bluuebunny/crossref_metadata_2025 huggingface dataset:
Elevated Platelet Count before Ileal Pouch–Anal Anastomosis for Ulcerative Colitis is Associated with the Development of Chronic Pouchitis
Authors: Okon Aderet , Dubinsky Marla , Vasiliauskas Eric A. , Papadakis Konstantinos A. , Ippoliti Andrew , Targan Stephan R. , Fleshner Phillip R.
Published: June 2020

Acute pouchitis (AP) after ileal pouch–anal anastomosis (IPAA) is common and easily treated. However, chronic pouchitis (CP) remains a difficult management problem and may represent a form of Crohn disease (CD) of the ileal pouch. Because CD patients have higher platelet counts than ulcerative colotis (UC) patients, we prospectively evaluated the association between preoperative platelet count and pouchitis development in 159 patients undergoing IPAA. Reactive thrombocytosis (RT) was defined as a platelet count >450 x 109/L. Median preoperative platelet count was 312 x 109/L (range, 103 x 109/L to 886 x 109/L). One hundred twenty-five patients (79%) had a normal (150 x 109/L to 450 x 109/L) platelet count (-RT patient group). Twenty-eight patients (18%) had RT. Six patients (3%) had a platelet count below 150 x 109/L. After a median follow-up of 13 months, 45 patients (28%) developed pouchitis. Pouchitis developed in 33 +RT patients (26%) versus 9 -RT patients (32%) ( P = NS). UC patients who had +RT had a 25 per cent incidence of CP compared to only 7 per cent of those UC patients who had -RT ( P = 0.03). The incidence of CP was significantly higher after IPAA in UC patients having thrombocytosis before surgery compared to UC patients having a normal platelet count before surgery.
Weekly Reading Assignments and Examinations Result in Sustained Improvement in American Board of Surgery In-Training Examination (ABSITE) Scores
Authors: De Virgilio Christian , Stabile Bruce E.
Published: June 2020

The American Board of Surgery In-Training Examination (ABSITE) score is used by general surgery training programs as a measure of the medical knowledge component of the Accreditation Council of Graduate Medical Education competencies. Poor performance on ABSITE (<35%) has correlated with high failure rates on the American Board of Surgery Qualifying Examination. We previously demonstrated an improvement in ABSITE scores over a 1-year period through the initiation of weekly reading assignments and review examinations. We sought to determine whether this educational endeavor would result in a sustained improvement in ABSITE scores over several years. ABSITE scores from two successive, 3-year time periods (1999-2001, Group 1, 2002-2004, Group 2), were compared. For Group 1, no formal reading assignments or preparatory exams were given. For Group 2, weekly reading assignments and examinations were administered by the faculty. For Group I, the mean ABSITE score was 60 per cent, versus 75 per cent ( P < 0.01) for Group 2. In Group 1,13 out of 76 scores (17%) were below 35 per cent, whereas in Group 2, only 4 out of 74 scores (5%) were below 35 per cent ( P = 0.03). Sustained improvement in ABSITE scores and fewer scores <35 per cent were achieved over a 3-year period with an educational program of weekly topic-specific reading assignments and written review examinations.
Delayed Diagnosis and Management of an “Occult” Stab Wound to the Heart
Authors: Dubose Robert A. , Karmy-Jones Riyad
Published: June 2020

Stab wounds to the heart can present without clinical evidence of injury. Echocardiography has been advocated as an alternative to subxyphoid exploration in these cases. We present a case in which two serial echocardiography exams missed a diagnosis. Electrocardiographic changes and elevation of serial troponin I levels suggested the diagnosis, which was confirmed by thoracoscopy. Repair was facilitated by use of adenosine cardiac standstill.
Advances in Treatment of Colorectal Cancer
Authors: McCafferty Michael H.
Published: June 2020

The purpose of this review is to provide the practicing surgeon with an outline of several significant developments in colorectal cancer treatment that have affected the care of patients. This review is not intended to report on every important publication of the past few years nor is it intended to be encyclopedic. The author simply hopes to provide a useful reference for surgeons in their daily practice.
Unexpected Findings during Thyroid Surgery in a Regional Community Hospital: A 5-Year Experience of 738 Consecutive Cases
Authors: Lokey Jonathan S. , Palmer Robert M. , Macfie Jefferys A.
Published: June 2020

Unexpected findings during thyroid surgery in a nonuniversity setting have rarely been reported in large series. Our goal was to describe the unexpected findings during thyroid surgery in a busy regional community hospital. All thyroid operations conducted by the teaching staff at Greenville Memorial Hospital, a 735-bed nonuniversity regional hospital, from December 1998 through December 2003 were reviewed. Pre- and post-operative diagnoses, surgical procedure, and specimen histopathology were examined. Unexpected findings were defined as either thyroid pathology not anticipated based on preoperative diagnosis or as unsuspected nonthyroidal disease found during cervicotomy. During the 5-year study period, 738 patients presented with thyroid disease requiring surgery. Incidental thyroid cancer was discovered in 28 cases (3.8%), the predominance being papillary microcarcinoma. Synchronous benign thyroid disease, separate from the indication from surgery, was observed in 56 patients (7.6%). Forty patients had unexpected nodular goiter and 16 had lymphocytic thyroiditis. Primary hyperparathyroidism was observed in 33 patients (4.5%). Both solitary adenomas (22 cases) and multigland parathyroid disease (11 cases) were seen. Unexpected nonendocrine findings were less common, including solitary cases of large cell carcinoma, metastatic endometrial carcinoma, and tracheal duplication (bronchogenic cyst). In conclusion, unexpected findings during thyroid surgery at a busy community hospital are fairly common. Indeed, an unanticipated finding is encountered in one out of seven operations on the thyroid gland. Although most are of unclear clinical significance, there is a surprisingly high incidence of hyperparathyroidism. This underscores the need for preoperative screening, as the “thyroid patient” may also be the “parathyroid patient.”
Calcifying Fibrous Pseudotumor of the Neck: Diagnostic Challenges of a Rare Benign Lesion
Authors: Goldstein Evan B. , Savel Richard H. , Sen Filiz , Shamamian Peter
Published: June 2020

Neck masses, frequently encountered by physicians, comprise a vast range of diagnoses, with malignancy being the greatest concern. Calcifying fibrous pseudotumor (CFP) is a rare lesion with unknown pathogenesis, characterized pathologically by a predominance of abundant hyalinized collagenous tissue with focal lymphoplasmacytic infiltrate and psammomatous or dystrophic calcifications. We present the case of a 29-year-old woman who presented with a 4-cm left neck mass, accompanied by constitutional symptoms of vague weakness and lethargy. After the lesion failed to respond to a course of antibiotic therapy, fine-needle aspiration was performed, the pathology of which was indeterminate. The concern was that the lesion was a lymphoproliferative disorder–further workup was performed. CT of the chest, abdomen, and pelvis revealed no evidence of adenopathy or neoplasms. Subsequently, an incisional biopsy was performed, suggesting a diagnosis of CFP. Magnetic resonance imaging with contrast, performed to delineate the anatomy, revealed the lesion in the left neck, deep to the left clavicle, that extended superiorly into the supraclavicular fossa. Complete surgical removal of the lesion was successfully performed, with immunophenotyping confirming the initial diagnosis of CFP. We present a case report of cervical CFP, discuss the approach to neck masses, and review the recent literature on this rare, benign entity.
Spontaneous Subcapsular Splenic Hematoma: A Rare Complication of Pancreatitis
Authors: Patel Vijaykumar G. , Eltayeb Osama M. , Zakaria Majed , Fortson James K. , Weaver William L.
Published: June 2020

Subcapsular hematoma of the spleen is a rare complication of pancreatitis despite its close proximity to the pancreas. Pancreatic pseudocyst involving the tail of the pancreas may erode into the splenic hilum causing hilar vessel bleeding with subcapsular dissection and hematoma formation. The management of such complication is still controversial. It has been suggested that most of these complications spontaneously regress and therefore can be managed conservatively. A case of spontaneous splenic subcapsular hematoma resulting from pancreatitis was managed conservatively with a good outcome.
Ruptured Giant Colonic Diverticulum
Authors: Abou-Nukta Fadi , Bakhus Charles , Ikekpeazu Nkemanekum , Ciardiello Kenneth
Published: June 2020

Giant colonic diverticulum (GCD) is a rare complication of diverticular disease with less than 150 cases reported in the English literature. The clinical presentation ranges from asymptomatic to that of an acute abdomen. In most cases, giant colonic diverticulum is found in the sigmoid colon. The ideal treatment is elective resection of the sigmoid colon with primary anastomosis. When the diverticulum presents with perforation or obstruction, however, the treatment is a sigmoid colectomy with diverting colostomy (Hartmann procedure).
Trauma Center Resource Consumption and Mortality
Authors: Maclennan Paul , Jones Bryan , Mcgwin Gerald , George Richard , Rue Loring W.
Published: June 2020

Studies suggesting that increased trauma center (TC) patient volume leads to improved patient outcomes have produced inconsistent results. It is possible that the combination of TC patient volume and TC resources has a greater influence over outcomes than TC volume alone. Patients admitted to 131 TCs from 1994 to 2002 were included. TC density was calculated as the ratio of TC adult beds to patient volume and categorized into quartiles. Adjusted risk ratios (RRs) and 95 per cent confidence intervals (CIs) compared mortality of groups (Q1 [low density]–Q4 [high density]). Relative to Q4 TCs, for penetrating injuries with ISS <15, elevated mortality was seen for Q2 (low-moderate density) TCs (RR 1.47, CI 1.09–1.99) and Q3 (high-moderate density) TCs (RR 1.81, CI 1.36–2.41); but for ISS ≥15, mortality was lowest for Q1 (RR 0.78, CI 0.68–0.89). For blunt injury, mortality was similar for low- and high-density TCs but elevated for low-moderate- and high-moderate-density TCs. Mortality at low-density TCs was decreased overall and for penetrating injuries specifically but similar for blunt injuries when compared with high-density TCs. Enhanced resources measurements will clarify the relationship between patient volume, resources, and mortality.
Are Resident Work-Hour Limitations Beneficial to the Trauma Profession?
Authors: Abraham Tara , Freitas Marilee , Frangos Spiros , Frankel Heidi L. , Rabinovici Reuven
Published: June 2020

In July 2003, work-hour restrictions were implemented by the Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty hours. Attending surgeon work-hours have not been similarly reduced, and many trauma services have added emergency general surgery responsibilities. We hypothesized that trauma attending/resident work-hour disparity may disincentivize residents from selecting trauma careers and that trauma directors would view ACGME regulations negatively. We conducted a 6-month study of resident and in-house trauma attending self-reported hours at a level I trauma center and sent a questionnaire to 172 national level I trauma directors (TDs) regarding work-hours restrictions. TD survey response rate was 48 per cent; 100 per cent of 15 residents and 6 trauma faculty completed work-hour logs. Attending mean hours (87.1/ wk), monthly calls (5), and shifts >30 hours exceeded that of all resident groups. Case volume was similar. Residents viewed their lifestyle more favorably than the lifestyle of the trauma attending (Likert score 3.6 ± 0.5 vs Likert score 2.5 ± 0.8, P = 0.0003). Seventy-one per cent cited attending work hours and lifestyle as a reason not to pursue a trauma career. Nationally, 80 per cent of trauma surgeons cover emergency general surgery; 40 per cent work greater than 80 hours weekly, compared with <1 per cent of surgical trainees (P < 0.0001). Most TDs feel that residents do not spend more time reading (89%) or operating (96%); 68 per cent feel patient care has suffered as a result of duty-hours restrictions. Seventy-one per cent feel residents will not select trauma surgery as a career as a result of changes in duty hours. Perceived trauma attending/resident work-hour disparity may disincentive trainees from trauma career selection. TDs view resident duty-hour restrictions negatively.
Annular Pancreas in the Adult: Management with Laparoscopic Gastrojejunostomy
Authors: De Ugarte Daniel A. , Dutson Eric P. , Hiyama Darryl T.
Published: June 2020

Annular pancreas is an uncommon congenital anomaly associated with duodenal atresia in neonates. Rarely, the condition may manifest later in life. These symptoms include abdominal pain, nausea, and vomiting and usually arise due to obstruction to gastric emptying. Abdominal CT scan with high resolution and angiography protocol and magnetic resonance imaging are useful in confirming the presence of annular pancreas. Operative management involves bypassing the obstructed duodenum. Duodenoduodenostomy is routinely performed in neonates with annular pancreas. In adults, the duodenum is less mobile, and duodenojejunostomy or gastrojejunostomy are recommended. We report two cases of annular pancreas in adults treated with laparoscopic gastrojejunostomy.
A Rare Presentation of Tuberculosis
Authors: Zhao Xian , Chen Stephen , Deanda Abe , Kiev Jon
Published: June 2020

Primary involvement of the musculoskeletal system with tuberculosis is rare. We present a case of a young, immunocompetent woman with primary sternal tuberculosis. The disease led to destruction of the manubrium and a portion of the gladiolus and required extensive debridement and partial sternectomy, followed by musculocutaneous flap closure. Long-term postoperative management included four-drug antitubercular therapy.
Management of General Surgical Problems in Patients with Left Ventricular Assist Devices
Authors: Eckhauser A.E. , Melvin W.V. , Sharp K.W.
Published: June 2020

Congestive heart failure (CHF) is a major health issue resulting in significant patient morbidity and mortality. Left ventricular assist devices (LVADs) are becoming an increasingly popular method of treatment for patients with end-stage CHF. As the use of LVADs increases, there is a greater likelihood that some of these patients will live to develop general surgical problems. It is important for general surgeons to be aware of the often complex evaluation and treatment of patients with these problems. We retrospectively reviewed the charts of three patients with LVADs who underwent nonthoracic general surgical procedures. We reviewed duration of LVAD, time from LVAD implantation to operation, type of anesthesia, and any postoperative complications. Three patients with LVADs underwent five nonthoracic general surgical procedures. Anticoagulation was reversed with heparinization in four cases, the fifth case requiring fresh-frozen plasma. There was no perioperative mortality. Two morbidities occurred in separate patients, a wound infection and driveline site infection. These were managed nonoperatively. These patients raise several important concerns. They are often anticoagulated and require reversal. Staff needs to be familiar with these devices, their operation and physiology. The placement of the LVAD imposes limitations on surgical site location that require the surgeon to be prepared, flexible, and often creative.
Neuroendocrine Tumor of the Breast
Authors: Valdes Edna K. , Feldman Sheldon M. , Krassilnik Nina
Published: June 2020

Mammary carcinoid is an uncommon neoplasm. It accounts for approximately 5 per cent of all breast carcinomas. It is well-known that neuroendocrine elements can be demonstrated in ductal and lobular carcinoma. However, it is still controversial whether mammary carcinoid tumors should be considered a distinct clinical entity or be treated as a variant of conventional breast carcinoma. Differentiating these lesions from benign lesions such as epithelial hyperplasia and papillomas can be challenging at times. We present a case of neuroendocrine tumor of the breast.
Congenital Duplication of the Gallbladder
Authors: Safioleas Michael C. , Papavassiliou Vassilios G. , Moulakakis Konstantinos G. , Angouras Dimitrios C. , Skandalakis Panagiotis
Published: June 2020

Duplication of the gallbladder is a rare congenital anomaly of the biliary system. In this article, two cases of gallbladder duplication are presented. The first case is a patient with double gallbladder and concomitant choledocholithiasis. The probable diagnosis of double gallbladder was made preoperatively by computed tomography. The patient underwent a successful open cholecystectomy and common bile duct exploration. In the second case, two cystic formations in the place of gallbladder are demonstrated with ultrasound scan in a woman with acute cholecystitis. At surgery, two gallbladders were found. A brief review of epidemiology and anatomy of double gallbladder is included, along with a discussion of the difficulties in diagnosis and treatment of this condition.
Gallstone-Induced Inflammatory Fibrosis: A Relentless Clinical Course of Retained Gallstones after Laparoscopic Cholecystectomy
Authors: Heestand Gregory , Morrison Bryant , Correa Adrian , Palmer Suzanne , Mateo Rod , Hagen Jeffrey , Genyk Yuri , Selby Rick , Sher Linda
Published: June 2020

Multiple reports in the literature confirm that retained gallstones spilled during laparoscopic cholecystectomy perpetuate chronic inflammation and suppuration long after the initial operation. Two patients who had previously undergone laparoscopic cholecystectomy presented to our institution with complications of retained stones. Patient 1 presented with right upper quadrant pain and a mass involving the right hepatic lobe. Patient 2 presented with a draining right flank abscess. Both underwent exploratory laparotomy at which time multiple abscess cavities were found, many of which contained retained gallstones. Patient 1 required reoperation for recurrent abscesses 7 months after the initial procedure and has been disease free for 6 months. Patient 2 had abscess recurrence that required percutaneous drainage 1 year after the original procedure and has not had recurrence for 4 years.

This paper was presented at the 6thWorld Congress of the International Hepato Pancreato Biliary Association, June 5, 2004, Washington, DC.
Lymphangiomatosis Masquerading as Metastatic Melanoma
Authors: Qutub William , Lewis Karl , Gonzalez Rene , Quaife Robert , Russ Paul , Mccarter Martin
Published: June 2020

A patient undergoing evaluation for malignant melanoma was thought to have a metastatic process involving the anterior mediastinum, axilla, spleen, and possibly liver based on radiologic findings from positron emission tomography and computed tomography scans. The clinical picture did not corroborate this suspicion, and biopsies ultimately confirmed lymphangioma in the accessory spleen and subcutaneous tissues, leading to a diagnosis of lymphangiomatosis. Diagnosis and management of lymphangiomatosis is clinically challenging. This report reviews the literature on the pathology, diagnostic imaging, and management of lymphangiomatosis.
Complications of Brain Death: Frequency and Impact on Organ Retrieval
Authors: Salim Ali , Martin Matthew , Brown Carlos , Belzberg Howard , Rhee Peter , Demetriades Demetrios
Published: June 2020

Brain death is associated with complex hemodynamic, endocrine, and metabolic dysfunction that can lead to major complications with the potential donor. Untreated, this can progress to cardiovascular collapse with loss of valuable organs for transplantation. We hypothesized that brain death-related complications would have no effect on the number of organs donated if an aggressive donor management protocol was in place. We identified all successful organ donations between January 2000 and December 2003 and evaluated them for brain death-associated complications (defined as vasopressor requirement, coagulopathy, diabetes insipidus, cardiac ischemia, lactic acidosis, renal failure, and acute respiratory distress syndrome) and donated organs per donor. Sixty-nine organ donors were identified. Complications identified were as follows: intravenous vasopressor requirement in 97.1 per cent, coagulopathy in 55.1 per cent, thrombocytopenia in 53.6 per cent, diabetes insipidus in 46.4 per cent, cardiac ischemia in 30.4 per cent, lactic acidosis in 24.6 per cent, renal failure in 20.3 per cent, and acute respiratory distress syndrome in 13 per cent. There was no significant effect of complications on the average number of organs harvested, with the exception of an increase in organs harvested in the presence of diabetes insipidus. With the implementation of an aggressive organ donor management protocol, these complications can be effectively managed with no impact on the number of organs harvested for transplant.
Giant Mesenteric Fibromatosis Presenting as Small Bowel Obstruction
Authors: Holubar Stefan , Dwivedi Amit J. , O'Connor James
Published: June 2020

Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery that may occur as a unique or multiple formation. Mesenteric fibromatosis is a rare, locally aggressive neoplasm and may present with abdominal discomfort, abdominal pain, weight loss, or symptoms of ureteral obstruction, mesenteric ischemia, or intestinal obstruction. It is of the utmost importance to distinguish mesenteric fibromatosis from gastrointestinal stromal tumors. Histopathology accurately differentiates between these two distinct entities. The preferred treatment is local surgical excision with a margin of uninvolved tissue. The involvement of important structures like the superior mesenteric artery and the superior mesenteric vein may pose a challenge during resection, but these tumors can be excised and the vessels repaired primarily.
Attracting Medical Students to Surgical Residency Programs
Authors: Crace Phillip P. , Nounou Joseph , Engel Amy M. , Welling Richard E.
Published: June 2020

With the goals of creating a better match between medical students and general surgery programs and providing a program that is desirable to medical students who are interested in pursuing careers in surgery, a survey was designed to categorize student interests and to determine what factors are used in choosing a general surgery program. The survey focused on the reasons that surgical resident candidates select a program. Each statement was rated for importance on a 5-point scale, and then the top 10 statements were ranked in order of importance. The survey was distributed to 19 community hospitals, 23 university programs, and medical students interviewing for surgical residency. A total of 286 surveys were returned from 18 programs and medical students. The statements with the three highest ratings were “amount of operative exposure,” “diversity of operative cases,” and “perceived relationships among faculty and residents.” “Amount of operative exposure,” “diversity of operative cases,” and “ability to pursue fellowship training after residency” received the top rankings. There was a significant difference between men and women in the ratings of three statements. However, there was no difference with the ranking of the statements. There was also a significant difference between residents early and late in their training on ratings of five statements and on the ranking of two statements. The ratings of six statements were significantly different between community and university programs. A significant difference between types of program was also found with the rankings of four statements. There was a difference between small and large programs on two ratings of statements and one ranking. This data provides a useful resource for programs and candidates in preparing for candidate/residency selection.
Care of Critically Ill Surgical Patients Using the 80-Hour Accreditation Council of Graduate Medical Education Work-Week Guidelines: A Survey of Current Strategies
Authors: Gordon Chad R. , Axelrad Alex , Alexander James B. , Dellinger R. Phillip , Ross Steven E.
Published: June 2020

As a result of the recently mandated work-hour restrictions, it has become more difficult to provide 24-hour intensive care unit (ICU) in-house coverage by the general surgical residents. To assess the current state of providing appropriate continuous care to surgical critical care patients during the era of resident work-hour constraints, a national survey was conducted by the Association of Program Directors of Surgery. The results revealed that 37 per cent of programs surveyed have residents other than general surgery housestaff providing cross-coverage and writing orders for surgical ICU patients. Residents in emergency medicine, anesthesia, family medicine, otorhinolaryngology, obstetrics/gynecology, internal medicine, urology, and orthopedic surgery have provided this cross-coverage. Some found it necessary to use physician extenders (i.e., nurse practitioners or physician assistants), thereby decreasing the burden of surgical housestaff coverage. The results indicated that 30 per cent use physician extenders to help cover the ICU during daytime hours and 11 per cent used them during nighttime hours. In addition, 24 per cent used a “night-float” system in an attempt to maintain continuous care, yet still adhere to the mandated guidelines. In conclusion, our survey found multiple strategies, including the use of physician extenders, a “night-float” system, and the use of nongeneral surgical residents in an attempt to provide continuous coverage for surgical ICU patients. The overall outcome of these new strategies still needs to be assessed before any beneficial results can be demonstrated.
Recurrent Asystole Resulting from High Cervical Spinal Cord Injuries
Authors: Franga D.L. , Hawkins M.L. , Medeiros R.S. , Adewumi D.
Published: June 2020

Cervical spinal cord injury is a highly morbid condition frequently associated with cardiovascular instability. This instability may include bradyarrhythmias, as well as hypotension, and usually resolves in a relatively short time. However, over a 3-year period (January 2003–December, 2005), 5 of 30 patients with complete cervical spinal cord injuries seen at our Level I trauma center required placement of permanent cardiac pacemakers for recurrent bradycardia/asystolic events. Strong consideration for pacemaker placement should be given for those spinal cord-injured patients with symptomatic bradyarrhythmic events still occurring 2 weeks after injury.
Independent Lung Ventilation in the Management of Traumatic Bronchopleural Fistula
Authors: Cheatham Michael L. , Promes John T.
Published: June 2020

Independent lung ventilation (ILV) is a technique for managing patients with unilateral lung disease or injury who have failed conventional mechanical ventilation. A 20-year-old man sustained severe ballistic injuries to the chest and abdomen. Damage control laparotomy controlled the patient's initial hemorrhage, however, an evolving cavitary pulmonary lesion subsequently developed into a high-volume bronchopleural fistula. Progressive atelectasis of the damaged lung resulted in profound hypoxemia and hypercarbia refractory to conventional mechanical ventilation. Synchronous ILV was initiated using a double-lumen endotracheal tube and two ventilators titrated to optimize the patient's oxygenation and ventilation and minimize ventilator-induced lung injury. Intensive ILV over the next 17 days resulted in recruitment of the atelectatic right lung, resolution of the bronchopleural fistula, and significant improvement in oxygenation and pulmonary compliance. This appears to be the longest reported use of ILV for traumatic lung injury.
Indications for Splenectomy
Authors: Katz Steven C. , Pachter H. Leon
Published: June 2020

In the new millennium, indications for splenectomy have expanded. Proper patient selection based on an understanding of the biology of each individual's disease is essential for a favorable outcome. We review the most common diseases for which surgeons may be called on to perform splenectomy and while highlighting potential pitfalls and caveats.
Laparoscopic Repair of Gastrointestinal Leaks after Laparoscopic Gastric Bypass
Authors: Madan Atul K. , Lanier Brock , Tichansky David S.
Published: June 2020

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75–182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4–78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.
Is Blood Sugar the Next Lactate?
Authors: Duane TherÈSe M. , Dechert Tracey , Dalesio Nicholas , Wolfe Luke G. , Dalesio Nicholas , Aboutanos Michel B. , Malhotra Ajai K. , Ivatury Rao R.
Published: June 2020

This study evaluates whether an initial blood glucose level is similarly predictive of injury severity and outcome as admission lactate in trauma patients. Between February 2004 and June 2005, we prospectively compared patients with presenting blood sugars of ≤150 mg/dL (LBS) with those with blood sugars >150 mg/dL (HBS). Fifty patients had BS above 150 mg/dL, whereas 176 patients were ≤150 mg/dL. These groups had similar demographics except for age. Injury Severity Score (ISS) of ≥15 was seen in 56.0 per cent of HBS patients versus 28.4 per cent of LBS patients (P = 0.0006). HBS patients had similar infection rates (12.0% HBS vs. 5.7% LBS, P = 0.13) but a higher mortality (30.0% HBS vs. 5.7% LBS, P < 0.0001). There was a linear relationship between ISS and BS (r2 = 0.18, P < 0.0001) and ISS and lactate (r2 = 0.17, P < 0.0001). Blood sugar trended with the lactate (r = 0.25, P = 0.0001). Hyperglycemic patients were more severely injured with higher mortality. BS correlated with lactate, and because it is easily obtainable, it may serve as a readily available predictor of injury severity and prognosis.
Adenosquamous Carcinoma of the Colon: A Rare Tumor
Authors: Kiran Ravi P. , Tripodi Guiseppe , Frederick William , Dudrick Stanley J.
Published: June 2020

Adenosquamous carcinoma of the colon is rare. A paraneoplastic syndrome presenting as hypercalcemia may occasionally occur in association with these tumors. Survival for more advanced stages of disease is lower than for patients with adenocarcinoma at a corresponding stage. We report a patient who presented with a primary adenosquamous carcinoma of the rectosigmoid junction and we review the literature regarding the clinical presentation, management, and prognosis of this tumor.
Minimally Invasive Repair of Pectus Excavatum in Adult Patients
Authors: Hebra Andre , Jacobs Jeffrey P. , Feliz Alexander , Arenas Jennifer , Moore Claudia B. , Larson Shawn
Published: June 2020

Since 1996, the technique for minimally invasive repair of pectus excavatum (MIRPE) has gained increasing acceptance among pediatric patients. However, the feasibility of the operation and outcomes have not yet been evaluated in adult patients. This study was a retrospective analysis of the author's experience combined with a survey of members of the American Pediatric Surgical Association in treating adult patients with MIRPE. Thirty adults (age range, 18–32 years; mean, 23 years; 75% men) with severe pectus excavatum (chest index > 3.2) were treated with MIRPE. The main indication for surgery was cosmetic (80%). One 32-year-old female patient underwent simultaneous MIRPE and breast augmentation. In 60 per cent of cases, the operative time was 1 to 2 hours. Thoracic epidural was successfully used for postoperative pain management in 90 per cent of patients. Two pectus bars were necessary in 16 per cent of cases, and bilateral stabilizers were used in 53 per cent of patients. Complications included seroma (10%), bar displacement (6%), pneumothorax requiring tube thoracostomy (6%), superficial wound infection (3%), and stabilizer bar fracture (3%). Two patients required conversion to modified Ravitch repair. Patient satisfaction was rated as excellent (50%), good (36%), and fair (14%). Less than 50 per cent of patients achieved 100 per cent correction of their deformity. MIRPE can be used safely for repair of pectus excavatum in adult patients. The complication rate appears to be similar to previously reported series of pediatric patients. Although adult patients may have residual asymmetry of the chest postrepair, overall satisfaction with the repair was very good or excellent in 86 per cent of patients.
Migrating Mesh Mimicking Colonic Malignancy
Authors: Ojo Peter , Abenthroth Alissa , Fiedler Paul , Yavorek George
Published: June 2020

The use of prosthetic mesh is the current acceptable standard for the repair of hernias. Recurrence rate has been greatly reduced since Lichtensen in 1986 first described mesh repair of inguinal hernias. The most common complication arising from inguinal hernia repair even with mesh is recurrence. There are isolated reports of migrated mesh in the three decades of mesh use in hernia repair. We present a case report of a migrated mesh plug presenting with features highly suggestive of an intra-abdominal neoplasm in a 63-year-old man who presented with weight loss, anorexia, fatigue, and a palpable right lower quadrant mass. Work up had revealed a large inflammatory mass involving the cecum and not amenable to percutaneous or colonoscopic biopsy, thus requiring diagnostic laparoscopy. He had a right inguinal hernia repair with mesh 8 years earlier. At diagnostic laparoscopy, an extensive right lower quadrant mass involving the cecum, bladder, and transverse colon and extending to the midline was found, necessitating conversion to open laparotomy and a right hemicolectomy. A mesh plug was found intimately involved with the specimen. Plugs used in inguinal hernia repair rarely migrate. It is rarer still for them to present as a possible colonic mass. This is the first known case report of mesh plug migration presenting as a suspected colonic malignancy.
Ischemic Proctitis: Case Series and Literature Review
Authors: Sharif Suhail , Hyser Matthew
Published: June 2020

Ischemic injury to the rectum is rare owing to its rich vascular supply, and is seldom seen in clinical practice. Risk factors include major vascular occlusive disease, disruption of collateral circulation, and low flow state. It is of paramount importance to diagnose this entity early in its course. Although CT scan can suggest the diagnosis and identify other causes of clinical deterioration, colonoscopy remains the key test in diagnosing and determining the extent of ischemic change. Endoscopic findings and the overall clinical picture determine patient management. Treatment is nonoperative for nongangrenous ischemic proctocolitis, whereas surgery is necessary for gangrenous, transmural rectal ischemia. Over a 20-year period, a retrospective review of cases of acute rectal ischemia were analyzed. Aortoiliac occlusive disease accounted for nearly one-half the cases (7/15), and 40 per cent (6/15) was secondary to a low flow state. In our series, two-thirds of the cases involved transmural necrosis of the rectal wall (40% mortality) and the remaining one-third presented with patchy ischemic changes (20% mortality).
Quantitative Analysis of Organ Tissue Damage after Septic Shock
Authors: Martens M. , Kumar M. M. , Kumar S. , Goldenberg M. , Kawata M. , Pennycooke O. , Strande L. , Hadeed J. , Camacho J. , Hewitt C. , Slotman G. J.
Published: June 2020

The objective of this study was to quantify end-organ damage caused by bacteremic sepsis. Twelve adult swine were divided into two groups. The anesthesia control group (n = 6) received general anesthesia for 4 hours. The septic shock group (n = 6) received an infusion of Aeromonas hydrophila under general anesthesia for 4 hours. Swine were sacrificed at the end of the 4-hour procedure. Tissues from lungs, kidneys, livers, and hearts were stained with hematoxylin and eosin. Images of tissues were studied with digital image analysis. In lungs, cytoplasmic area (CA), nuclear area (NA), intra-alveolar hemorrhage (IAH), total airspace (TAS), and alveolar septum thickness (ST) were measured. Nuclear and cytoplasmic intensities (NI and CI) were measured in integrated optical density units (IOD). In kidneys, livers, and hearts, CA, CI, NA, and NI were measured similarly. Sinusoidal blood in the liver and vacuolization (VAC) in the kidney were also measured. In septic lungs, CI, NA, NI, ST, IAH, TAS, and ratios of NA/CA, NI/CI, and IAH/TAS were significantly increased compared with the control ( P < 0.02). In septic kidneys, CI, NA, VAC, NA/CA, and NI/CI were significantly increased ( P < 0.0005). In livers, CA, CI, and NI/CI were significantly increased ( P < 0.005). In hearts, the ratios of NA/CA and NI/CI were statistically significant. End organs from septic swine, with exception of the heart, showed significantly higher levels of cellular damage. Digital image analysis provides an objective, precise, and accurate method of quantifying image characteristics. Automating these tasks is a high priority in the research and clinical community in providing a reproducible method for longitudinal analysis of various biological studies.
A Successful Application of the Intraoperative Parathyroid Hormone Assay in Tertiary Hyperparathyroidism
Authors: Thanasoulis Leila , Bingener Juliane , Sirinek Kenneth , Richards Melanie
Published: June 2020

The role of the intraoperative parathyroid hormone (IOPTH) assay in patients with tertiary hyperparathyroidism (3HPT) is not well defined. To evaluate the utility of the IOPTH in 3HPT, we compared its use in 72 patients with primary hyperparathyroidism (1HPT) and 3HPT undergoing parathyroidectomy. Sixty-three patients with 1HPT and nine patients with 3HPT were identified. There were 30 men and 42 women (mean age, 58 years). The mean serum calcium and preoperative intact PTH levels in 1HPT were 11.1 mg/dL and 214 pg/mL compared with 11.2 mg/dL and 849 pg/mL in 3HPT (Ca, non significant; PTH, P < 0.05). Intraoperatively, a solitary abnormal gland was found in 62 of 72 (86%) patients. Seven patients with 3HPT had three- or four-gland hyperplasia. The two groups were compared to determine if a 10-minute postexcision IOPTH decline >50 per cent would have similar success rates. Seventy-one of 72 (98.6%) patients had a >50 per cent decline from the baseline IOPTH at the end of the operation. The average reduction from baseline was 85.3 per cent in 1HPT and 88.6 per cent in 3HPT (not significant). Average follow-up was 9.8 months for 1HPT and 11.1 months in 3HPT. Three of 63 patients (4.8%) with 1HPT and five of nine patients (55.6%) with 3HPT had inappropriate elevations in PTH ( P < 0.05). All patients with 3HPT were normocalcemic compared with 62 of 64 (97%) patients with 1HPT (not significant). The IOPTH assay can be used in 3HPT in an identical fashion with an equivalent rate of normocalcemia compared with its applications in 1HPT.
Rosai-Dorfman Disease Presenting as a Male Breast Mass
Authors: Dias Perera Anton S.N. , Keleher Angela J. , Nath Manju
Published: June 2020

A 23-year-old man presented with a 6-week history of a left breast mass. Mammography and ultrasonography confirmed a 1.1 x 0.7-cm mass suggestive of breast cancer. An excisional biopsy revealed Rosai-Dorfman disease of the breast. As illustrated by this case, extranodal Rosai-Dorfman disease can mimic breast cancer. Surgical resection is considered appropriate treatment for this condition.
Asymptomatic Intussusception of the Appendix Secondary to Endometriosis
Authors: Offodile Anaeze , Hodgin Jeffrey B. , Arnell Tracey
Published: June 2020

This is a report of a 47-year-old woman with an asymptomatic clinical presentation of appendiceal intussusception secondary to endometriosis. Initially discovered during routine colonoscopy as a submucosal mass, it was ultimately diagnosed after surgical resection by pathology findings. The theories regarding the pathogenesis of appendiceal intussusception are reviewed and discussed here.
Classification of Lymph Node Metastases from Gastric Cancer: Comparison between N-Site and N-Number Systems. Our Experience and Review of the Literature
Authors: Aurello Paolo , D'Angelo Francesco , Rossi Simone , Bellagamba Riccardo , Cicchini Claudia , Nigri Giuseppe , Ercolani Giorgio , De Angelis Renato , Ramacciato Giovanni
Published: June 2020

The tumor, node, metastasis (TNM) system has become the principal method for assessing the extent of disease, determining prognosis in gastric cancer patients, and affecting the therapy strategies. The extent of lymph node metastasis is the most important prognostic factor. The aim of this study was to compare the N-classifications of the 4th and the 5th-6th TNM editions and to evaluate retrospectively the prognostic value of the 2002 TNM edition. We evaluated 344 patients who underwent curative total or subtotal gastrectomy. Nodal involvement was detected in 221 (64%) patients. Median follow-up period was 76 months. Thirty per cent of the old N1 patients were reclassified as pN2 (18.5%) and pN3 (11.3%). Eighty-eight per cent of the old N2 patients were reclassified as pN1 (75%) and pN3 (13.7%). In reclassifying the patients, statistically significant changes were reported between 1987 and 2002 TNM stage grouping, mainly in stage IIIB and IV. The 5-year survival rate per stage group did not statistically differ between the 4th and the 5th–6th editions, although a diminutive trend was registered in the IIIA stage. pTNM stage, nodal numerical stage, nodal topographical stage, and depth of tumor invasion resulted in significantly independent prognostic factors. Our data confirm the simplicity and easy application of the new stadiation and the better prognostic stratification of the N-stage. The pN3 group showed a worse prognosis independent of location. On the other hand, prognostic value of pN1 and pN2 stage is lower, probably depending on lymph node location. In multivariate analysis, the difference between old and new TNM staging is low. Hence, we suggest comparing lymph node location and number in larger series. In our series, in pT1 tumors, neither pN2 nor pN3 involvement was found. Hence, in our opinion, for correct N-staging, 10 lymph nodes in early gastric cancer and at least 16 in the other pT-stages seem sufficient for a real pN0 stadiation.
Article Commentary: Strategies in the Prevention and Management of Ventilator-Associated Pneumonia
Authors: Pieracci Fredric M. , Barie Philip S.
Published: June 2020

Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in the intensive care unit. Prevention of VAP is possible through the use of several evidence-based strategies intended to minimize intubation, the duration of mechanical ventilation, and the risk of aspiration of oropharyngeal pathogens. Current data favor the quantitative analysis of lower respiratory tract cultures for the diagnosis of VAP, accompanied by the initiation of broad-spectrum empiric antimicrobial therapy based on patient risk factors for infection with multi-drug-resistant pathogens and data from unit-specific antibiograms. Eventual choice of antibiotic and duration of therapy are selected based on culture results and patient stability, with an emphasis on minimization of unnecessary antibiotic use.
The Quality of a Surgeon Defined by Internal Medicine and Family Practice Physicians: A Closed-Ended Survey with Importance Scale
Authors: Frezza Eldo E. , Wachtel Mitchell S.
Published: June 2020

An anonymously completed, closed-ended questionnaire with an importance scale was sent to physicians to assess which qualities were important in their selection of a surgeon. Differences in proportions of rankings that were designated “extremely important” were assessed by binomial logistic regression was used. Null hypotheses were rejected if P < 0.05. Forty-two of 61 questionnaires were returned for analysis. Differences between dependability and other characteristics were statistically significant (G = 35.62, P = 0.001). The only characteristics that were statistically significantly less likely to receive a ranking of “extremely important” were facility appearance, subspecialty fellowship, and graduation from a good residency. All other differences could have been explained by chance ( P > 0.05). Surgeons’ character, equipment, and staffing of the facility were ranked extremely important, whereas training of the surgeon or the appearance of the facility was not.
Patch Repair of Ileoanal Pouch-Vaginal Fistula with Permacol™ Collagen Implant
Authors: Smith Maurice , Hooks Vendie H. , Jenkins Barry
Published: June 2020

Though uncommon, ileoanal pouch-vaginal fistulas after restorative proctocolectomy present quite a challenge. Multiple salvage procedures, including endoanal, transabdominal, and trans-vaginal, have been used. Because of high recurrence rates, multiple operations are not uncommon, and ultimate pouch failure rates have been reported as high as 45 per cent. The Permacol™ Collagen Implant is a surgical implant that has been used successfully in a variety of operations ranging from urological to maxillofacial. Its properties allow fibroblast infiltration and revascularization so that it gradually becomes permanently incorporated into the surrounding tissue, providing strength and inhibiting scarring and contraction. We report the first documented case of Permacol™ use in repair of ileoanal pouch-vaginal fistula and we feel that it warrants further investigation as an option in the treatment of these fistulas.