bluuebunny/crossref_metadata_2025 huggingface dataset:
Resectional Therapy for Cystic Neoplasms of the Pancreas
Authors: Harper Amy E. , Eckhauser Frederic E. , Mulholland Michael W.
Published: November 2022

Currently there is uncertainty in diagnosis between the serous (benign) and mucinous (premalignant) forms of cystic neoplasms of the pancreas without operation. Our objective is to evaluate resectional therapy as a treatment for these lesions. A retrospective review of cases from 1985 to 1999 were performed. There were 14 cases of serous cystadenoma (SCA), 11 cases of mucinous cystadenoma (MCA), and five cases of mucinous cystadenocarcinoma (MCAC). A female predominance was seen in all lesions (100% in SCA, 64% in MCA, and 80% in MCAC) with a mean age at presentation of 59 years. Most patients presented with pain (SCA = 64%, MCA = 55%, and MCAC = 80%). Weight loss was seen in 35 per cent of all patients and was present in all cases of MCAC. Importantly 36 per cent of MCA patients were asymptomatic. Lesions were identified as multicystic on CT reports of 62 per cent of SCA patients, 50 per cent of MCA patients and 75 per cent of MCAC patients. Size was similar between groups. All patients were treated with surgical resection; operative morbidity was 27 per cent and mortality was zero. Actuarial 5-year survival for SCA, MCA, and MCAC was 100, 100, and 33 per cent, respectively. Differentiating serous from mucinous is not possible based on presenting symptoms and radiologic findings. Surgical resection is justified on the basis of low morbidity and negligible mortality rates.
Continuing Experience with Liver Resection and Vena Cava Reconstruction using Cardiopulmonary Bypass and Hypothermic Circulatory Arrest
Authors: Sener Stephen F. , Winchester David J. , Votapka Timothy V. , Mcguire Michael S. , O'Connor Brent , Szokol Joseph W.
Published: November 2022

When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. Morbidity consisted of prolonged bile leak (one), pulmonary embolism (one), and stroke (one). Control of the liver was secured in six of seven patients who had a liver resection. There were three significant advantages to this technique. First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.
Empyema Complicating Muscle-Sparing Thoracotomy: The Role of Wound Management
Authors: Sees Maj David W. , Obney Maj James A. , Tripp Ltc Henry F.
Published: November 2022

The fascial layers bordering the latissimus dorsi and anchoring the serratus muscles often do not lend themselves to impervious closure during muscle-sparing thoracotomy. Fluid from the subcutaneous space may therefore drain into the pleural cavity after such procedures. If this fluid is contaminated with microorganisms the potential for development of empyema is present. Two patients are presented in whom this scenario was presumed to have occurred. Early intervention in the second patient was felt to have avoided the development of a major empyema.
Percutaneous Subclavian Central Venous Catheterization in Children Younger than One Year of Age
Authors: Finck Christine , Smith Sam , Jackson Richard , Wagner Charles
Published: November 2022

Children younger than one year of age frequently require central venous lines (CVLs) for total parenteral nutrition, intravenous antibiotics, and chemotherapy. In many instances surgical cut-down has been favored over percutaneous access. The purpose of this study was to demonstrate the safety and success of percutaneous central venous access in children less than one year of age. Percutaneous access of the subclavian vein was obtained by Seldinger technique. Using the medical procedure code index we reviewed the charts of those patients less than one year of age from January 1, 1999 through December 31, 1999 requiring central venous access. Age, diagnosis, number of CVLs required, site placed, success rate, and weight were recorded. In 1999 a total of 84 patients younger than one year of age received a total of 110 CVLs. In patients less than 6 months of age the success rate for percutaneous access of the subclavian vein was 78.8 per cent and for those children over 6 months the success rate was 96 per cent. The average weight for those less than 6 months was 3.1 kg and for those older than 6 months was 7.63 kg. There were no complications from the procedure. Percutaneous CVL placement in children younger than one year of age is safe and effective. This paper details our technique and reviews infant venous anatomy in the subclavian area.
Duodenal Varices: A Novel Treatment and Literature Review
Authors: Cottam Daniel R. , Clark Robert , Hayn Ernesto , Shaftan Gerald
Published: November 2022

Hemorrhage associated with duodenal varices is an uncommon but often fatal manifestation of portal hypertension. We report a case of duodenal varices, review the literature, and present a new treatment modality. A 63-year-old man presented with hematemesis and hematochezia. An upper gastrointestinal endoscopy revealed hemorrhage from the duodenal varices that was initially controlled with injections of epinephrine. However, this was only partially successful, as the patient had repeated episodes of bleeding that was not amenable to injection sclerotherapy. The patient was taken emergently to the operating room after endoscopy failed to control the hemorrhage. The bleeding was controlled with simple oversewing of the duodenal varices through a duodenotomy. Three years later the patient remains symptom free. We propose that simple oversewing of duodenal variceal veins combined with a beta-blocker is an effective treatment for duodenal variceal hemorrhage.
Traumatic Pseudoaneurysm of the Pulmonary Artery: Case Report and Review of the Literature
Authors: Donaldson B. , Ngo-Nonga B.
Published: November 2022

Pulmonary artery pseudoaneurysm is a very rare but potential complication of chest trauma. These aneurysms are usually produced by penetrating trauma although a few cases have been reported after blunt injury. They should be suspected if there is a persistence of opacity on chest radiograph that when evaluated by contrast-enhanced CT shows an increased opacification of the mass. Diagnosis is confirmed with a pulmonary arteriogram.
The Esophageal Coin: Is it a Penny?
Authors: Cantu Santos , Conners Gregory P.
Published: November 2022

Because of their high zinc content modern U.S. pennies that become lodged in the esophagus may react with stomach acid thereby damaging the esophageal mucosa. Management of esophageal pennies may therefore differ from that of other esophageal coins making differentiation of pennies from other coins important. We reviewed the records of 111 children who underwent endoscopic esophageal coin removal over a 19-year period to determine the ability of history and size of esophageal coin images on posterior-anterior and lateral chest radiographs alone and in combination to differentiate esophageal pennies from other esophageal coins. History alone accurately identified 83 per cent of esophageal coins. Ranges of two standard deviations around mean image sizes were determined for each coin denominations. We determined the probability of an esophageal coin being a penny based on combinations of historical data and whether or not image sizes fell within the calculated range for a penny. When all data agree that a coin is or is not a penny they are nearly always correct. When there is disagreement among historical and image size data the probability that is a coin is a penny is strongly influenced by the size of the radiographic images.
Emergency Room Thoracotomy: Updated Guidelines for a Level I Trauma Center
Authors: Ladd Alan P. , Gomez Gerardo A. , Jacobson Lewis E. , Broadie Thomas A. , Scherer L.R. , Solotkin Kathleen C.
Published: November 2022

The purpose of this study was to evaluate whether 1995 study conclusions influenced patient selection and subsequent survival and whether indications for emergency room thoracotomy (ERT) could be further limited on the basis of patient physiologic status. A retrospective review of patient demographics, physiologic status both at the scene and on arrival to the emergency room (ER), and survival was performed on those who underwent ERT from July 1995 to December 1999. Sixty-five patients underwent ERT for sustained gunshot wounds and 14 patients for stab wounds. There were no survivors from Class I or II at the scene or Class I on presentation to the ER. Although there was a significant decrease in patients of Class I at the scene (27% vs 8%) and in the ER (58.3% vs 35.4%) the overall survival rate remained the same (2.6%). ERT could be eliminated for patients of Class I or II at the scene and for those of Class I on arrival to the ER without negating survivors; survival would improve to 16.2 per cent.
Management of Perforated Gastric Carcinoma: A Report of 16 Cases and Review of World Literature
Authors: Kasakura Yuichi , Ajani Jaffer A. , Fujii Masashi , Mochizuki Fumiro , Takayama Tadatoshi
Published: November 2022

Perforated gastric carcinoma is rare; however, it is a serious condition associated with complications. To understand the proper management of this disease and to characterize its clinical course we reviewed available data on 16 patients with perforated gastric carcinoma. We collected data on the age and sex of the patients as well as operative findings and histological features of the primary tumor. The depth of invasion and presence of lymph node metastasis were also recorded. The Union Internationale Contre Cancer stage, extent of resection, and surgical method used were reviewed. We also reviewed published information on the management of perforated gastric carcinoma. The carcinoma was stage I in three cases, stage II in one case, stage III in three cases, and stage IV in nine cases. Many patients had distant metastases. Fourteen patients underwent gastrectomy. Two patients whose preoperative condition was poor died of surgery-related complications, but patients with early-stage carcinoma underwent an R0 resection (resection of the primary tumor with negative margins) and had minimal complications. We conclude that the outcome of patients who were able to undergo radical surgery was good and correlated with the stage of cancer. It is important to perform gastrectomy rather than repair the perforation first, and a proper lymphadenectomy should follow—thus a two-step surgery when necessary.
Pedal Branch Arterial Bypass for Limb Salvage
Authors: Friedman Steven G. , Safa Toufic K.
Published: November 2022

In patients with critical lower extremity ischemia and occlusion of the distal tibial and pedal arteries bypasses to pedal artery branches may offer the only alternative to primary amputation. The results of 22 pedal branch arterial bypasses are reported, and a review of the literature is offered. The charts of 22 patients undergoing pedal branch arterial bypass during a 12-year period were retrospectively reviewed. The results of six additional reports of this technique were also evaluated. In the present series the cumulative primary graft patency rate was 72 per cent after 2 years. The cumulative limb salvage rate during this interval was 82 per cent. Similar graft patency and limb salvage rates were obtained with the approximately 200 other bypasses of this nature as reported in six other series. Pedal branch arterial bypass offers limb salvage results that are comparable to perimalleolar and pedal artery bypasses. In patients with critical limb ischemia and occlusion of distal tibial and pedal arteries, pedal artery branches should be sought as potential outflow sites. Bypasses to these arteries result in good long-term limb salvage, improved survival, and good functional ability for amputation. Pedal artery branch bypasses are a superior alternative to primary amputation.
Clinical Rib Fractures: Are Follow-Up Chest X-Rays A Waste of Resources?
Authors: Bansidhar Brian J. , Lagares-Garcia Jorge A. , Miller S.L.
Published: November 2022

Rib fractures (RFs) are estimated to be present in 10 per cent of all traumatic injuries. However, up to 50 per cent of all fractures go undetected on the screening chest X-ray (CXR). The purpose of this study was to identify the incidence of clinical (CRFs) and objective rib fractures (ORFs) as well as to examine the utility of the routine follow-up CXR with regard to patient recovery and healthcare cost. We identified patients sustaining RF in addition to other traumatic injuries with an Injury Severity Score (ISS) ≤15 and RF as the primary pathology. Five hundred fifty-two patients sustained blunt thoracic trauma with resultant RF. Two hundred nine patients had RFs and an ISS ≤15. The average ISS was 8. Follow-up films illustrated that 93 per cent of CRFs had resolution of any pathology, 4 per cent had persistent X-ray findings, and 4 per cent were lost to follow-up. Ultimately 93 per cent of patients with CRF were able to resume daily activities without disability and 3 per cent incurred lifestyle changes at home or work, which was significantly better than those with ORFs ( P < 0.05). Follow-up films produced no change in clinical management and cost approximately $2000/year. The prognosis for CRFs is excellent if treatment consists of appropriate pain management and pulmonary rehabilitation. We do not advocate routine follow-up CXRs in addition to physical examination for the evaluation of CRFs unless clinical deterioration is evident.
Nontraumatic Clostridial Myonecrosis: An Indication for Colonoscopy?
Authors: Jacob Zvi Charles , Dedekian Michael , Seoudi Hani
Published: November 2022

Clostridial myonecrosis (CM) is a rare infection that usually arises after traumatic injury. Spontaneous or nontraumatic CM is even more rare and has been described in association with colorectal malignancy. These infections carry a high mortality rate and require urgent surgical intervention and intensive antibiotic therapy. This report describes a patient who presented with nontraumatic CM of the lower extremity in association with adenocarcinoma of the cecum.
Through-the-Knee Amputation: An Improved Technique
Authors: Nellis Noel , Van De Water Joseph M.
Published: November 2022

Through-the-knee amputation (TKA) is an excellent lower extremity treatment for the ischemic extremity when revascularization is not feasible and a prosthesis is not practical. Over the past 8 years 185 major amputations have been performed at our hospital of which 63 were of the TKA type. In 61 of these an improved technique was used that resulted in nonischemic, strong, and aesthetic stumps with 100 per cent primary healing. Our technique consists of removing the distal 2 cm of the femoral head with the two condyles and allowing the patella to ankylose to the new distal femoral end. In comparison with the other major amputations the TKA with this technique had significant advantages over the above-knee amputation and often was found to be superior to the below-knee amputation especially when rehabilitative ambulation with a prosthesis was not possible.
Compliance with Sequential Compression Device Prophylaxis in At-Risk Trauma Patients: A Prospective Analysis
Authors: Cornwell Edward E. , Chang David , Velmahos George , Jindal Anurag , Baker Deborah , Phillips Judy , Bonar James , Campbell Kurtis
Published: November 2022

The Sequential Compression Device (SCD) is frequently the sole measure used to prevent deep venous thrombosis (DVT) in trauma patients. The purpose of this study was to evaluate the compliance with physician orders for the application of SCD prophylaxis among nonambulatory trauma patients at risk for DVT. We conducted a prospective observational study at two Level I university-affiliated trauma centers. Nonambulatory trauma patients were observed during their early postadmission period in a non-critical care setting. Six observations were made as to proper SCD applications during a 24-hour period (two times in the morning shift, two in the evening shift, and two overnight). “Full compliance” was defined as SCD on and functioning properly in all six observations. In a total of 1343 observations in 227 patients only 42 patients (19%) were fully compliant. The devices were on and functioning in 712 (53%) observations. Among the 185 patients who were not fully compliant DVT risk factors were common (83%) and adjunctive heparin prophylaxis was infrequent (27%). The most common times for “noncompliant” observations were early afternoon and midmorning. On multivariate analysis only spinal column injury correlated with increased compliance. In nearly half of the observations trauma patients at risk for DVT were not receiving their SCD prophylaxis as per physician orders. Fewer than 20 per cent of patients had the devices on and functioning during each of the six observations during a 24-hour period. These data point to the need for education of hospital staff and for additional prophylactic measures in at-risk patients.
Prognostic Significance of Nodal Disease following Preoperative Radiation for Rectal Adenocarcinoma
Authors: Rinkus Keith M. , Russell Gregory B. , Levine Edward A.
Published: November 2022

The administration of preoperative radiation (Pre-Op) therapy for adenocarcinoma of the rectum is evolving. The prognostic value of nodal disease found after preoperative therapy is unclear. The purpose of this study is to evaluate the impact of Pre-Op therapy on nodal staging and thus prognosis in patients with operable cancer of the rectum. Retrospective review of 292 cases revealed that 20% (N = 58) received Pre-Op radiation and 33% (N = 97) received Post-Op radiation. Of the Pre-Op group 66% received 5-fluorouracil-based chemotherapy concomitantly ( vs 48% Post-Op). Radiation dose averaged 50 Gy for both groups. Node-positive disease was found after Pre-Op therapy at a similar rate to that of Post-Op or surgery-only patients (45% vs 46%, P = 0.95). Fewer nodes were found in Pre-Op resection specimens (6.8 vs 10.0 nodes/specimen, P = 0.003), which altered the fraction of positive nodes (27% Pre-Op vs 18% Post-Op, P = 0.003). The N0 cases had better survival than N+ in both Pre-Op (80% vs 34%, P = 0.0001) and Post-Op (70% vs 40%, P = 0.02) groups. There was no significant difference in survival between Pre-Op versus Post-Op. Pre-Op chemoradiation improved patient survival over radiation alone and should be considered routinely with radiation therapy for rectal cancer. Pre-Op radiotherapy decreases the number of nodes recovered but does not influence the presence of nodal metastasis. Nodal disease remains a strong prognostic indicator of survival after Pre-Op radiation therapy.
Laparoscopic Repair of Large Incisional Hernias
Authors: Parker Harris H. , Nottingham James M. , Bynoe Raymond P. , Yost Michael J.
Published: November 2022

Incisional hernias after abdominal operations are a significant cause of long-term morbidity and have been reported to occur in 3 to 20 per cent of laparotomy incisions. Traditional primary suture closure repair is plagued with up to a 50 per cent recurrence rate. With the introduction of prosthetic mesh repair recurrence decreased, but complications with mesh placement emerged ushering in the development of laparoscopic incisional herniorrhaphy. The records of patients who underwent laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001 were reviewed. Patient demographics, hernia defect size, recurrence, operative time, and procedure-related complications were evaluated. Fifty patients (22 male and 28 female, mean age 57 years with range of 24–83) were scheduled for laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001. The average patient was obese with a mean body mass index of 35.8 kg/m2(range 16–57 kg/m2). Two patients (4%) had primary ventral hernias. Forty-eight patients (96%) had incisional hernias with 22 (46%) of these previously repaired with prosthetic mesh. Mean defect size was 206.1 cm2(range 48–594 cm2). The average mesh size was 510.2 cm2(range 224–1050 cm2). Gore-Tex® DualMesh and Bard® Composite Mesh were used in 84 and 16 per cent of the repairs, respectively. Mean operating time was 97 minutes. There were no deaths. Complications were seen in 12 per cent patients (six occurrences) and included two small bowel enterotomies, a symptomatic seroma requiring aspirate, a mesh reaction requiring a short course of intravenous antibiotics, and trocar site pain (two patients). There were no recurrences during a mean follow-up of 41 months (range 3–74 months). We conclude that laparoscopic incisional herniorrhaphy offers a safe and effective repair for large primary and recurrent ventral hernia with low morbidity.
Laparoscopic Paraesophageal Hernia Repair Has an Acceptable Recurrence Rate
Authors: Khaitan Leena , Houston Hugh , Sharp Kenneth , Holzman Michael , Richards William
Published: November 2022

Recent literature has reported as high as a 42 per cent recurrence rate after laparoscopic paraesophageal hernia repair (LPEHR). We report long-term follow-up in a cohort of patients undergoing LPEHR at Vanderbilt University. Thirty-one patients underwent attempted LPEHR between September 1993 and May 2000. Six of 31 patients (19%) were converted to an open procedure and were excluded from the study. All patients had complete excision of the sac, primary closure of the crura, and an antireflux procedure. An Institutional Review Board-approved follow-up barium esophagram was performed at a mean of 25 months postoperatively. Three experienced laparoscopic surgeons (K.S., M.H., and W.R.) collectively reviewed the esophagrams for evidence of recurrence. The mean age of patients was 61 years (range 41–92). There were six males and 19 females. Fifteen of 25 patients (60%) returned for an esophagram. Only one of 15 patients (7%) had a recurrent paraesophageal hernia. However, five of 15 patients (33%) had herniated an intact wrap 2 to 4 cm above the diaphragm. The patient with a true paraesophageal hernia recurrence returned with symptoms of dysphagia. Two of the five patients (40%) with a herniated wrap complained of heartburn, which was controlled with a proton pump inhibitor. All other patients were asymptomatic. Our recurrence rate of true paraesophageal hernias after LPEHR is low (7%) and compares with that reported in the literature for open repairs. However, 33 per cent of the patients in this study were found to have a herniated wrap. Because there is no risk of strangulation we have not operated on any of these patients. LPEHR is our procedure of choice for Type II and III hiatal hernias with good symptom relief and a low true recurrence rate.
An Analysis of Eastern Association for the Surgery of Trauma Practice Guidelines for Cervical Spine Evaluation in a Series of Patients with Multiple Imaging Techniques
Authors: Ghanta Manmohan K. , Smith Lou M. , Polin Richard S. , Mark Alan B. , Spires William V.
Published: November 2022

We conducted a retrospective review of 124 consecutive patients who received all of the following studies between October 1998 and December 1999: three-view plain films (3VPF), full CT survey (CTS), and MRI of the cervical spine. We compared the EAST guidelines for 1) patients with persistent neck pain, 2) those with neurologic deficits (NDs), and 3) those who were obtunded in our study group to determine whether EAST recommendations would risk a significant missed injury rate. The average age was 28 years (range 5 months–78 years). There were 94 males and 30 females. The mean Injury Severity Score (ISS) was 16.8 and the mean Glasgow Coma Score (GCS) 10.87. The most common mechanism of injury was motor vehicle crash (58%) followed by falling (15%), auto versus pedestrian (9%), all-terrain vehicle accident (4%), assault (3%) and other (11%). For comparisons we identified a group of 33 patients with normal mental status and normal 3VPF. Twenty patients had MRI for persistent neck pain. Eleven of 20 had normal MRI. The nine abnormal MRIs showed: six ligamentous injuries, two cord compressions, and one nonligamentous soft-tissue injury. Thirteen of the 33 patients had MRI for ND. Six had normal MRI and all these NDs resolved. The remaining seven MRIs showed: two disc herniations, two cord contusions, one cord edema, one lumbar fracture, and one brachial plexus avulsion. We also examined a group of 51 obtunded patients with normal 3VPF. Thirty-six of 51 had normal CTS and MRI. Ten patients had an abnormal MRI, two an abnormal CTS, and three abnormal MRI and CTS. No obtunded patient with an adequate 3VPF had an injury identified below C2 using CTS and MRI. In the 10 patients with abnormal MRI the mean age was 28.4 years, the mean GCS 6.6 ( P = 0.0025), and the mean ISS 24.3 ( P = 0.03) (Wilcoxson two-sample test). The injuries identified by MRI were four disc herniations, two ligamentous injuries, two soft-tissue traumas, one meningeal tear, and one cord transection. Thirty per cent of patients with persistent neck pain had potentially unstable injuries not detected by 3VPF or CTS. Fifty-four per cent of patients with ND had abnormal MRI. Twenty-two per cent of obtunded patients with normal 3VPF and CTS had an abnormal MRI. These patients have a significantly lower GCS and a higher ISS. Six per cent of these injuries were potentially unstable. Our data support EAST guidelines for patients with persistent neck pain and ND. The guidelines for obtunded patients appear safe in detecting bony injury but may not be sensitive enough for unstable ligamentous injury and significant disc herniations.
The Economic Impact of Motor Vehicle Crashes: The Cost of Restrained versus Unrestrained Occupants in South Carolina
Authors: Gill Satinderjit S. , Jakub James W. , Pease Mary C. , Woollen Claude D.
Published: November 2022

The purpose of our study was to evaluate the difference in hospital charges between restrained and unrestrained motor vehicle occupants. We were also interested in identifying whether a relationship existed between restraint usage and insurance status. The data for this study were collected from two sources. The 1998 and 1999 Crash Outcome Data Evaluation System was used to compare the hospital charges and restraint usage for all motor vehicle crashes in the state of South Carolina. The patient's insurance status was also analyzed. The hospital charges and restraint usage were also compared from one of the state's Level I trauma centers for the year 1999. These data were prospectively collected and retrospectively reviewed. The average inpatient hospital charges for the state of South Carolina were approximately 25 per cent greater or $4500 more per admission for an unrestrained versus a restrained occupant. There also appears to be a relationship between payer status and restraint usage. Medicaid and self-pay patients were least likely to be using a restraining device at the time of a motor vehicle crash. The data from a Level I trauma center showed similar but more dramatic trends. Hospital charges for unrestrained occupants were 87 per cent higher than those for restrained occupants, which translates into a cost difference of $22,358 per hospital admission. This study highlights the significant economic impact of a simple preventative strategy. The cost savings for a single Level I trauma center translate into almost 9.4 million dollars for a single year. There also appears to be a relationship between usage of a restraining device and payer status.
Genistein Inhibits Tamoxifen Effects on Cell Proliferation and Cell Cycle Arrest in T47D Breast Cancer Cells
Authors: Jones Julie L. , Daley Brian J. , Enderson Blaine L. , Zhou Jin-Rong , Karlstad Michael D.
Published: November 2022

Tamoxifen is an antiestrogen used in the treatment of estrogen receptor-positive breast cancer in postmenopausal women. It functions by competitively inhibiting the estrogen receptor and inducing apoptosis and G1 cell cycle arrest. Genistein is a soy phytoestrogen that inhibits breast cancer cell growth in vitro at doses of 10 μM or above. At lower doses genistein may stimulate cell growth and entry into the cell cycle. We hypothesized that treatment with low-dose genistein would reverse the inhibitory effects of tamoxifen in estrogen-receptor-positive breast cancer cells. Cell cycle kinetics and cell proliferation in T47-D human breast cancer cells were examined after exposure to genistein and tamoxifen in a low-estrogen environment designed to mimic a postmenopausal state. Cell proliferation was assessed by a colorimetric assay. Cell cycle kinetics were determined by flow cytometry. Tamoxifen caused G1 arrest and a decrease in proliferation. Genistein reversed the inhibitory effects of tamoxifen on both proliferation and G1 arrest. Thus low-dose genistein was able to inhibit the therapeutic effects of tamoxifen in this postmenopausal model of breast cancer.
Adenocarcinoma of the Gastric Cardia: Treatment via a Left Thoracoabdominal Approach
Authors: Lekakos Leonidas N. , Triantafillopoulos John K. , Milingos Nicholas D. , Sfikakis Petros G.
Published: November 2022

We examined the outcome of adenocarcinomas of the gastric cardia treated by total or proximal gastrectomy, lower esophagectomy, and D2 lymphadenectomy via a left thoracoabdominal approach. We compare these results with those of other methods as well as review the literature. During a 10-year period (1991–2000) 180 patients with primary gastric cancer were admitted to our department. Thirty-six of the patients had adenocarcinoma of the cardia. Twenty-four patients underwent total gastrectomy, D2 lymphadenectomy, and esophagectomy, and four others underwent proximal gastrectomy and esophagectomy with esophagogastric anastomosis via a left thoracoabdominal approach. These latter 28 patients compose our study group. We had no operative mortality, the morbidity varied, and the quality of life and the loss of body weight ranged within satisfactory levels, but the survival rate was rather poor. The median survival time was 19 ± 1.2 months. Survival was significantly longer in patients with less than 40 per cent positive resected lymph nodes ( P = 0.035). From the resulting data and our experience we believe that the left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of such tumors. This approach combined with total gastrectomy and D2 lymphadenectomy can be performed with an acceptably low mortality rate; it provides good palliation but not encouraging survival rates. Although it is less radical proximal gastrectomy gives the same results and a better quality of life but may be performed only in the early stages of the disease.
Transmural Migration of a Retained Laparotomy Sponge
Authors: Dhillon Jasbir S. , Park Adrian
Published: November 2022

The most common surgically retained foreign body is the laparotomy sponge. The clinical presentation of a retained sponge can vary from an incidental finding on plain radiograph to an intense inflammatory response with obstruction or perforation. In the case described here a patient reported abdominal pain 11 months after her hysterectomy. Although two sponge counts appeared in the operative record one laparotomy sponge had been overlooked. Apparently an inflammatory response created an abscess pocket around the sponge between the abdominal wall and the ileum resulting in perforation of the ileum. Through this opening the sponge migrated into the lumen of the small bowel, from which it was surgically removed. The patient recovered without complications. The case highlights the importance of a thorough exploration of all quadrants of the abdomen at the termination of surgical cases.
Non-Greater Saphenous Vein Grafting for Infrageniculate Bypass
Authors: Alexander Jason , Gutierrez Charles , Katz Steven
Published: November 2022

Infrainguinal bypass grafting with greater saphenous vein has proven to be a highly effective procedure with primary 5-year patency and limb salvage rates exceeding 80 per cent. However, because of prior usage or intrinsic venous disease the greater saphenous vein is often not available as a conduit. Numerous studies have shown that patency rates for prosthetic bypass grafting to the infrageniculate vessels are clearly inferior to that reported for greater saphenous vein bypass. In this report we summarize our experience with the use of alternate autogenous vein grafting to the infrageniculate vessels. The records of all patients undergoing autogenous bypass grafting to the infrageniculate vessels using a conduit other than the greater saphenous vein between 1992 and 1999 were reviewed. Graft survival curves were plotted using the Kaplan-Meier method and results are reported using the Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines. Forty-eight patients underwent a total of 51 infrageniculate bypass procedures using non-greater saphenous autogenous conduits. Thirty-nine patients had reconstructions performed with single segments of arm vein, two had their operations performed with lesser saphenous vein, and ten had grafts created with two segments of non-greater saphenous autogenous vein. Twenty-one grafts were performed to the infrageniculate popliteal artery and 30 were performed to the tibial vessels. Primary and primary assisted patency rates at 30 months were 49 and 75 per cent. Limb salvage was 87 per cent. Infrainguinal bypass grafting using non-greater saphenous autogenous conduits can yield quite satisfactory intermediate limb salvage and patency rates. However, close graft surveillance and prompt intervention are required to avoid graft failure.
Closure of Proximal Colorectal Fistulas Using Fibrin Sealant
Authors: Lamont Jeffrey P. , Hooker Glen , Espenschied Jonathan R. , Lichliter Warren E. , Franko Edward
Published: November 2022

Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel® kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4–365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1–5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6–65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.
Anal Complications after Restorative Proctocolectomy (J-Pouch)
Authors: Rossi Heather L. , Brand Marc I. , Saclarides Theodore J.
Published: November 2022

A prospective assessment was performed to determine the incidence of anal complications after ileoanal J-pouch anastomosis procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). From 1989 to 2000, 75 patients (50 male and 25 female) underwent proctocolectomy and ileal pouch-anal anastomosis with temporary loop ileostomy for UC (N = 68) and FAP (N = 7). Overall 33 patients (44%) developed anal complications postoperatively. Nineteen patients (25%) had mild anal stenosis amenable to digital dilatation in the office. Ten patients (13%) had severe anal stenosis requiring operative dilatation. Ileostomy closure was delayed longer than 3 months in four patients because of anal stenosis. One patient never had his ileostomy closed secondary to severe anal stenosis. Anal fissures developed in one patient that resolved with conservative treatment. Three patients developed fistula-in-ano and one patient developed a pouch-vaginal fistula. Of these four patients two later manifested signs of Crohn's disease. Four patients developed perirectal abscesses (three without fistulas) that were treated with incision and drainage. Two patients had presacral (anastomotic) abscesses; one patient was treated with temporary anastomotic diversion and the other underwent a permanent ileostomy and pouch resection. Both of these patients were later diagnosed with Crohn's disease. Anal complications developed in 17 of 41 (41%) handsewn anastomoses, 16 of 34 (47%) stapled anastomoses, three of seven (43%) patients with FAP, and 30 of 68 (44%) patients with UC. Operative technique and disease type did not significantly correlate with the type of anal complication. However, hand-sewn anastomoses had a higher incidence of severe strictures and FAP patients did not develop anal abscesses, fistulas, or fissures. Forty-five per cent of our patients with abscesses/fistulas and all of our patients with presacral abscesses from anastomotic dehiscence were later diagnosed with Crohn's disease. Anal complications after ileoanal J-pouch anastomosis are relatively common.
Obturator Bypass: A Classic Approach for the Treatment of Contemporary Groin Infection
Authors: Patel Ajay , Taylor Spence M. , Langan Eugene M. , Snyder Bruce A. , Cull David L. , Sullivan Timothy M. , Youkey Jerry R. , Gray Bruce H. , Carsten Christopher G.
Published: November 2022

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.
Cytoreductive Surgery in Patients with Advanced-Stage Carcinoid Tumors
Authors: Gulec Seza A. , Mountcastle Timothy S. , Frey Daniel , Cundiff Jason D. , Mathews Elizabeth , Anthony Lowell , O'leary J. Patrick , Boudreaux J. Philip
Published: November 2022

The role of aggressive surgical resections as well as criteria for resectability in patients with advanced carcinoid tumors is not clearly defined. Thirty patients (17 male and 13 female) who were previously diagnosed to have “unresectable carcinoid disease” were treated using a multi-modality approach over a period of 2 years. Extensive liver involvement was present in 28 of 30 (93%) of the cases. Small bowel involvement was noted in 22 of 30 (73%), and peritoneal/retroperitoneal/mesenteric invasion was observed in 15 of 30 (50%) of the cases. Three patients had remote metastases (brain, bone, and eye). Twenty of 30 (66%) patients had carcinoid syndrome with severely disabling symptoms. Eight patients (26%) had small bowel obstruction. All patients underwent at least one surgical exploration/intervention. Radiofrequency ablation (RFA) of one or more liver lesions was performed as an adjunct in 22 of 30 (73%) patients. Six patients (20%) had a second surgical procedure. There were 11 complications in eight patients (27%) after the initial operation. Median hospital stay for patients who underwent RFA only, RFA/liver resection, and liver resection with abdominal tumor debulking were 2,4, 8, and 16 days respectively. Twenty-five of 30 patients (83%) showed symptomatic improvement. Mean pre- and postoperative Karnofsky physical performance scores were 55 and 85 respectively ( P < 0.02). Small bowel obstruction was due to adhesions in five patients. All patients with intestinal obstruction had complete relief of their symptoms postoperatively. 5-Hydroxyindolacetic acid levels decreased by 50 per cent in all patients with follow-up determinations available. Aggressive surgical exploration and tumor debulking could be performed with significantly improved symptomatic outcome and relatively minor complications. Longer follow-up is needed for assessment of effect on survival.
Cryosurgery of Close or Positive Margins after Hepatic Resection for Primary and Metastatic Hepatobiliary Malignancies
Authors: Shen Perry , Hoffman Aaron , Howerton Russell , Loggie Brian W.
Published: November 2022

Obtaining a one-centimeter negative margin is an important factor in preventing disease recurrence after surgery for hepatic tumors. Cryotherapy of the resected edge has been used to achieve optimal margin clearance in cases in which the alternative would be an extended high-risk liver resection. The effect of this technique on margin recurrence was examined. Between 1994 and 2001 a total of 56 patients underwent cryosurgery with or without resection for primary and metastatic hepatobiliary malignancies. A 5-cm cryotherapy lollipop probe was used to ablate surgical margins less than one centimeter in 13 of these patients. There were seven colorectal metastases, three hepatocellular carcinomas, and three gallbladder carcinomas. The median size of the colorectal and hepatocellular lesions was 3 cm (range 2–14 cm), and all gallbladder primaries were T2 tumors. All tumors except three were located centrally in the liver requiring cryoablation of margins at segments 4, 5, and 8. Most patients had one site frozen (n = 9) with a median target temperature of -190°C and a median of two freeze-thaw cycles. Final pathological analysis of the resected specimens revealed nine close (<1 cm) and four positive margins. With a median follow-up of 16 months seven patients are alive with no evidence of disease and six have developed recurrences with three of them dying of their disease. Only one (8%) of the initial recurrences was at the cryoablated margin. Cryosurgery of the resection edge facilitates liver resection for malignant tumors when margins are close or positive. Because disease recurrence at the cryoablated margin is low this technique may allow more patients to undergo effective surgical treatment of their hepatobiliary cancers.
Efficacy of Computed Tomography in the Diagnosis of Pancreatic Injury in Adult Blunt Trauma Patients: A Single-Institutional Study
Authors: Ilahi Obeid , Bochicchio Grant V. , Scalea Thomas M.
Published: November 2022

Blunt trauma to the pancreas is an uncommon injury, which can be difficult to diagnose. Most studies are multi-institutional, include both helical and axial CT, and report sensitivities of 40 to 67 per cent. We evaluated the efficacy of spiral CT for the diagnosis of blunt pancreatic injury in a single large-volume institution. We retrospectively reviewed 22,000 blunt trauma patients seen between 1996 and 2000. Pancreatic injury was identified in 40 patients (0.2%). All patients evaluated with spiral CT were given both oral and intravenous contrast. A total of 40 blunt pancreatic injuries were identified. The mean age was 35 years. Seventy-five per cent were male. Mean Injury Severity Scale score was 29 and overall mortality 12.5 per cent. Thirty-one patients (78%) underwent laparotomy. Twelve patients went directly to the operating room for urgent exploration and 19 had a preoperative CT. CT was positive for pancreatic injury in 13 patients (sensitivity 68%). All 13 patients had confirmed pancreatic injury at the time of surgery (positive predictive value = 100%). Using the American Association for the Surgery of Trauma grading system operative findings and CT correlated in 68 per cent of those patients who had both CT and laparotomy. CT underestimated pancreatic injury in the remaining 31 per cent. Nine patients were managed nonoperatively without complication, and six had pancreatic injury on CT. The other three had a negative CT but had clinical and laboratory evidence of pancreatic injury. Overall CT scan was 68 per cent (19 of 28) accurate in diagnosing pancreatic injury. We conclude that CT scan is only moderately sensitive and can underestimate or miss pancreatic injury. Although CT moderately correlated with injury grade it was highly predictive for presence of injury. The new multide-tector helical scanner may improve our diagnostic ability.