predisposing factors as the condition is rare compared with the frequency of severe constipation. One of the hypotheses includes the association of nonsteroidal anti-inflammatory drugs (NSAIDs) with stercoral perforation of the colon. Our case report lends support to this association with NSAID use; thus there need to be greater awareness and caution when using NSAIDs in chronically constipated patients.
Morbidity and Mortality of Short-Bowel Syndrome in Infants with Abdominal Wall Defects
Authors: Thakur Anjani , Chiu Charles , Quiros-Tejeira Ruben E. , Reyen Laurie , Ament Marvin , Atkinson James B. , Fonkalsrud Eric W.
Published: November 2022

Total parenteral nutrition (TPN) has made survival beyond infancy possible for many infants who have sustained small intestinal loss as a result of gastroschisis or omphalocele. The length and quality of life in these patients have often been limited by the development of late sequelae secondary both to the protracted use of TPN and the long-term complications of a shortened gut. This study was undertaken to determine what factors influence the morbidity and mortality of short-bowel syndrome (SBS) due to gastroschisis or omphalocele. A retrospective chart review of 850 infants who received TPN from January 1977 through December 1999 was carried out. All infants were treated at one academic medical center; those who had received ≤3 months of TPN were further segregated and their diagnosis, surgical procedures, length of bowel, ability to wean from TPN, follow-up weight and height, and developmental progress were recorded. Seventeen children were identified with SBS and either gastroschisis or omphalocele. Tight primary or secondary closure of the abdominal wall was believed to be a major cause of bowel necrosis and SBS in at least ten of the 17 patients. Overall survival was 76 per cent (13/17); survival was correlated with length of remaining bowel and was 86 per cent in patients having more than 15 cm of small bowel remaining but only 33 per cent in patients with less than 15 cm of small bowel remaining ( P = 0.05). A longer length of residual small bowel resulted in a significantly shorter duration of TPN with a mean duration of 1.0 year for survivors having >38 cm and 10.0 years for survivors with <38 cm of bowel remaining ( P = 0.03). Hepatic dysfunction with progressive failure resulting from TPN was related to death in three of the four nonsurvivors. The presence or absence of an ileocecal valve appeared unrelated both to the success of TPN weaning and to the length of time on TPN ( P > 0.2). Eight of the 13 survivors have no ileocecal valve; five have undergone >50 per cent colonic resection. Nine of the survivors have adapted to enteral feedings (mean 36 ± 60 months) during which time weaning from TPN occurred. The mean age of survivors is 7.9 ± 5.1 years. Near-normal weights (defined as exceeding the fifth percentile for weight) were achieved for 92 per cent of the patients (12/13) with 46 per cent of the patients (6/13) exceeding the 50th percentile. Near-normal heights (exceeding the fifth percentile) were achieved for 77 per cent of the patients (10/13) with 15 per cent of the patients (2/13) exceeding the 50th percentile. Quality of life was measured on the basis of return to public school: nine of ten school-age survivors attend school and eight are normal without signs of developmental delay. Tight abdominal closure of gastroschisis or omphalocele may cause bowel necrosis and SBS. TPN has improved the long-term survival and quality of life in infants with SBS.
Cardiac Surgery after Renal Transplantation
Authors: Reddy V. Seenu , Chen Ashton C. , Johnson H. Keith , Pierson Richard N. , Christian Karla J. , Drinkwater Davis C. , Merrill Walter H.
Published: November 2022

Renal transplantation remains a mainstay of therapy for end-stage renal disease. Cardiac disease has a high prevalence in this patient population. This study reviews the factors and outcomes associated with cardiac surgery in renal transplant recipients. We performed a retrospective review of all patients at our institution with a functioning renal allograft at the time of their cardiac surgical procedure. Between June 1971 and April 2000, 2343 patients underwent renal transplantation at Vanderbilt University Medical Center. Twenty-six patients with a functioning renal allograft subsequently underwent a cardiac procedure requiring cardiopulmonary bypass. There were 11 women and 15 men. Twenty-four patients underwent coronary bypass, one had a double valve replacement, and one had a combined coronary bypass/valve replacement. The interval from renal transplant to heart surgery ranged between 0.6 and 227 months (mean 79.1). Operative mortality was zero but there were two hospital deaths: one due to multisystem organ failure and one due to pulmonary embolism. Six additional patients died late with only one due to heart disease. Four patients required perioperative dialysis, and one of these went on to require permanent dialysis. Two additional patients returned to dialysis late postoperatively. The requirement for acute perioperative dialysis was predicted by preoperative creatinine, hematocrit, and intraoperative urine output. The overall survival is 69 per cent (18 of 26) with a median follow-up of 38 months. The majority of long-term survivors have minimal cardiac symptoms. Standard cardiac surgery procedures can be performed with relative safety in patients with functioning renal allografts. The incidence of perioperative and late development of renal failure requiring dialysis is low. The long-term survival and symptomatic improvement achieved are favorable and warrant continued performance of cardiac surgery in patients with functioning renal allografts.