bluuebunny/crossref_metadata_2025 huggingface dataset:
Idiopathic Necrotizing Fasciitis: Risk Factors and Strategies for Management
Authors: Taviloglu Korhan , Cabioglu Neslihan , Cagatay Atahan , Yanar Hakan , Ertekin Cemalettin , Baspinar Irfan , Ozsut Halit , Guloglu Recep
Published: June 2020

The prognosis of necrotizing fasciitis (NF) depends on early diagnosis and management. Idiopathic NF may be more challenging, because it occurs in the absence of a known causative factor. Therefore, our purpose in this study was to identify the distinct features of idiopathic NF that may be important in early recognition of this disease and determine the factors associated with mortality. A retrospective chart review was performed in patients with a diagnosis of NF between 1988 and 2003. Patients were classified as idiopathic and secondary NF, and data were analyzed in terms of etiological and predisposing factors, causative microbiological organisms, and clinical outcome. The study included 98 patients, 63 men and 35 women, with a diagnosis of NF. The median age was 55.5 years (range, 13–80). Idiopathic NF occurred in 60 of 98 patients (61%). The principal anatomic sites of infection for NF were perineal localisation in 55 patients (66%) and extremities in 31 patients (32%). Characteristics that distinguish patients with idiopathic NF from secondary NF were as follows: age older than 55 years ( P = 0.0001), presence of comorbid illnesses like DM ( P = 0.007) or chronic renal failure ( P = 0.041), and perineal localization ( P = 0.008). By logistic regression analysis, independent risk factors for idiopathic NF remained age >55 years and perineal localization as statistically significant factors, when all the significant variables found in univariate analysis were included in the model. The majority of patients (82%) had polymicrobial infections. The mortality rate was 35 per cent. All patients were treated with radical surgical debridement and a combination of antibiotics. Female gender, presence of malignant disease, and diabetes mellitus (DM) were found to be associated with increased mortality as independent factors in logistic regression analysis, when all of these three factors were included in the model. Understanding the distinct clinical characteristics and the factors associated with mortality in patients with NF may lead to rapid diagnosis and improve the survival rates. Therefore, idiopathic NF is a crucial entity that requires serious suspicion for its diagnosis.
A Prospective Study Comparing Diathermy and Scalpel Incisions in Tension-Free Inguinal Hernioplasty
Authors: Chrysos Emmanuel , Athanasakis Elias , Antonakakis Sokratis , Xynos Evaghelos , Zoras Odysseas
Published: June 2020

Although still controversial, the use of diathermy instead of scalpel for skin incision and underlying tissue dissection is gradually gaining wide acceptance. This is due to the observation that no change in wound complication rates or postoperative pain are reported with the use of electrocautery. However, these studies include operations without the use of prosthetic materials during abdominal wall closure. The purpose of this study was to investigate the hypothesis that a) application of extreme heat may result in significant postoperative pain and poor wound healing because of excessive tissue damage and scarring respectively, and b) skin incision with the use of diathermy entails increased risk of wound infection in the presence of an underlying prosthetic material. One hundred twenty-five consecutive patients submitted to inguinal hernioplasty using the tension-free technique and fulfilling the inclusion criteria for the study were allocated alternately to either scalpel (n = 60), or diathermy (n = 57) groups. Eight patients had bilateral hernias. Five of them were allocated to the scalpel group and three to the diathermy group. According to the study protocol, they received both approaches for skin and underlying tissues incision, thus resulting in a total of 68 scalpel and 65 diathermy individual hernioplasties. Parameters measured included blood loss during the skin incision and underlying tissue dissection, postoperative pain and requirements for analgesics, the presence of wound dehiscence in the absence of infection, and postoperative wound infection on the day of discharge, on the day staples were removed, and 1 month after surgery. The two groups of patients were similar in relation to patient demographics, type of hernias, and operation details. Blood loss was minimal, and the amount of blood lost did not differ between the two groups. Diathermy group patients required less parenteral analgesics on the first postoperative day. A higher proportion of patients in the scalpel group continued to need oral analgesics on the second postoperative day compared to patients in the diathermy group. There was no difference between the two groups in terms of wound strength. Infectious complications were totally absent. The use of diathermy for skin incision during inguinal hernioplasty is as safe as the use of scalpel in terms of wound healing and reduces the analgesics requirements in the postoperative period.
Metastatic Choriocarcinoma to the Pancreas
Authors: Alvarez Nicolas R. , Lambrou Nicholas , Solorzano Carmen C.
Published: June 2020

Gestational choriocarcinoma is a highly metastatic neoplasm derived from placental tissue, occurring in approximately 1:20,000–40,000 pregnancies. Although gestational choriocarcinoma may follow any gestational event, it most commonly follows molar pregnancies. We report a case of a 24-year-old Hispanic woman with persistent trophoblastic disease who, after failing to respond to chemotherapy, was found to have metastasis to the liver and pancreas. The patient underwent successful distal pancreatectomy and splenectomy to be followed by salvage chemotherapy. Strong risk factors for choriocarcinoma include previous molar pregnancy or spontaneous abortion and increased maternal age. Gestational choriocarcinoma is classically responsive to chemotherapy; surgical excision is reserved for acute emergencies and is an acceptable option for patients with persistent disease in need of palliative treatment and tissue diagnosis.
APC, K-ras, and p53 Gene Mutations in Colorectal Cancer Patients: Correlation to Clinicopathologic Features and Postoperative Surveillance
Authors: Hsieh Jan-Sing , Lin Shiu-Ru , Chang Mei-Yin , Chen Fang-Ming , Lu Chien-Yu , Huang Tsung-Jen , Huang Yu-Sheng , Huang Che-Jen , Wang Jaw-Yuan
Published: June 2020

Current researches have proposed a genetic model for colorectal cancer (CRC), in which the sequential accumulation of mutations in specific cancer-related genes, including adenomatous polyposis coli (APC), K- ras, and p53, drives the transition from normal epithelium through increasing adenomatous dysplasia to colorectal cancer. To identify patients with an increased risk of tumor recurrence or metastasis and evaluate the prognostic values of APC, K- ras, and p53 gene mutations, we investigated the frequency of these three mutated genes in tumors and sera of CRC patients. APC, K- ras, and p53 gene mutations in primary tumor tissues and their paired preoperative serum samples of 118 CRC patients were detected by using polymerase chain reaction– single strand conformation polymorphism (PCR-SSCP) analysis, followed by direct DNA sequencing of the PCR-amplified genomic DNA. Subsequently, serum molecular markers were analyzed for their correlation with patients’ clinicopathologic features and presence of postoperative recurrence/metastasis. We did not observe any significant difference in the association of APC or K- ras or p53 gene mutations in primary tumors with patients’ demographic data (all were P > 0.05). In contrast, both serum APC and p53 molecular markers were closely correlated with lymph node metastasis and TNM stage (both P < 0.05). Moreover, the serum overall molecular markers (at least one of the three markers) were prominently associated with depth of tumor invasion ( P = 0.033), lymph node metastasis ( P < 0.001), and TNM stage ( P < 0.001). In addition, a significantly higher postoperative metastasis/recurrence rate in patients positive for overall molecular markers compared to those negative for these molecular markers were also demonstrated ( P < 0.001). APC and K- ras molecular markers were more frequently observed in patients with locoregional metastasis (both P < 0.05), while p53 molecular marker was usually detected in the cases of peritoneal metastasis ( P = 0.004). Our findings suggest that serum molecular markers are potentially useful in the determination of colorectal cancer patients harboring gene mutations at high risk of metastasis. Serial analysis is warranted in order to assess their long-term prognostic significance and the therapeutic implications.
Major Hepatobiliary Surgery during Pregnancy: Safety and Timing
Authors: Jabbour Nicolas , Brenner Megan , Gagandeep Singh , Lin Abe , Genyk Yuri , Selby Rick , Mateo Rodrigo
Published: June 2020

Hepatobiliary disease, although rare, may present during pregnancy with potential complications for mother and fetus. We present two cases of choledochal cysts and one case of a hepatic adenoma diagnosed in gravid patients. All three patients had acute events or failed medical management and were successfully treated with open resection, excision, or reconstruction during the second or third trimesters of pregnancy without requiring blood transfusions or tocolytic therapy. Although conservative treatment may be indicated in select patients due to the risk of underlying disease, we recommend surgical treatment preferably in the second trimester. With diligent intra- and postoperative management, pregnant patients can safely proceed with major hepatobiliary surgery.
Recurrent Intramucosal Gastric Carcinoma with Extensive Invasion to Duodenal Mucosa after Endoscopic Mucosal Resection: A Case Report
Authors: Ishikawa Makoto , Kitayama Joji , Fujii Shin , Ishigami Hironori , Kaizaki Shoichi , Nagawa Hirokazu
Published: June 2020

The occurrence of early gastric carcinoma with invasion to the duodenum is supposed to be very low, although advanced cancers arising in the antrum can often invade the duodenal area. Generally, malignant invasion of the duodenum is difficult to diagnose preoperatively, as spread of gastric cancer to the duodenum is often infiltrative and invades through the submucosal or subserosal layer. We report an unusual case of an intramucosal gastric carcinoma with extensive duodenal invasion that was preoperatively diagnosed by endoscopy.
A New Complication from a New Technology: What a General Surgeon Should Know about Wireless Capsule Endoscopy
Authors: Chang Phillip K. , Holt Elizabeth G. , De Villiers Willem J.S. , Boulanger Bernard R.
Published: June 2020

Wireless capsule endoscopy has revolutionized the diagnostic evaluation of the small intestine and is increasingly used by gastroenterologists. However, complications can occur with this seemingly safe procedure. We report two cases of Crohn's disease in which capsule endoscopy was performed with retention of the capsules. Both patients were taken to the operating room electively after careful preoperative planning to address both the surgical aspect of Crohn's disease and the retained capsule. We reviewed the literature on the use of wireless capsule endoscopy in patients with Crohn's disease and discuss the approach to a new surgical complication.
Thyroglossal Duct Cysts: A Consideration in Adults
Authors: Mohan Pradeep S. , Chokshi Ravi A. , Moser Robert L. , Razvi Sadeq A.
Published: June 2020

Thyroglossal duct cysts (TDC) are one of the most common pediatric midline neck lesions. Although they are present from birth, they usually become symptomatic in early childhood as a mass or draining sinus. Infection and abscess formation are frequent complications due to a communication between the cyst and the mouth with subsequent contamination by oral flora. We present a case of a 37-year-old male who presented with a newly symptomatic thyroglossal duct cyst. The patient presented to the infirmary with pain in the anterior neck particularly with swallowing. A midline mass was visible and palpable on examination. Subsequent neck exploration revealed a thyroglossal duct cyst filled with purulent material. Although uncommon in adults, thyroglossal duct cysts should be a part of the surgeon's differential diagnosis when presented with a neck mass. One should remember that an infected neck mass is the common presentation of thyroglossal duct cysts in adults, and the appropriate diagnostic studies need to be performed in order to best determine the diagnosis. Once diagnosed, the TDC is best treated using the Sistrunk procedure to limit recurrence.
Endovascular Management of Ruptured, Mycotic Abdominal Aortic Aneurysm
Authors: Corso J. Eduardo , Kasirajan Karthikeshwar , Milner Ross
Published: June 2020

Patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. Magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.
De Garengeot Hernia: Appendicitis within a Femoral Hernia
Authors: Akopian Gabriel , Alexander Magdi
Published: June 2020

Many surgeons are familiar with Amyand hernia, which is an inguinal hernia sac containing an appendix. However, few surgeons know of the contribution of Rene Jacques Croissant de Garengeot, an 18th century Parisian surgeon, to hernias. He is quoted in the literature as the first to describe the appendix in a femoral hernia sac. We discuss the case of an 81-year-old woman who presented with appendicitis within a femoral hernia, a rare finding at surgery that is almost never diagnosed preoperatively. We also propose crediting Croissant de Garengeot by naming this condition after him. Although his full last name is Croissant de Garengeot, for convenience we suggest the simple diagnosis of “de Garengeot hernia.”
5-Year Follow-up after Sentinel Node Mapping for Breast Cancer Demonstrates Better than Expected Treatment Outcomes
Authors: Fuhrman George M. , Gambino Jamie , Bolton John S. , Farr Gist , Jiang Xiaozhang
Published: June 2020

We conducted this study to provide one of the initial assessments of treatment outcomes for breast cancer patients evaluated with sentinel node mapping. All patients diagnosed with breast carcinoma, evaluated with sentinel node mapping, and followed for 5 years were divided into three groups depending on sentinel node(s) status. Group I (node negative) included 91 patients, 77 with invasive cancer, and 7 lost to follow-up. Of the remaining 70 patients, 3 (4.3%) suffered a distant recurrence and died, 1 developed an in-breast recurrence, and 9 (12.9%) developed a contralateral cancer during the study. Group II (IHC positive) included 28 patients. One (3.6%) developed a distant recurrence and died of breast cancer, and one developed a contralateral cancer during follow. Group III (H&E positive) included 36 patients with 1 lost to follow-up. Five patients (14.3%) died of breast cancer and two (5.7%) developed contralateral carcinomas during follow-up. The most striking observation was a lower than expected rate of distant recurrences in these patients followed for 5 years after a diagnosis of breast cancer and staging with sentinel node mapping. The ability to identify subtle nodal metastasis and design appropriate systemic therapeutic strategies may explain this finding.
Metastatic Thymic Carcinoid: A Case Report
Authors: Talton Charles C. , Hopkins Judith O. , Walley Bruce D. , Kincaid Edward H.
Published: June 2020

Thymic neuroendocrine carcinomas (carcinoid) are rare tumors. They have malignant potential, the capacity for distant metastasis, and often present with associated endocrinopathies. This report describes a patient who was diagnosed with thymic carcinoid and Cushing syndrome at age 19 that, despite complete surgical excision of his tumor, developed local recurrence with distant metastases to his brain, lungs, and bone. We discuss the evolution of this patient's illness as well as the therapies used in his care. Due to the nature of these tumors to recur both locally and distant, the importance of aggressive surgical management is emphasized. We also discuss the role of adjuvant therapy, which in our case consisted of chemotherapy, radiotherapy, and several new therapies including an antiangiogenesis agent and a tyrosine kinase inhibitor.
Common Femoral Vein Aneurysm Simulating an Inguinal Hernia
Authors: Castaldo Eric T. , Williams Eric H. , Dattilo Jeffrey , Passman Mark , Naslund Thomas , Guzman Raul J.
Published: June 2020

Common femoral vein aneurysms are rare, yet knowledge of this entity is important for the surgeon who performs hernia repairs. This is because common femoral vein aneurysms can simulate inguinal or femoral hernias, and misdiagnosis can lead to significant morbidity if treated incorrectly. To our knowledge, only five other cases of femoral aneurysms simulating inguinal or femoral hernias have been reported. We present the case of a 50-year-old male with inguinal pain and swelling who was found to have a common femoral vein aneurysm at surgical exploration for hernia repair. The etiology, diagnostic strategy, and management options for common femoral vein aneurysm are presented and are followed by recommendations for operative management. In the case of an unanticipated femoral aneurysm found during hernia repair, we recommend termination of the procedure followed by elective repair to be performed after appropriate diagnostic testing has been completed.
Components Separation Technique and Laparoscopic Approach: A Review of Two Evolving Strategies for Ventral Hernia Repair
Authors: Gonzalez Rodrigo , Rehnke Robert D. , Ramaswamy Archana , Smith C. Daniel , Clarke John M. , Ramshaw Bruce J.
Published: June 2020

When faced with large ventral hernias, surgeons frequently must choose between higher incidence of recurrence after primary repair and higher incidence of wound complications after repair with mesh. The aim of this study is to compare early outcomes between laparoscopic repair (LR) and components separation technique (CST), two evolving strategies for the management of large ventral hernias. We reviewed 42 consecutive patients who underwent CST and 45 consecutive patients who underwent LR of ventral hernia defects of at least 12 cm2. Demographics, hernia characteristics, and short-term outcomes were compared between groups. Patients in the LR group were younger (53 ± 2 vs 68 ± 2 years, P < 0.0001), had greater body mass index (34 ± 2 vs 29 ± 1 kg/m2, P = 0.02), and had larger hernia defects (318 ± 49 vs 101 ± 16 cm2, P < 0.0001) than patients in the CST group. The LR resulted in shorter length of hospital stay (4.9 ± 0.9 vs 9.6 ± 1.8 days, P < 0.0001), lower incidence of ileus (7% vs 48%, P < 0.0001), and lower incidence of wound complications (2% vs 33%, P < 0.001) than the CST. Both techniques resulted in similar operative times, transfusion requirements, and mortality. Recurrences occurred in 7 per cent of patients at mean follow-up of 16 months in the CST group and 0 per cent at mean follow-up of 9 months after LR. The LR may have a short-term advantage over the CST in terms of incidence of ileus, wound complications, and hospital stay. Because of their unique advantage over traditional hernia repairs, both techniques may play a significant role in the future treatment of large ventral hernias. Adequate training will be essential for the safe and effective implementation of these techniques within the surgical community.
The General Surgery Model: A More Appealing and Sustainable Alternative for the Care of Trauma Patients
Authors: Roettger Richard H. , Taylor Spence M. , Youkey Jerry R. , Blackhurst Dawn W.
Published: June 2020

The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable. Little objective data, however, is available documenting that a better model exists. From September 2002 through August 2003, the trauma model at a 735-bed level I trauma teaching hospital was changed from the contemporary model to a new one where selected general surgeons with Advanced Trauma Life Support (ATLS) certification covered in-house trauma and emergency surgery call on a rotational basis. As well, each pursued elective practices, admitting all inpatients (trauma, emergent, elective) to a single teaching service (formerly the trauma service). Critical care was managed by a separate group of intensivists. The purpose of this study was to objectively compare the two models. Quantitative, financial, and qualitative data were derived from August 2001 to January 2002 (trauma/critical care model) and compared to August 2003 to January 2004 (general surgery model). During the two periods (trauma/critical care vs general surgery), the mean Revised Trauma Score (7.1 vs 7.2; P = 0.029), the mean Injury Severity Score (ISS) (10.9 vs 10.8; P = 0.84), and the percentage of penetrating trauma (12.5% vs 13.2%; P = 0.79) were similar. Differences (trauma/critical care vs general surgery, % increase/ P value) included average daily census (24 vs 54, 225%), cases/attending (262 vs 543, 207%), cases/resident (54 vs 262, 485%), charges/attending ($353,811 vs $471,725, 133%), collections/attending ($106,143 vs $165,103, 156%), number of trauma patients (643 vs 748, 116%), trauma mortality (7.3% vs 4.0%; P = 0.007), trauma mortality with ISS >15 (21.7% vs 12.0%; P = 0.035), trauma complications (33.1% vs 17%; P < 0.001), and ICU morbidity (66.8% vs 43.9%; P < .001). The new general surgery model produced superior financial results and better quantitative surgical experience while exceeding trauma and ICU quality outcomes compared to the former trauma/critical care model. These data objectively support a model such as ours–one that is financially sustainable and more professionally attractive.
Postoperative Outcomes According to Preoperative Medical and Functional Status after Infrainguinal Revascularization for Critical Limb Ischemia in Patients 80 Years and Older
Authors: Taylor Spence M. , Kalbaugh Corey A. , Blackhurst Dawn W. , Langan Eugene M. , Cull David L. , Snyder Bruce A. , Carsten Christopher G. , Jackson Mark R. , York John W. , Youkey Jerry R.
Published: June 2020

The purpose of this study was to provide outcomes after intervention for critical limb ischemia (CLI) in elderly patients (≥80 years) according to medical and functional status at presentation. From January 1998 to September 2003, 140 limbs/122 patients (age range 80–97 years) were treated (57 patients/66 limbs, infrainguinal bypass; 65 patients/74 limbs, infrainguinal angioplasty) for CLI. At presentation, 71 (58.2%) patients were functionally ambulatory, 41 (33.6%) were home-bound ambulators, and 10 (8.2%) were transfer-only ambulators. Overall end points after treatment as well as outcomes according to type of treatment and preoperative medical and functional status were determined. End points included reconstruction patency, limb salvage, survival, amputation-free survival, and maintenance of ambulatory and independent living status. Results for the 140 limbs/122 patients at 3 years (Kaplan-Meier curves) include primary patency, 55.3%; secondary patency, 73.2%; limb salvage, 78.3%; survival, 62.5%; amputation-free survival, 49.7%; maintenance of ambulation, 77.8%; and maintenance of independent living status, 82.9%. There was essentially no difference in outcomes based on type of treatment (endovascular vs open operation). When analyzing 2-year outcomes by functional status (ambulatory vs homebound vs transfer), there was deterioration in outcomes according to declining functional status at presentation for mortality (84.7% vs 66.4% vs 42%; P < 0.001), amputation-free survival (73.3% vs 48.2% vs 36.9%; P < 0.001), limb salvage (86% vs 66.5% vs 71.9%; P = 0.022), and secondary patency (84.3% vs 61.5% vs 69.2%; P = 0.005) regardless of treatment. Homebound ambulators were two times and transfer-only patients five times more likely to experience death (Cox hazard model); diabetics were four times more likely to lose a limb and experience a decline in ambulation and living status. Overall medical and functional status at presentation predicts postoperative functional outcomes. These data support a policy of aggressive vascular intervention in the functional elderly and clinical restraint in the functionally impaired patient with CLI.
Absorbable Cyanoacrylate as a Vascular Hemostatic Sealant: A Preliminary Trial
Authors: Schenk Worthington G. , Spotnitz William D. , Burks Sandra G. , Lin Peter H. , Bush Ruth L. , Lumsden Alan B.
Published: June 2020

No absorbable cyanoacrylate tissue adhesive for safe internal surgical use is available. This prospective multicenter preliminary study was designed to evaluate the safety and effectiveness of an investigational absorbable cyanoacrylate (IAC) as an adjunct to hemostasis in arteriovenous shunt (AVS) procedures for dialysis access. Consenting adults (10) underwent placement of expanded polytetrafluoroethylene (ePTFE) upper extremity vascular grafts for AVS access using continuous 5-0 or 6-0 polypropylene after heparinization (≥3,000 units IV). Arterial anastomoses were evaluated after sealing with IAC followed by 120 seconds of polymerization time. After vascular clamp removal, the mean time to hemostasis was 9.1 ± 28.8 seconds. Additionally, 90 per cent (9/10) and 100 per cent (10/10) achieved hemostasis by 1 and 5 minutes, respectively. No patients required further adjunctive hemostatic measures. Adverse event safety data analysis through 12 weeks revealed occlusion of graft or vessel in four patients and graft thrombosis in one patient, all thought unrelated to sealant use. Other unrelated adverse events (bleeding, death, deep venous thrombosis, edema, erythema, hematoma, infection, and rash) occurred in single patients. Thus, IAC could be a useful sealant for vascular procedures with a potentially satisfactory safety profile. Larger, randomized, multicenter, prospective trials to further evaluate the use of this material are indicated and appropriate.
A Survey of the Work Effort of Full-time Surgeons of the Southeastern Surgical Congress
Authors: Gadacz Thomas R. , Bason James J.
Published: June 2020

This is a survey research project to determine the work hours of practicing surgeons and compare those hours with hours that have been mandated for graduate medical education programs by the Accreditation Council for Graduate Medical Education (ACGME). The survey conducted of the membership of the Southeastern Surgical Congress focused on the amount of time devoted to professional activity. Although several categories of membership were surveyed, those surgeons in full-time practice were used for this report. Five hundred ninety-two general surgeons and some surgical specialties from 17 states reported a total professional work effort of 65 hours per week averaged over a month. Twenty per cent reported working more than 80 hours per week. Statistically significant ( P < 0.05) factors that characterized these individuals included years in practice (1 to 10 years), more clinical hours per week, fewer administrative hours per week, fewer teaching hours per week, fewer continuing medical education (CME) hours per year, and an increase in recent clinical practice. Interestingly, there was no significant difference in CME over a 2- or 5-year period. Other factors such as type of practice did not have statistical significance. There was no difference between states and no difference in time commitment to political or community activities. This survey indicates that surgeons going into practice in the Southeast from general surgery graduate medical education programs can expect to have a mean work week of 65 hours, and 20 per cent can expect to exceed an 80-hour work week.
Preoperative Oral Rofecoxib and Postoperative Pain in Patients after Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial
Authors: Schuster Rob , Stewart David , Schuster Lynn , Greaney Gregory , Waxman Kenneth
Published: June 2020

Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 ± 1.93 in the rofecoxib group versus 4.38 ± 1.34 in the placebo group ( P = 0.36); at 6 hours, 3.00 ± 1.12 in the rofecoxib group versus 2.78 ± 0.78 in the placebo group ( P = 0.42); and at 24 hours, 1.64 ± 0.67 in the rofecoxib group versus 2.68 ± 1.90 in the placebo group ( P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.
Recent Trends in the Management of Combined Pancreatoduodenal Injuries
Authors: Lopez Peter P. , Benjamin Robert , Cockburn Mark , Amortegui Jose D. , Schulman Carl I. , Soffer Dror , Blackbourne Lorne H. , Habib Fahim , Jerokhimov Igor , Trankel Susan , Cohn Stephen M.
Published: June 2020

In an effort to better characterize the natural history of pancreatoduodenal injuries, we present a review of clinical experiences in the treatment of combined traumatic pancreatoduodenal injuries, focusing on patients in extremis. Records of patients with abdominal trauma admitted to a level 1 trauma center from 1997 to 2001 were reviewed. Of 240 patients who sustained a pancreatic or duodenal injury, 33 had combined pancreatoduodenal injuries. Eighty-two per cent of the patients (27/33) in this series had penetrating injuries, 72 per cent (24) sustained gunshot wounds (GSW). Thirty-one patients were male, and the mean age was 33 years (range, 7–74). These patients presented with an average Injury Severity Score (ISS) of 22 ± 12 and an average Glasgow Coma Score of 14 ± 2. Overall length of stay was 39 ± 59 days (range, 0–351 days). These 33 patients underwent a total of 57 laparotomies with an average of 1.7 operations per patient (range, 1 to 5 operations). Eighty-four per cent of the patients had an associated gastrointestinal injury and 45 per cent had a major vascular injury. Thirteen of the 33 (39%) patients presented in extremis, all 13 underwent an abbreviated laparotomy. The complication rate was 36 per cent, including fistula, abscess, pancreatitis, and organ dysfunction. There were 6 hospital deaths for a mortality rate of 18 per cent. Pancreatoduodenal injuries are associated with a variety of other serious injuries, which add to the overall complexity of these patients. Abbreviated laparotomy may be helpful when managing combined pancreatoduodenal injuries in patients who are in extremis.
Successful Treatment of Bouveret Syndrome Using Holmium: YAG Laser Lithotripsy
Authors: Goldstein Evan B. , Savel Richard H. , Pachter H. Leon , Cohen Jonathan , Shamamian Peter
Published: June 2020

Although gallstone disease is highly prevalent, cholelithiasis causing gallstone ileus is uncommon. Consideration has been given for nonoperative strategies to resolve obstruction due to the significant age and comorbidities afflicting this population. A 94-year-old man presented with a 5-day history of abdominal distension and tenderness. CT scan revealed multiple large gallstones within the gallbladder, pneumobilia, and two ectopic gallstones (antrum of the stomach and distal ileum). The patient was taken to the operating room where an enterolithotomy and gastrotomy was performed with removal of gallstones and subsequent relief of obstruction. During the postoperative course, the patient developed symptoms of gastric outlet obstruction and underwent gastrointestinal endoscopy for diagnosis and treatment. Two large gallstones, present in the duodenum, were retracted into the stomach using a Roth net but could not be retrieved beyond the upper esophageal sphincter. A holmium: yttrium-aluminum-garnet (Holmium: YAG) laser was used for fragmentation of the stones, with subsequent successful removal. This is the first documented successful use of the holmium: YAG laser for the treatment of recurrent gallstone ileus. Physicians should remember that in a small but important subgroup of patients, endoscopy accompanied by laser lithotripsy may prove beneficial.
Obesity Status and Use of General Surgery Resources
Authors: Finan Kelly R. , Leeth Ruth R. , Ritchie Gilbert , Vickers Selwyn M. , Hawn Mary T.
Published: June 2020

Obesity is a rapidly growing epidemic. This study assesses the impact of obesity on surgeon workload for general surgical services. A retrospective study of patients undergoing cholecystectomy, unilateral mastectomy, and colectomy between January 2000 and December 2003 was undertaken. Obesity was defined as body mass index ≥30. The proportion of obese patients was compared to the 2002 BRFSS obesity prevalence data for Alabama. Data were adjusted to control for potential confounders. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 1,385 patients were included in analysis. The prevalence of obesity in the study population was 35.5 per cent compared to the statewide prevalence of 25.2 per cent (OR = 1.73, 95% CI = 1.51, 1.98). These data were stratified by procedure, age, and gender. The cholecystectomy group had a significantly higher proportion of obese for all age groups and female gender. The mastectomy group had a higher proportion of obese in the 45–64 age group. The stratified colectomy group did not reach statistical significance. There was no evidence of referral bias to explain these findings. This study demonstrates there is a greater use of general surgery services, particularly cholecystectomy and mastectomy, in obese patients than predicted by the prevalence of obesity in the population.
Personal Satisfaction and Mentorship are Critical Factors for Today's Resident Surgeons to Seek Surgical Training
Authors: Lukish Jeffrey , Cruess David ,   EXECUTIVE COMMITTEE OF THE RESIDENT AND ASSOCIATE SOCIETY OF THE AMERICAN COLLEGE OF SURGEONS
Published: June 2020

The specific aim of this study was to summarize the viewpoints of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) membership regarding current training and quality of life–related issues prior to implementation of the new duty-hour guidelines. The goal was to gain insight of the members that may be useful to recruit and guide the future training of surgical residents. An Internet-based survey was developed to evaluate the viewpoints of RAS-ACS. The survey was administered by Esurveymaker.com via the ACS Web page from 2000 to 2003. RAS-ACS member participation was voluntary and anonymous. Analyses were performed to determine the frequency of response for each survey item. Two hundred thirty-five members completed the survey representing 5 per cent of RAS-ACS. Eighty-four per cent were general surgery residents. Personal satisfaction (64%) and mentorship (49%) were top factors for respondents to pursue surgical training; discussion with colleagues and future income was less important. Forty-five per cent reported that job performance was their most important concern during residency. A rewarding surgical career and family life were ranked as the most important expectations. Eighty-six per cent reported that they were satisfied with their residency, and 66 per cent reported that work hours should be limited. Personal satisfaction and mentorship were critical factors for members of the RAS-ACS to seek surgical training. Although most of the members report that work hours should be limited, an overwhelming majority reports satisfaction with surgical training prior to institution of the new duty-hour guidelines. Further emphasis on mentorship and work-hour reform may be beneficial in recruiting medical students into surgical residencies.
Civilian Craniocerebral Gunshot Wounds: An Update in Predicting Outcomes
Authors: Murano Tiffany , Mohr Alicia M. , Lavery Robert F. , Lynch Catherine , Homnick Adena T. , Livingston David H.
Published: June 2020

Given the high mortality in patients sustaining intracranial injury secondary to gunshot wounds (GSWs), predictors to identify patients at increased risk of death are needed to assist clinicians early in determining optimal treatment. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients, which do not allow for adequate prediction of mortality. A retrospective chart review of 298 patients who sustained GSWs to the head between 1992 and 2003 was conducted at a level 1 trauma center. Demographics, bullet trajectory, admitting Glasgow Coma Scale (GCS), head Abbreviated Injury Score (AIS), as well as admission blood pressure and respiratory rate were evaluated. Univariate testing followed by multivariate logistic regression was performed to identify independent predictors of death. In-hospital mortality for patients with intracranial injury secondary to GSW was 51 per cent. A GCS <5 on admission and a high Injury Severity Score (ISS >25) was associated with mortality as compared with survivors ( P < 0.05). Of those patients presenting with a GCS of 3, there were seven survivors to discharge. Logistic regression identified the following variables as predictors of death: respiratory arrest on admission, hypotension on admission, transhemispheric and transventricular GSW. Identification of those patients at the highest risk of death secondary to a craniocerebral GSW allows clinicians to better predict outcome and prognosis. This is not only important in determining treatment algorithms for physicians but also for appropriate counseling of family members to educate them with regard to patients’ outcomes.
Evaluation of a Tensiometer to Provide Objective Feedback in Knot-Tying Performance
Authors: Van Sickle Kent R. , Smith Brittany , McClusky David A. , Baghai Mercedeh , Smith C. Daniel , Gallagher Anthony G.
Published: June 2020

Training and assessment methods for knot tying by medical students or residents have traditionally been subjective. Objective methods for evaluating creation of a tied knot should include assessing the strength and quality of the knotted suture. The purpose of this study was to evaluate the use of a tensiometer as a feedback device for improving knot-tying performance. Twelve medical students with no knot-tying experience were selected to perform three-throw instrument ties with 00 silk suture. Students were randomly assigned to perform between 10 and 20 baseline knots and then received one of four feedback training conditions followed by 10 completion knots. Subjects were timed, and all knots were pulled in the tensiometer to assess for strength and slippage. Differences between baseline and completed knots for each subject were analyzed with an unpaired t test. Subjects receiving both subjective and tensiometer feedback demonstrated the greatest improvements in knot quality score (KQS) and slip percentage (Subject 1: 0.15 ± 0.9 vs 0.21 ± 0.05, P < 0.04, 75% vs 60%, P = NS; Subject 2: 0.22 ± 0.10 vs 0.29 ± 0.05, P < 0.02, 33% vs 0%, P < 0.05; Subject 3: 0.10 ± 0.07 vs 0.25 ± 0.07, P < 0.0001, 60% vs 10%, P < 0.01). Objective assessment of knot-tying performance is possible using the tensiometer device. Introduction of the tensiometer during the learning phase produced improved KQS and slip percentage in most students regardless of the number of baseline knots tied. Greatest improvements in performance were seen when the tensiometer was used in combination with subjective instruction.
Subdiaphragmatic Bronchogenic Cysts: A Comprehensive Review of the Literature
Authors: Liang Mike K. , Yee Herman T. , Song Jae W. , Marks Jenifer L.
Published: June 2020

Bronchogenic cysts are foregut-derived developmental anomalies most commonly encountered in the mediastinum and rarely in the abdomen or retroperitoneally. A comprehensive review of the English-language literature of subdiaphragmatic bronchogenic cysts (sBCs) revealed only 48 reported cases of sBC. Although most cases are incidentally discovered, preoperative differential diagnosis often includes tumors with malignant potential and necessitates surgical resection to obtain a definitive diagnosis. Herein, we describe a case of a 46-year-old female presenting with intermittent left flank pain, upon which computed tomography demonstrated a retroperitoneal mass. Upon resection, histopathology revealed the mass to be a thin-walled cystic mass lined by ciliated columnar cells and cartilage, consistent with a subdiaphragmatic bronchogenic cyst. A comprehensive literature review of sBC was also performed.
A Rare case of Classic Biphasic Pulmonary Blastoma
Authors: Schulze S.M. , Sbayi S. , Costic J.T. , Moser R.L.
Published: June 2020

Biphasic pulmonary blastomas are rare tumors that together with pulmonary carcinosarcomas comprise less than 2 per cent of all lung neoplasms. They can be defined as tumors that are composed of an admixture of immature mesenchyme and epithelium and that recapitulate morphologically the embryonal structure of the lung. First described in 1945 by Barnett and Barnard, their existence is well documented although their occurrence is rare. We present a case of a 40-year-old Hispanic female that presented with a 2-month history of retrosternal and midepigastric pain. A GI etiology was initially treated unsuccessfully with antireflux medications. A chest radiograph showed a 4.6-cm mass in the right upper lobe of the lung, and computed tomography showed right apical bullous formation with no lymphadenopathy. Bronchoscopy revealed no endobronchial lesions, and biopsy was nondiagnostic. The histopathologic and immunophenotypic analysis of a right upper lobectomy specimen was diagnostic of classic biphasic pulmonary blastoma. The rarity of these tumors makes easy identification difficult. Immunohistochemical analysis must be used to arrive at the proper diagnosis. It is imperative that there be good communication between the surgeon and pathologist and that institutions have access to facilities with the ability of identifying these complex tumors.
Pancreatic Mass of Unusual Etiology: Case Report of Metastatic Disease after a Prolonged Lag Phase
Authors: Haque Saadiya , Gopaldas Raja R. , Plymyer Matthew R. , Glantz Andrew I.
Published: June 2020

Although not a typical site, the pancreas does occasionally harbor metastatic disease. Management of these metastases differs from the management of conventional primary cancers. Our case is one of an 85-year-old female presenting with obstructive jaundice and whose workup revealed a pancreatic mass. Her past medical history included a mastectomy 14 years previous for invasive lobular carcinoma. She underwent celiotomy, and an intraoperative diagnosis of metastatic lobular carcinoma of the breast was made based on frozen section. Due to pulmonary metastasis and vascular infiltration, which precluded pancreatoduodenectomy, the patient underwent palliative bypass and fared well postoperatively. With more aggressive management of primary breast cancers in the past decade, isolated metastatic disease is of increasing concern and raises questions about surgical strategies to be implemented with these patients. For instance, should palliative treatment be considered or should a radical intention to cure procedure be performed despite the metastatic disease? Factors favoring radical procedures include prolonged lag phase between the primary and the recurrence; presence of well-differentiated tumors; and isolated metastatic disease. Primary lung and renal cancers metastasize more frequently than breast cancers do to the pancreas. Hence, existing literature has not clearly defined indications for radical treatment of metastatic breast cancers to the pancreas. Based on experiences with metastatic renal and lung cancers, one can reasonably infer that radical procedures performed on selected cases could possibly achieve a cure or prolonged disease-free survival. The key factor in determining whether the patient undergoes palliative versus radical treatment is a slow growth pattern of the tumor, characterized by a prolonged lag phase between the primary and the metastatic disease.
The (Absence of a) Role of Venous Duplex Scan in the Diagnosis of Pulmonary Embolism after Severe Trauma
Authors: Velmahos George C. , Brown Carlos V. , Demetriades Demetrios
Published: June 2020

Venous duplex scan (VDS) has been used for interim bedside diagnosis of pulmonary embolism (PE) in severely injured patients deemed to be at risk if transported out of the intensive care unit. In combination with the level of clinical suspicion for PE, VDS helps select patients for temporary treatment until definitive diagnosis is made. We evaluate the sensitivity and specificity of VDS in critically injured patients with a high level of clinical suspicion for PE. We performed a prospective observational cohort study at the surgical intensive care unit of an academic level 1 trauma center. Patients were 59 critically injured patients suspected to have PE over a 30-month period. The level of clinical suspicion for PE was classified as low or high according to preset criteria. Interventions were VDS and a PE outcome test (conventional or computed tomographic pulmonary angiography). The sensitivity and specificity of VDS to detect PE in all patients and in patients with high level of clinical suspicion was calculated against the results of the outcome test. PE was diagnosed in 21 patients (35.5%). The sensitivity and specificity of VDS was 33 per cent and 89 per cent, respectively. Among the 28 patients who had a high level of clinical suspicion for PE, the sensitivity of VDS was 23 per cent and the specificity 93 per cent. In this latter population, 1 of the 4 (25%) positive VDS was of a patient without PE and 10 of the 24 (42%) negative VDS were of patients who had PE. VDS does not accurately predict PE in severely injured patients, even in the presence of a high level of clinical suspicion.