bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical Shunting versus Transjugular Intrahepatic Portasystemic Shunting for Bleeding Varices Resulting from Portal Hypertension and Cirrhosis: A Meta-Analysis
Authors: Clark Whalen , Hernandez Jonathan , McKeon Brianne , Villadolid Desiree , Al-Saadi Sam , Mullinax John , Ross Sharona B. , Rosemurgy Alexander S.
Published: June 2020

Surgical shunting was the mainstay in treating portal hypertension for years. Recently, trans-jugular intrahepatic portasystemic shunting (TIPS) has replaced surgical shunting, first as a “bridge” to transplantation and ultimately as first-line therapy for bleeding varices. This study was undertaken to examine evidence from trials comparing TIPS with surgical shunting to reassess the role of surgery in treating portal hypertension. The National Library of Medicine and the National Institutes of Health were searched for clinical trials comparing surgical shunting with TIPS. Meta-analysis using the fixed effects model was undertaken with end points of 30-day and 1- and 2-year survival and shunt failure (inability to complete shunt, irreversible shunt occlusion, major rehemorrhage, unanticipated liver transplantation, death). Three prospective randomized trials and one retrospective case-controlled study were identified. Analysis was limited to patients of Child Classes A or B. Significantly better 2-year survival (OR 2.5 [1.2-5.2]) and significantly less frequent shunt failure (OR 0.3 [0.1-0.9]) were seen in patients undergoing surgical shunting compared with TIPS. Meta-analysis promotes surgical shunting relative to TIPS because of improved survival and less frequent shunt failure. Surgical shunting should be accepted as first-line therapy for bleeding varices resulting from portal hypertension.
Anastomotic Leak Rate after Low Anterior Resection for Rectal Cancer after Chemoradiation Therapy
Authors: Phillips Benjamin R. , Harris Lisa J. , Maxwell Pinckney J. , Isenberg Gerald A , Goldstein Scott D.
Published: June 2020

Anastomotic leak may be the most concerning complication after colorectal anastomosis. To compare open with laparoscopic rectal resection, we must have accurate leak rates in patients who have received neoadjuvant chemoradiation therapy to serve as a benchmark for comparison. All patients who had preoperative chemoradiation therapy with rectal resection and low pelvic anastomosis for cancer in a single colorectal practice over a 7-year period were retrospectively reviewed. All patients had proximal diversion and a contrast enema study before stoma reversal. Eighty-seven consecutive patients were included in the study. Average age was 58 years. Fifty-nine per cent of patients were male. Sixty-six per cent were smokers. Pathologic T stage was 5 per cent TO, 16 per cent T1, 28 per cent T2, 47 per cent T3, and 5 per cent T4. Seventy-five per cent of patients were pathologically lymph node-negative. Average time to stoma reversal was 122 days. Total anastomotic leak rate was 10.3 per cent (8% clinical leaks). Five (56%) patients with leak successfully underwent reversal of their diverting stoma (average time to reversal, 290 days). Patients who had the complication of anastomotic leakage had less likelihood of stoma reversal and a significantly prolonged time to stoma reversal.
Postcolonoscopy Appendicitis
Authors: Moorman Matthew L. , Miller Jerad P. , Khanduja Karamjit S. , Price Phillip D.
Published: June 2020

Outpatient colonoscopy has been proven safe but can rarely be associated with serious complications. The addition of polypectomy to the procedure increases the incidence of all complications with hemorrhage accounting for approximately half. The use of electrocautery for hot biopsy or polyp removal can result in a full-thickness burn without perforation in approximately 1 per cent of cases and typically presents as focal peritonitis without pneumoperitoneum. This so-called “postpolypectomy syndrome” or “serositis” is often successfully managed medically with resolution of symptoms in 24 to 48 hours. Bowel perforation occurs in less than 1 per cent of patients but requires emergent laparotomy. Appendicitis, both acute and perforated, has been reported as a rare complication of colonoscopy.
Internal Ring Occlusion and Floor Support: A Novel Technique for Inguinal Hernia Mesh Repair
Authors: Subhas Gokulakkrishna , Bakston Daniel , Gupta Aditya , Jacobs Michael J. , Mittal Vijay K. , Silapaswan Sumet
Published: June 2020

Tension-free, open-mesh, inguinal herniorrhaphies have gained wide acceptance. Current mesh techniques reinforcing the internal ring do not provide a comfortable lay to the mesh. To address this, we used the internal ring occlusion and floor support (IROFS) technique. A retrospective review was undertaken of all hernias operated on with the IROFS technique from January 2001 to December 2006. Five hundred twenty-five inguinal hernia repairs were done in 477 male patients. Telephone questionnaires looking into their postoperative course and recurrence were recorded. We contacted 275 (58%) patients. Patients’ ages ranged from 29 to 81 years (mean, 57 years). The hernia was indirect in 50 per cent (n = 146), direct in 35 per cent (n = 102), or both in 15 per cent (n = 44) of patients. The average operative time was 40 minutes. Acute wound pain lasted for less than 1 week in 55 per cent (n = 151) and for 1 to 2 weeks in 24 per cent (n = 66). Postoperative analgesic requirement was less than 1 week in 54 per cent (n = 147) and 1 to 2 weeks in 27 per cent (n = 74). Most patients returned to their daily activities in 2 weeks (75%) and to work in 3 weeks (74%). Chronic pain lasted for 6 to 48 months (mean, 20 months) in only seven patients. No recurrence of hernia was observed during follow-up visits (range, 26-96 months; mean, 53 months). In conclusion, IROFS can be performed with little difficulty, is cost-effective, and is well tolerated by the patient.
In Defense of Industry-Physician Relationships
Authors: Nakayama Don K.
Published: June 2020

The objective was to examine the economic, ethical, and legal foundations for conflict of interest restrictions between physicians and pharmaceutical and medical device industries (“industry”). Recently academic medical centers and professional organizations have adopted policies that restrict permissible interactions between industry and physicians. The motive is to avoid financial conflicts of interest that compromise core values of altruism and fiduciary relationships. Productive relationships between industry and physicians provide novel drugs and devices of immense benefit to society. The issues are opposing views of medical economics, profit motives, medical professionalism, and extent to which interactions should be lawfully restricted. Industry goals are congruent with those of physicians: patient welfare, safety, and running a profitable business. Profits are necessary to develop drugs and devices. Physician collaborators invent products, refine them, and provide feedback and so are appropriately paid. Marketing is necessary to bring approved products to patients. Economic realities limit the extent to which physicians treat their patients altruistically and as fiduciaries. Providing excellent service to patients may be a more realistic standard. Statements from industry and the American College of Surgeons appropriately guide professional behavior. Preservation of industry-physician relationships is vital to maintain medical innovation and progress.
Does Health Care Insurance Affect Outcomes after Traumatic Brain Injury? Analysis of the National Trauma Databank
Authors: Alban Rodrigo F. , Berry Cherisse , Ley Eric , Mirocha James , Margulies Daniel R. , Tillou Areti , Salim Ali
Published: June 2020

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 ± 22.4 vs 37.3 ± 16.3 years, P < 0.0001), more severely injured (ISS > 16: 78.4% vs 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 ± 9.4 vs 5.1 ± 7.6, P < 0.0001) and had higher mortality (9.3% vs 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.
Is Postoperative Chronic Pain Syndrome Higher with Mesh Repair of Inguinal Hernia?
Authors: Masukawa Kristin , Wilson Samuel E.
Published: June 2020

Chronic postoperative pain has been associated with mesh repair in meta-analysis of clinical trials. We compared the incidence of early complications, recurrence, and chronic pain syndrome in anatomic and mesh repairs in 200 patients. We defined chronic pain syndrome as pain in the inguinal area more than 3 months after inguinal hernia repair, patient referral to pain management, or necessity of a secondary procedure for pain control. The mean follow-up time was 4 years and 2 months for anatomic repair and 3 years and 7 months for mesh repair. The clinical outcomes did not reveal a significant disparity between the 100 consecutive patients who had mesh repair versus the 100 patients who had anatomic repair with regard to the incidence of superficial wound infection (0 vs 2%, P = 0.497), testicular swelling (12 vs 7%, P = 0.335), hematoma (1 vs 0%, P = 0.99), recurrence (3 vs 2%, P = 0.99), or chronic postoperative pain (4 vs 1%, P = 0.369). The anatomic procedure without mesh should continue to be offered to patients who have an initial inguinal hernia repair.
Impact of Nonresective Operations for Complicated Peptic Ulcer Disease in a High-Risk Population
Authors: Smith Brian R. , Wilson Samuel Eric
Published: June 2020

Over the past two decades, surgery for complicated peptic ulcer disease has evolved to a “less-is-more” approach due predominately to improved medical therapy. This study sought to determine whether a nonresective operative strategy has been an effective and prudent approach. A 20-year retrospective evaluation was conducted to compare outcomes of patients from the first decade (1990-1999) with those from the more recent decade (2000-2009). In all, 50 patients underwent surgery for complications of peptic ulcer disease, 36 in the early period and 14 in the later period, with 94 per cent being urgent or emergent. Acid-reducing procedures (vagotomy) decreased significantly from 29 to 7 over the two periods ( P = 0.04), as did gastric resections from 23 to 3 ( P = 0.01). The prevalence of H. pylori and use of NSAIDs both increased from 28 per cent to 36 per cent and 31 per cent to 43 per cent, respectively. Postoperative mortality remained unchanged, 22 per cent vs 7 per cent ( P = 0.41) over the two periods. Resections and definitive acid-reducing procedures continue to decline with no increase in adverse outcomes. This more moderate operative approach to complicated peptic ulcer surgery is appropriate given the trend towards lower mortality and improved medical treatment. In our high-risk veteran population, overall perioperative mortality, length of stay, and reoperations have been reduced.
Successful Enhanced Recovery Program after Colorectal Surgery in a County Institution
Authors: Aboulian Armen , Hassan Zailani , Lin Matthew Y.C. , Kaji Amy H. , Kumar Ravin R.
Published: June 2020

Enhanced recovery programs after colorectal surgery have gained acceptance recently as they have shown a decrease length of hospital stay. However, these pathways require strict adherence to standardized programs with patient education and high compliance. This study was designed to assess the feasibility of such a program in a large county hospital. A retrospective review was performed of 54 consecutive patients who underwent laparoscopic or open segmental colorectal resection without an ostomy. The first 27 patients were treated in a conventional manner, whereas the latter 27 were treated using a protocol promoting early feeding and ambulation with decreased intravenous fluids and narcotic use. There were no baseline differences between the groups, however, there was a significant difference in the patients treated with the enhanced recovery program in terms of less intravenous fluids administered in surgery ( P = 0.001), and over the subsequent 3 days ( P = 0.0017), with a decrease in length of hospital stay of 4 compared with 6 days ( P = 0.003). There were no differences in terms of complication and readmission rates. Based on this study, we conclude that strict adherence to a standard enhanced recovery program was effective in reducing hospital stay in patients undergoing colorectal resection without any increase in complications.
Umbilical Herniorrhaphy Reinforced with Biologic Mesh
Authors: Edelman David S. , Bellows Charles F.
Published: June 2020

The true recurrence rate after umbilical hernia repair in not known. After simple closure, the reported rate of recurrence in the literature is as high as 54 per cent. With synthetic mesh repair, the recurrence rates are lowered to less than 10 per cent. However, synthetic mesh is associated with complications such as enterocutaneous fistula and mesh infections. This preliminary study looks at the safety and effectiveness of biologic extracellular matrix mesh reinforcement in the repair of umbilical hernias. We retrospectively reviewed all patients who underwent repair of an umbilical hernia defect (2-3 cm) with primary approximation of the margins and reinforced using a biologic mesh placed beneath the umbilical fascia from 2007 to 2009. Demographic data were collected. Patients were followed prospectively at 2 weeks, 8 weeks, 6 months, and 1 year. Data were reviewed for postoperative complications, hernia recurrence, and patient satisfaction. During the study period, 16 patients completed the 1 year follow-up. There were 10 men and six women. Ages ranged from 28 to 75 years with a mean age of 47.6 years. The hernias were 2 to 3 cm in size. Complications were minimal. Overall patient satisfaction with the procedure was high. There were no mesh infections. During a mean follow-up of 12 months, only one patient had recurrent hernia (6%). This preliminary evaluation shows promise for an alternative treatment of umbilical hernias using biologic extracellular matrix mesh added as an underlay to reinforce a primary closure. The biologic mesh has a low incidence of infection and complications and results in high patient satisfaction. This preliminary study begs for a randomized, prospective evaluation with long-term follow-up.
Epidemiology of Post-Traumatic Limb Amputation: A National Trauma Databank Analysis
Authors: Barmparas Galinos , Inaba Kenji , Teixeira Pedro G.R. , Dubose Joseph J. , Criscuoli Michele , Talving Peep , Plurad David , Green Donald , Demetriades Demetrios
Published: June 2020

The purpose of this study was to examine the epidemiology and outcomes of posttraumatic upper (UEA) and lower extremity amputations (LEA). The National Trauma Databank version 5 was used to identify all posttraumatic amputations. From 2000 to 2004 there were 8910 amputated patients (1.0% of all trauma patients). Of these, 6855 (76.9%) had digit and 2055 (23.1%) had limb amputation. Of those with limb amputation, 92.7 per cent (1904/2055) had a single limb amputation. LEA were more frequent than UEA among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt in 83 per cent; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%, P < 0.001), whereas motorcyclists (86.2% vs 13.8%, P < 0.001) and pedestrians (91.9% vs 8.1%, P < 0.001) had more LEA. Patients with LEA were more likely to require discharge to a skilled nursing facility; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. Although single limb amputation did not impact mortality, the need for multiple limb amputation was an independent risk factor for death.
The Use of Extracorporeal Membrane Oxygenation in Severe Necrotizing Soft Tissue Infections Complicated by Septic Shock
Authors: Firstenberg Michael S. , Abel Erik , Blais Danielle , Louis Louis B. , Steinberg Steven , Sai-Sudhakar Chittoor , Martin Stanley , Sun Benjamin
Published: June 2020

Necrotizing soft tissue infections remain a challenging clinical problem. Delays in diagnosis, incomplete debridement of necrotic tissues, and the hemodynamic instability and end-organ failure associated with overwhelming sepsis all contribute to significant mortality. Extracorporeal support is a well-established tool to support profound cardiopulmonary failure. To broaden the indications for use, we present two cases of young adults with necrotizing soft tissue infections who sustained sepsis-induced hemodynamic collapse and required extracorporeal support to facilitate adequate tissue debridement as a bridge to recovery.
Biological Mesh in Hernia Repair, Abdominal Wall Defects, and Reconstruction and Treatment of Pelvic Organ Prolapse: A Review of the Clinical Evidence
Authors: Peppas George , Gkegkes Ioannis D. , Makris Marinos C. , Falagas Matthew E.
Published: June 2020

The use of biological meshes seems to be an innovation that influences all surgical fields. The existing evidence indicates that biological meshes cannot only be applied on the area of hernia repair, but also on cases of abdominal reconstruction and pelvic organ prolapse treatment, especially in the presence of contaminated or potentially contaminated surgical fields. Low risks of graft rejection, complications, and infection seem to be the main advantages of biological meshes in comparison with the synthetic nonabsorbable ones. Nevertheless, the elevated costs suggest that biological mesh implantation should be evaluated in correlation to the needs of each clinical case.
Article Commentary: Historical Reminiscence: Origin of the Greenfield Filter
Authors: Greenfield Lazar J.
Published: June 2020

The Greenfield filter was the result of collaboration between a surgeon and a petroleum engineer. Originally it was a component of a catheter management approach to massive pulmonary embolism. Industry support allowed further technical improvements and long-term patient followup studies.
Single-Incision Laparoscopic Placement of an Adjustable Gastric Band versus Conventional Multiport Laparoscopic Gastric Banding: A Comparative Study
Authors: Saber Alan A. , El-Ghazaly Tarek H. , Elain Alain , Dewoolkar Aditya V.
Published: June 2020

Single-incision laparoscopic surgery (SILS™) is rapidly becoming the focal point of attraction for early adopters of minimally invasive surgery nationwide. Having achieved a rapid crossover to the realm of advanced surgical procedures, SILS™ has shown remarkable versatility and adaptability, making it no longer limited to basic laparoscopic procedures. We report our experience performing laparoscopic placement of gastric bands with an emphasis on comparison of the single-incision laparoscopic approach with the conventional multiport laparoscopic approach. From December 2008 to September 2009, 27 patients underwent laparoscopic placement of an adjustable gastric band at Michigan State University/Kalamazoo Center for Medical Studies. This included 15 patients who underwent single-incision laparoscopic gastric banding and 12 patients who underwent conventional multiport laparoscopic gastric banding procedures. The overall pain score was found to be significantly less in the SILS group than that for the conventional multiport laparoscopic gastric banding group with a statistically significant P value of 0.012. The operating time was found to be significantly less in the multiport group with a P value of 0.000. Differences in immediate postoperative pain scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant. Single-incision laparoscopic gastric banding is associated with significantly less overall postoperative pain than the conventional laparoscopic approach; in addition, it provides improved cosmetic outcome despite a modest increase in operative time.
Champ Lyons, Holt McDowell, and the Evolution of Vascular Surgery at the University of Alabama at Birmingham: A Personal Perspective
Authors: Trotter Michael C.
Published: June 2020

The history of medical centers, hospitals, clinics, and their evolution are important contributions and resources to medical history. Likewise, evolution of specialties within these healthcare centers frequently parallels their growth and development. This contribution depicts the evolution of a specialty, vascular surgery, within a major medical center, the University of Alabama at Birmingham. It recounts the major participants involved and their contributions and pioneering efforts, some of which have received little attention or were overshadowed by other events. Perspectives from participants—a patient and a trainee—provide insight into this process that has supported the growth and development of a major world-class medical center.
Importance of Methicillin-Resistant Staphylococcus aureus Eradication in Carriers to Prevent Postoperative Methicillin-Resistant Staphylococcus aureus Surgical Site Infection
Authors: Pofahl Walter E. , Ramsey Keith M. , Nobles Delores L. , Cochran M. Kathy , Goettler Claudia
Published: June 2020

Although infrequent, postoperative methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection (SSI) is associated with significant morbidity and cost. Previous studies have identified the importance of MRSA screening to diminish the risk of postoperative MRSA SSI. The current study quantifies the importance of eradication of the MRSA carrier state to prevent MRSA SSI. Beginning February 2007, all admissions to an 800-bed tertiary care hospital were screened for MRSA by nasal swab using rapid polymerase chain reaction-based testing. Patients found to be nasal carriers of MRSA were treated with 2 per cent mupirocin nasal ointment and 4 per cent chlorhexidine soap before surgery. The subset of patients undergoing procedures that are part of the Surgical Care Improvement Project (SCIP) were followed for MRSA SSI (n = 8980). The results of preoperative MRSA screening and eradication of the carrier state were analyzed. Since the initiation of universal MRSA screening, 11 patients undergoing SCIP procedures have developed MRSA SSI (0.12%). Of these, six patients (55%) had negative preoperative screens. Of the five patients with positive preoperative screens, only one received treatment to eradicate the carrier state. In patients who develop MRSA SSI, failure to treat the carrier state before surgery results in MRSA SSI.
Statins and the Bariatric Patient: Characterization and Perioperative Effects of Statin Therapy in the Gastric Bypass Patient
Authors: Perna Mark , Baker Megan , Byrne Thomas Karl , Morgan Katherine
Published: June 2020

In surgical patients, statins have been shown to have beneficial effects independent of the lipid-lowering properties. Statin use has not been well studied in the bariatric patient. The objective of this study was to characterize the use of statins in the bariatric surgery patient and compare outcomes, including complications, weight loss, and changes in comorbidities. A retrospective chart review of patients undergoing bariatric surgery between 2005 and 2008 was conducted. Four hundred forty surgical patients charts were reviewed, of which 151 (34%) were taking a perioperative statin. The two groups were similar in length of stay, baseline body mass index, type of procedure, smoking status, and hospital charges. However, the statin group was older, more likely male, and with more baseline comorbidities, including hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), coronary artery disease, and obstructive sleep apnea (OSA). There was no statistical significance noted in the any complication or death. There was no difference in weight loss over time between the two groups. The statin group was more likely to report resolution in HLD (27.5 vs 9.5%, P = 0.004), but not DM, HTN, or OSA. In summary, there are differences in bariatric patients who take statins compared with their counterparts. Statins with gastric bypass may improve resolution of HLD, which may eventually alter long-term cardiac risk in these patients.
Laparoscopic Colectomy: Complications Causing Reoperation or Emergency Room/Hospital Readmissions
Authors: Abarca Francisco , Saclarides Theodore J. , Brand Marc I.
Published: June 2020

The purpose of this study was to determine the incidence of complications causing reoperation or emergency room(ER)/hospital readmission after laparoscopic colectomy (LC). We retrospectively reviewed a prospectively managed database of 358 patients undergoing LC. Nonhand assisted LC was jointly performed by two surgeons assisted by a general surgery resident. Trochar site fascial wounds larger than 5 millimeters were not closed for the first 283 cases, mesenteric defects were not closed. Forty-one patients (11%) required reoperation. Of the 19 hernias (17 incisional, 2 mesenteric), seven caused early postoperative obstructions either within the first week of surgery or within 4 days after discharge. Twelve hernias presented in a delayed fashion and were repaired months later. Eight hernias occurred at trochar sites, nine at specimen extraction sites, and two were in the mesenteric defect. There were eight adhesive small bowel obstructions, five were treated with early reoperation. Other causes included perforations in six cases (2%), anastomotic leak in seven cases (2%) and bleeding in two cases (0.5%). Fifty-nine (16%) separate patients required evaluation in the ER. Fifty-three patients had one ER visit, six patients had two. Causes included nausea and vomiting in 19 cases (5%), wound infection in 16 cases (4%), pain in 13 cases (4%), fever in five cases (1%), thrombosis in four cases (1%); 46 were admitted to the hospital, 70 per cent were discharged within 4 days. Eleven per cent of patients required reoperation after LC, usually for hernias or adhesive small bowel obstruction. Fifty-three per cent of the hernias could have been avoided by routine closure of the fascia. An additional 16 per cent of patients required ER evaluation for complications. Of these, 78 per cent were admitted, 70 per cent were discharged within 4 days. LC is not without potential complications and is not necessarily a less morbid operation.
Does Use of Intraoperative Irrigation with Open or Laparoscopic Appendectomy Reduce Post-Operative Intra-abdominal Abscess?
Authors: Moore Christopher B. , Smith R. Stephen , Herbertson Robert , Toevs Christine
Published: June 2020

To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation ( P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.
Cost-Effective Analysis of Transjugular Intrahepatic Portosystemic Shunt versus Surgical Portacaval Shunt for Variceal Bleeding in Early Cirrhosis
Authors: Pierce Damon S. , Sperry Jason , Nirula Raminder
Published: June 2020

Upper gastrointestinal hemorrhage carries significant morbidity and mortality in patients with portal hypertension and cirrhosis. The optimal prevention strategy for rebleeding in these patients remains controversial with respect to the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) versus a portocaval surgical shunt (PC). We sought to determine the long-term cost-effectiveness of these two treatments. A Markov state transition decision analysis was created and Monte Carlo sensitivity analysis performed to follow patients with early cirrhosis who have an upper gastrointestinal bleed despite medical therapy into either TIPS or PC. Patients were followed throughout the transition states until either death or survival. Probabilities of gastrointestinal rebleed, hepatic encephalopathy, surgical and TIPS-related complications as well as death were obtained from an extensive literature review. Costs were derived from average Medicare reimbursements. The main outcome was dollars per life-year saved. For patients with mild to moderate cirrhosis with upper gastrointestinal variceal bleed, the average cost per life year saved was $17,771 (SD = 471) and $21,438 (SD = 308) for TIPS and PC, respectively. The average life expectancy was 5.0 years and 7.0 years for TIPS and PC, respectively. This yielded an incremental cost-effectiveness rate for portocaval shunt of $3,299 per life year saved. Compared with TIPS, surgical PC shunt resulted in improved survival with minimal increase in cost. Therefore, given the low incremental cost of PC, it should be adopted as a cost-effective strategy in managing this patient population.
Neuroendocrine Tumors of the Rectum: A 10-Year Review of Management
Authors: Moore Jason R. , Greenwell Brian , Nuckolls Kaylee , Schammel David , Schisler Nicholas , Schammel Christine , Culumovic Patrick , Mckinley Brian P. , Trocha Steven D.
Published: June 2020

Neuroendocrine tumors of the rectum constitute ∼19 per cent of gastrointestinal neuroendocrine tumors (NETs). The histologic characteristics of the tumor seem to be an indicative prognostic factor. Optimal treatment of NETS of the rectum has been widely debated, but more recent studies suggest that treatment depends upon the size. The medical records of 37 patients with NETS of the rectum were retrospectively reviewed. We reviewed their presentation, surgical treatment, pathology, and outcome. All pathological specimens were reviewed. Neuroendocrine tumors of the rectum were classified as either well-differentiated tumors, well-differentiated neuroendocrine carcinoma, or poorly differentiated neuroendocrine carcinoma. Evaluating tumor size, we found 35/37 patients had tumors less than 1 cm, 1 patient had a tumor between 1 and 2 cm, and one had a tumor greater than 2 cm. Pathologic evaluation of the tumors revealed that 35 of the tumors invaded the submucosa only, one invaded the muscularis propria, and one invaded the perirectal adipose tissue. The histopathologic features of the tumors revealed that 34 of the tumors were well-differentiated NETS with benign features, one tumor had invaded the submucosa, with angioinvasion, and two tumors were neuroendocrine carcinoma. Thirty-five patients underwent local excision. Eleven had reexcisions for positive margins. Two patients had local excision for recurrence, and one patient underwent low anterior resection (4 cm). Twelve patients had negative margins, 25 had positive margins. Eleven patients underwent reexcision. Six had no evidence of residual disease, and five had persistent positive margins and were offered no further treatment. Nineteen patients had positive margins and did not have reexcision. They all had tumors < 1 cm. Despite half of the lesions being resected with final pathologic positive margins, we have seen no significant influence on recurrence or overall survival. This raises the question of margin clearance in early lesions.
Appendix Diameter: A Predictor of Wound Infection after Laparoscopic Appendectomy
Authors: Liang Hung-Hua , Wang Weu , Huang Ming-Te , Hung Chin-Sheng , Yen Ko-Li , Lee Wei-Jei , Wu Chih-Hsiung , Wei Po-Li
Published: June 2020

Our aim was to investigate whether appendix diameter is an independent risk factor for wound infection in laparoscopic appendectomy (LA). Patients who underwent LA (n = 582) were grouped into those with wound infections and those without. Possible factors associated with wound infection were analyzed using univariate and multivariate logistic regression analysis. When the diameter of the appendix was greater than 15 mm, patients were 2.32 times as likely to have a wound infection (95% CI, 1.02 to 5.29; P = 0.045) than if the appendix was less than 10 mm in diameter. Patients with perforated appendices were 2.51 times as likely to have a wound infection (95% CI, 1.25 to 5.02; P = 0.010) than if the appendix was not perforated. Wound infection was associated with longer operation time, return to oral intake, and hospital stay. Appendix diameter may predict postoperative wound infection after laparoscopic appendectomy.
Retrospective Review of the Costs of Routine Pelvic X-rays in a Trauma Setting
Authors: Feeney James , Jayaraman Vijay , Luk Stephen , Shapiro David , Virk Mandeep , Twohig Michael , Jacobs Lenworth
Published: June 2020

Multidetector Computed Tomography (MDCT) technology plays an important role in the evaluation of injured patients. At our institution pelvic X-ray (PXR) is obtained routinely on trauma patients. Many also receive MDCT of the abdomen and pelvis for other indications. We hypothesized that there would be a substantial cost savings in adopting a policy of deferring PXR in a hemodynamically normal patient who will also proceed to MDCT for other indications. We retrospectively reviewed the charts of trauma patients from February 1, 2008 to February 1, 2009. We reviewed whether a PXR was done, the result, whether an MDCT was also done, and the presence or absence of pelvic fractures. We collected billing and cost data from various hospital sources. We identified 1,330 patients with PXR between February 1, 2008 and February 1, 2009. Of those patients, 810 (61%) had MDCT after PXR. Sixty-six patients (8.0%) had pelvic fractures; 39 were correctly identified on PXR (59% of fractures). Twenty-seven were detected only by MDCT (41% of fractures); all pelvic fractures were identified on MDCT. Seven hundred and forty-four patients (92% of patients with both PXR and MDCT) had negative PXR and negative MDCT. Using three methods of cost analysis, the estimated cost savings range is from $77,011 to $331,080. MDCT of the pelvis is more sensitive and more specific than PXR. In patients who are hemodynamically normal and asymptomatic, forgoing routine PXR could result in an estimated savings from $77,011 to $331,080, depending on the method used to calculate costs.
Operative Decision-Making for Follicular Thyroid Lesions: A Community Hospital System Experience
Authors: Grannan Kevin , Snyder Jonathan , Mcdonough Sarah , Engel Amy , Farnum James
Published: June 2020

Follicular neoplasms of the thyroid are a frequent indication for surgery of the thyroid gland. We evaluated the use of frozen sections on intraoperative decision-making, possible avoidance of reoperative surgery, and histologic findings in a retrospective cohort. A database was created of all thyroid operations from 2001 to 2007. Data collected included age, gender, preoperative cytology, indication for surgery, surgeon, intraoperative decision-making, and histologic findings. Of the 723 thyroidectomies, 203 were performed for follicular neoplasms diagnosed by fine needle aspiration. Of these, 135 had cytology reports available within our electronic medical record; 44 per cent (59 of 135) of these patients had an intraoperative frozen section. Only two of 59 (3.4%) were positive for carcinoma, both of which were papillary carcinomas. One was interpreted as “suspicious” for carcinoma by the pathologist. In these three cases, the surgeon proceeded with total thyroidectomy at the time of initial surgery. The results of frozen section altered the operation in only three of 59 cases (5.1%). Intraoperative frozen section rarely impacts the conduct of thyroidectomy for follicular neoplasms.
Long-Term Outcomes with Transfascial Sutures versus Tacks in Laparoscopic Ventral Hernia Repair: A Review
Authors: Brill Jason B. , Turner Patricia L.
Published: June 2020

Although most surgeons report using both transfascial sutures and laparoscopically placed tacks to secure prostheses in laparoscopic ventral hernia repair, a significant minority have reported large series in which sutures were omitted. A systematic review of the available literature was conducted for large case series and controlled trials documenting long-term follow-up. Forty-three articles were identified, including 6015 patients whose prostheses were secured with transfascial sutures (with or without tacks), and 2450 patients receiving tacks or staples alone. The mean follow-up time reported was 30.1 months. No significant difference was found in rates of hernia recurrence, mesh removal, prolonged postoperative pain, patient body mass index, or hernia defect size between the two groups. The suture group did experience a significantly higher rate of surgical site infection. Although suture tensile strength is greater than that of tacks, and despite numerous anecdotal reports of hernia recurrence secondary to suture failure or omission, the existing literature does not show superiority of one mesh fixation technique over the other for recurrence, whereas infection rates increase when transfascial suture is used.
Operative Intervention for Complete Pancreatic Transection in Children Sustaining Blunt Abdominal Trauma: Revisiting an Organ Salvage Technique
Authors: Borkon Matthew J. , Morrow Stephen E. , Koehler Elizabeth A. , Shyr Yu , Hilmes Melissa A. , Miller Richard S. , Neblett Wallace W. , Lovvorn Harold N.
Published: June 2020

Complete pancreatic transection (CPT) in children is managed commonly with distal pancreatectomy (DP). Alternatively, Roux-en-Y distal pancreaticojejunostomy (RYPJ) may be performed to preserve pancreatic tissue. The purpose of this study was to review our experience using either procedure in the management of children sustaining CPT after blunt abdominal trauma. We retrospectively reviewed the records of all children admitted to our institution during the last 15 years who were confirmed at operation to have CPT after blunt mechanisms. Summary statistics of demographic data were performed to describe children receiving either RYPJ or DP. CPT occurred in 28 children: 15 had DP, 10 had RYPJ, and three had cystogastrostomy. RYPJ children, compared with DP, were younger (7.5 vs 12.3 years, P = 0.039) and sustained more grade IV pancreatic injuries (70% vs 14%, P = 0.01). DP patients were 5.63 times more likely to tolerate full enteral feeds ( P = 0.009). Nevertheless, when controlling for age, injury severity score, and pancreatic injury grade, procedure type did not statistically affect total and postoperative lengths of stay and postoperative complications. In the operative management algorithm of children sustaining CPT, DP may afford an earlier return to full enteral feeds. RYPJ seems otherwise equivalent to DP and preserves significant pancreatic glandular tissue and the spleen.
Defining Incidence and Outcome of Contrast-Induced Nephropathy Among Trauma: Is It Overhyped?
Authors: Kulvatunyou Narong , Rhee Peter M. , Carter Steven N. , Roberts Pamela M. , Lees Jason S. , Bender Jeffrey S. , Albrecht Roxie M.
Published: June 2020

Contrast-induced nephropathy (CIN) in trauma patients is uncommon and the incidence is unknown. We studied the incidence of CIN and its outcome. A retrospective chart review of trauma patients 16 years of age and older who were admitted to our Level I trauma center during 2005 was performed. Patients who received the intravenous contrast CT scan and had their serum creatinine (Cr) monitored at admission and at 48 to 72 hours were identified. CIN was defined as a 0.5-mg/dL rise of serum Cr or a 25 per cent increase from the baseline if the baseline Cr was abnormal. We excluded patients transferred from an outside facility, patients without repeated serum Cr measurements, patients who had cardiac arrest or persistent hypotension, and patients who had received N-acetylcysteine (Mucomyst) before their CT scan. We compared CIN and non-CIN groups. During 2005, 543 fit our study criteria, of whom 19 (3.5%) had CIN. CIN (vs non-CIN) had a higher baseline serum Cr (1.48 + 0.23 vs 1.06 + 0.02, P < 0.001), a longer intensive care unit stay (17 vs 5 days, P < 0.001), and a longer hospital stay (19 vs 8 days, P < 0.001); the mortality rate was not different (10 vs 4%, P = 0.2). We found elevated baseline serum Cr (OR, 1.92; 95% CI, 1.13 to 3.27; P = 0.016) to be associated with increased risk for CIN. All but two serum Cr levels peaked within 48 hours; all returned to baseline. One patient with an underlying congenital kidney disease required temporary dialysis. CIN incidence in trauma is low and the clinical course is benign.
Improving Mortality Predictions in Trauma Patients Undergoing Damage Control Strategies
Authors: Ordoñez Carlos A. , Badiel Marisol , SÁNchez ÁLvaro I. , Granados Marcela , GarcÍA Alberto F. , Ospina Gustavo , Blanco Gonzalo , Parra Viviana , GutiÉRrez-MartÍNez MarÍA I. , Peitzman Andrew B. , Puyana Juan-Carlos
Published: June 2020

The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A “clinical” model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score ( P value = 0.049), abdominal trauma index ( P value = 0.049), and acute physiology and chronic health evaluations II ( P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the “clinical” model and revised trauma score ( P value = 0.4) and trauma score-injury severity score ( P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.
Quality of Documented Consent for the De-escalation of Care on a General and Trauma Surgery Service
Authors: Thomasson Joseph , Petros Tommy , Lorenzo-Rivero Shauna , Moore Richard A. , Stanley J. Daniel
Published: June 2020

Postoperative and posttrauma mortality in the acute care setting often occurs after a decision for de-escalation of care. It is important that the quality of consent for de-escalation of care is maintained to ensure patient autonomy. This retrospective review aims to determine the quality of the consent process for care de-escalation in patients on a trauma and general surgery service who sustained in-hospital mortality. One hundred thirty-three patients (99 trauma) were identified who died in 1 year. Of these patient deaths, 80 (60%) involved de-escalation of care. In three (3%) cases, there were no documented discussions for de-escalation consent. Of the remaining cases, documentation was considered optimal 21 per cent of the time. Only nine (11%) patients were able to participate in a discussion of their end-of-life care. The other 23 patients who were initially competent lost their ability to participate in discussions after a debilitating event. In this study, the majority of patients who died on a surgical service underwent a de-escalation of care. The documentation quality was suboptimal in most cases. Earlier and more thorough discussion of the patient's end-of-life wishes may improve the de-escalation of care consent process.
A Critical Assessment of Outcomes in Emergency versus Nonemergency General Surgery Using the American College of Surgeons National Surgical Quality Improvement Program Database
Authors: Becher Robert D. , Hoth J. Jason , Miller Preston R. , Mowery Nathan T. , Chang Michael C. , Meredith J. Wayne
Published: June 2020

Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objective of our study was to assess and quantify postoperative morbidity and mortality for emergency versus nonemergency general surgery operations. All general surgery inpatients were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 database. Preoperative, intraoperative, and postoperative clinical metrics and occurrences were assessed. A total of 25,770 emergent and 98,867 nonemergent cases were identified. Postoperative morbidity was significantly worse in the emergent group, including ventilation more than 48 hours, bleeding requiring transfusion, deep vein thrombosis, renal failure, and need for reoperation. Overall, emergent cases had significantly more postoperative complications (22.8% vs 14.2%) and higher mortality rates (6.5% vs 1.4%). General surgery patients who undergo emergent operations have significantly poorer outcomes when compared with nonemergent patients; our analysis has quantified these differences. Emergent patients seem to manifest unique clinical, pathophysiologic, and inflammatory responses to their surgical disease. This data suggests that there is a need for improvement in both methods and systems of care for the emergent population.