bluuebunny/crossref_metadata_2025 huggingface dataset:
Later Stage Disease and Earlier Onset of Rectal Cancer: Epidemiology and Outcomes Comparison of Rectal Cancer in a Rural Appalachian Area to State and National Rates
Authors: Wolbert Thao , Leigh Emilia C. , Barry Rahman , Thompson Errington C. , Gress Todd , Ajmera Akash , Arrington Amanda K.
Published: June 2020

Although the overall rate of colorectal cancer (CRC) has remained stable, studies have shown an increase in the rate of CRC in young patients (<50) nationwide. We hypothesize that the rectal cancer (RC) rate in young people has increased in rural Appalachia. The goal is to provide insight into the future of RC epidemiology in underserved populations. This Institutional Review Board–approved retrospective study evaluated RC patients diagnosed in 2003 to 2016, and compared the ratio of early-onset RC to the state and national ratios using West Virginia State Cancer Registry, North American Association of Central Cancer Registries (NAACCR) and Surveillance, Epidemiology, and End Results Program Database. Demographics include age, gender, ethnicity, and county. We also evaluated cancer stage, family history, and comorbidities, including body mass index, smoking, and alcohol history. The rate of early-onset RC in our area is 1.5 times higher than the national rates. In our population, 100 per cent of patients were white with an equal gender distribution. Young patients with RC were noted to be more overweight than national rates. Young RC patients are more likely to have a first- or second-degree relative with cancer diagnosis. Smoking was strongly associated with young RC. Compared with national statistics, a higher proportion of young patients had Stage 1 or 2 disease which correlated with better survival. The rate of early-onset RC in the Tristate Appalachian area in West Virginia is higher than the national rate with risk factors including white ethnicity, obesity, diabetes mellitus, smoking, family history, and history of pelvic surgeries. It warrants further investigation and discussion of current CRC screening guidelines that begin at age 50.
Factors Influencing Length of Stay after Elective Bowel Resection within an Enhanced Recovery Protocol
Authors: Stethen Trent W. , Ghazi Yasir A. , Heidel R. Eric , Daley Brian J. , Barnes Linda , McLoughlin James M.
Published: June 2020

A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P < 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.
Defining Outcomes after Colon Resection in Blunt Trauma: Is Diversion or Primary Anastomosis More Favorable?
Authors: Lasinski Alaina M. , Gil Lindsay , Kothari Anai N. , Anstadt Michael J. , Gonzalez Richard P.
Published: June 2020

Previous literature demonstrates the safety of primary repair in penetrating colon injury requiring resection, without the creation of a diverting ostomy. It is unknown whether a similar approach can be applied to patients with blunt colon injury. The aim of this study was to measure outcomes in patients who underwent colon resection with and without ostomy creation after blunt trauma injury to help direct future management. Using the National Trauma Data Bank for years 2008 to 2012, we identified patients with blunt trauma mechanisms who underwent colectomy. Patients were stratified into two groups: primary anastomosis and diversion with ostomy. Primary outcome was inpatient mortality. Secondary outcomes included length of stay and perioperative complications. All risk-adjusted analyses were performed using logistic regression with consideration of interactions. Five hundred eighty-one observations met our inclusion criteria. Baseline characteristics between the two groups were similar with the exception of age (37.3 vs 42.2 years, P < 0.001) and admission Glasgow coma score (13.2 vs 12.1, P = 0.002). Risk-adjusted mortality for the two groups was not statistically significant (2.3% vs 3.0%, P = 0.63); however, patients with primary anastomosis had a shorter length of stay (18.2 vs 28.1, P < 0.001), fewer days in the intensive care unit (10.9 vs 16.2, P < 0.001), and fewer ventilator days (10.5 vs 14.6, P = 0.01). In patients requiring colon resection after blunt trauma, mortality is not different for those who receive a primary anastomosis versus ostomy. Patients without diversion had shorter hospital stays, intensive care unit days, and ventilator days. These data support that primary anastomosis is safe in this patient population.
Dogma without Data: A Clinical Decision-Making Tool for Postoperative Blood Cultures
Authors: Copeland-Halperin Libby R. , Emery Erica , Collins Devon , Liu Chang , Dort Jonathan
Published: June 2020

Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are often nondiagnostic. We previously reported a 4 per cent overall yield of positive cultures in postoperative patients. To reduce unnecessary testing, we present a predictive model to identify patients in whom growth of pathogens is unlikely and provide a clinical decision-making guide. Retrospective analysis of nonpregnant patients ≥18 years who had BCx within 10 days postoperatively was performed. Generalized linear mixed models identified clinical predictors of high- and low-yield cultures. A clinical algorithm was created using significant predictors, and positive predictive value, negative predictive value, sensitivity, and specificity calculated. Among 1759 BCx, hypotension, maximum temperature ≥101.5 °F within 24 hours of culture, and culture collected after postoperative day (POD) two were statistically significant predictors of positive cultures. Forty nine per cent of BCx were sent ≤ POD 2, and <1 per cent of these were positive. When all three criteria were met, the probability of a positive culture increased to 17 per cent. When absent, the probability of a negative culture was 99 per cent. When applied to the initial data set, the model resulted in 85 per cent reduction of cultures with 9 per cent yield of positive cultures. Drawing BCx based on a single predictor is inadequate. Reducing the number of cultures reflexively ordered within the first two POD could significantly reduce the number of unnecessary BCx. Several clinical features identified patients most likely to have positive BCx within the first 10 POD and could reduce unnecessary BCx. This model should be validated in an independent, prospective cohort.
Gunshot Injuries to the Extremity: Is Immediate General Surgery Presence Needed?
Authors: Harbrecht Brian G. , Miller Keith R. , Motameni Amirrezat , Benns Matthew V. , Bozeman Matthew C. , Nash Nicholas A. , Franklin Glen A. , Smith Jason W.
Published: June 2020

Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSW require frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for a GSW isolated to the extremity is low.
Racial Disparities in the Incidence of Pulmonary Embolism after Colectomy
Authors: Sanaiha Yas , Bailey Katherine L. , Aguayo Esteban , Seo Young-Ji , Dobaria Vishal , Lin Anne Y. , Benharash Peyman
Published: June 2020

Disparities in the incidence of pulmonary embolism (PE) based on racial and socioeconomic factors remain ill-defined. The present study evaluated the impact of race and hospital characteristics on rates of PE for all adult colectomy patients in the 2005 to 2014 Nationwide Inpatient Sample. Hospitals were designated as high-burden hospitals (HBHs) or low-burden hospitals of underinsured payers. Chi-squared tests of trend and multivariable regression adjusting for patient and hospital characteristics were performed. Of the 2,737,977 adult patients who underwent colectomy in the study period, 79 per cent were White, 10 per cent Black, and 7 per cent Hispanic. The annual rate of PE increased from 0.6 per cent in 2005 to 0.95 per cent in 2014 ( P < 0.0001). Black patients had significantly higher incidence of PE than Whites (1.5% vs 0.9%, P < 0.001) and Hispanics (1.5% vs 0.8%, P < 0.001). Colectomy at HBHs was also associated with significantly higher rates of PE (1% vs 0.86%, P < 0.001). After adjusting for baseline differences, colectomy at HBHs (odds ratio 1.14, 95% confidence interval 1.02–1.27, P = 0.02) and Black race (odds ratio 1.4, 95% confidence interval 1.26–1.66, P < 0.001) were independent predictors of PE. In this national study of colectomy patients, Black patients experienced a disproportionate burden of postoperative PE. Further investigation into the causes and prevention of PE in vulnerable populations may identify targets for surgical quality improvement.
Long-Term Outcomes after Elective versus Emergency Surgery for Small Bowel Neuroendocrine Tumors
Authors: Manguso Nicholas , Gangi Alexandra , Nissen Nicholas , Harit Attiya , Siegel Emily , Hendifar Andrew , Amersi Farin
Published: June 2020

Small bowel neuroendocrine tumors (SBNETs) are often indolent, but occasionally, patients present with acute symptoms requiring emergent operative intervention. Our aim was to determine whether emergency surgery for SBNETs affects long-term outcomes. An institutional database was reviewed to identify patients with SBNET diagnosed between 1990 and 2015. Need for emergency resection (ER) was compared with elective resection (ELR). One hundred and thirty-four patients met inclusion criteria. Median age was 59 years (range, 21–91), and median tumor size was 1.5 cm (range, 0.1–5). Median follow-up time was 5.5 years. One hundred (74.6%) patients had ELR, whereas 34 (25.4%) required ER. ELR had a higher number of lymph nodes resected (median 12.5 vs 8 ER, P = 0.04); however, there was no difference in the number of positive nodes (median 3 vs 2, P = 0.85). There were 45 (33.6%) recurrences (31 [31.0%] ELR vs 14 [41.7%] ER, P = 0.29) and 13 (9.7%) deaths (7 [7.0%] ELR; 6 [17.6%] ER). There was no significant difference in 5-year disease-free survival (ELR 72.6% vs ER 77.9%, P = 0.71) or overall survival (ELR 97.2% vs ER 96.6%, P = 0.81). Although patients undergoing ER have significantly fewer lymph nodes resected, they have comparable recurrence rates and long-term outcomes with those patients undergoing ER.
Stop the Bleed: Does the Training Work One Month Out?
Authors: Pasley Amelia M. , Parker Brandon M. , Levy Matthew J. , Christiani Anthony , Dubose Joseph , Brenner Megan L. , Scalea Thomas , Pasley Jason D.
Published: June 2020

The Stop the Bleed initiative empowers and trains citizens as immediate responders, to recognize and control severe hemorrhage. We sought to determine the retention of short-term knowledge and ability to apply a Combat Application Tourniquet (CAT) in 10 nonmedical personnel. A standard “Stop the Bleed” (Bleeding Control) course was taught including CAT application. Posttraining performance was assessed at 30 days using a standardized mannequin with a traumatic below-knee amputation. Technique, time, pitfalls, and feedback were all recorded. No participant had placed a CAT before the initial class. After the initial class, self-report by a Likert scale survey revealed an increased confidence in tourniquet application from 2.4 pretraining to 4.7 posttraining. At 30 days, confidence decreased to 3.4 before testing. Six of 10 were successful at tourniquet placement. Completion time was 77.75 seconds (43–157 seconds). Successful participants reported a confidence level of 4.7 versus those unsuccessful at 3.3. The “Stop the Bleed” initiative teaches lifesaving skills to the public through a short training course. This information regarding the training of nonmedical personnel may assist in strengthening training efforts for the public. Further investigations are needed to characterize skill degradation and retention over time.
Tertiary Care Multidisciplinary Teams Associated with Improved Survival in Rectal Cancer Patients: A Comparative Study
Authors: Tambe Beverly , Wang Clara V. , Noren Erik , Duldulao M. Philip , Barzi Afsaneh , Lee Sang W.
Published: June 2020

For stage II/III rectal cancer patients, comprehensive multidisciplinary care (MDC) affects outcomes. Randomized trials have shown the effectiveness of adjuvant and neoadjuvant therapy in treatment of these patients. However, the effectiveness of collaboration within MDC is undetermined. It is possible that regional variation in survival outcomes may be tied to treatment facility. We retrospectively reviewed a prospectively collected database of patients with stage II/III rectal cancer who received MDC at any location and underwent oncologic colorectal resection at a tertiary care center (TCC) between 2005 and 2011. Of the 571 rectal cancer patients, 391 had a stage II/III rectal cancer and received surgery at a TCC. After exclusion criteria, we observed that 120 patients received neoadjuvant therapy and 119 patients received adjuvant therapy. For neoadjuvant patients, no difference in overall survival was observed between treatment received at a TCC versus an outside facility. However, a significant improvement in survival was observed in patients who received adjuvant therapy at a TCC ( P = 0.01). Thus, the location of postoperative adjuvant therapy shows improvement in 10-year survival at a TCC versus elsewhere. Thus, standardization of care can impact outcomes for invasive rectal cancer patients. The limitations of this study are its retrospective nature and relatively small sample size.
Simplicity and Safety: Minimized Pancreatic Fistula Rate after Distal Pancreatectomy through Pancreas Stump Sutured Fish-Mouth Closure
Authors: Minarich Michael J. , Schwarz Roderich E.
Published: June 2020

Pancreatic stump leak after distal pancreatectomy (DP) is a major determinant for impaired postoperative recovery. Factors influencing pancreatic fistula (PF) occurrence remain of interest. Prospectively collected data from an academic surgical oncology practice were examined for predictors of PF. Seventy-five of 294 pancreatectomy patients underwent DP (26%). There were 33 men and 42 women, with a median age of 61 years (range: 18–85 years). Underlying conditions included cancer (60%) and benign processes (40%). Resections were comprising open DP (64%), laparoscopic DP (21%), and open multivisceral resections (15%). Of 21 cases with postoperative complications (28%, no death), six were PFs (8%, 2 grade A and 4 grade B). The median length of stay was six days (4–24). The PF rate was 2.0 per cent in 50 patients after sutured fish-mouth closures, but 20 per cent in cases using other techniques including stapling ( P = 0.007); no other variable was linked to PF occurrence. Length of stay was linked to complications, resection extent, malignancy, and transfusions (all at P < 0.02), but not to PF. PF rate after DP in this experience is unaffected by splenic vessel resection but seems to be minimized through a sutured fish-mouth closure technique.
Failure Rate of Prehospital Needle Decompression for Tension Pneumothorax in Trauma Patients
Authors: Lesperance Richard N. , Carroll Colin M. , Aden James K. , Young Jason B. , Nunez Timothy C.
Published: June 2020

Tension pneumothorax is commonly treated with needle decompression (ND) at the 2nd intercostal space midclavicular line (2nd ICS MCL) but is thought to have a high failure rate. Few studies have attempted to directly measure the failure rate in patients receiving the intervention. We performed a retrospective analysis of 10 years of patients receiving prehospital ND. CT scans were reviewed to record the location of catheters left indwelling and the proportion of patients who did not have any pneumothorax. Chest wall thickness was measured on both injured and uninjured sides at the 2nd ICS MCL and compared with the recommended alternative, the 5th ICS anterior axillary line (5th ICS AAL). We identified 335 patients that underwent prehospital ND who had CT scans performed. Using our two different radiologic methods of assessing failure, 39 per cent and 76 per cent of attempts at ND failed to reach the pleural space. In addition, at least 39 per cent of patients did not have a tension pneumothorax. Injured chest walls were significantly thicker than uninjured chest walls at both the 2nd ICS MCL and the 5th ICS AAL (both P < 0.005.) Increasing chest wall thickness correlated with the failure of the catheter to reach the pleural space. Using an 8-cm catheter at the 5th ICS AAL, iatrogenic cardiac injury was at risk in 42 per cent of patients. This series confirms the high failure rate of ND at the 2nd ICS MCL, but further studies are needed to assure the safety of using larger catheters at the 5th ICS AAL.
A Comparison of Outcomes between Lichtenstein and Laparoscopic Transabdominal Preperitoneal Hernioplasty for Recurrent Inguinal Hernia
Authors: Yang Bin , Zhou Shengning , Li Yingru , Tan Jianan , Chen Shuang , Han Fanghai
Published: June 2020

There remain concerns about the optimal technique for repairing recurrent inguinal hernias because of the high risks of complications and recurrence. The aim of this study was to compare Lichtenstein hernioplasty with the transabdominal preperitoneal (TAPP) laparoscopic technique in the treatment of recurrent inguinal hernias. One hundred twenty-two patients who underwent surgery for recurrent inguinal hernia were prospectively randomized to receive either Lichtenstein (n = 63) or TAPP (n = 59) hernioplasty between January 2010 and December 2014. Baseline characteristics, intraoperative complications, and short- and long-term postoperative factors were evaluated. Preoperative factors were comparable between the two groups. The average follow-up period was 46.2 ± 8.5 months. The two groups had similar intraoperative and short-term postoperative complication rates, whereas the rate of long-term postoperative complications was lower for the TAPP group than the Lichtenstein group (6.8% vs 23.8%, respectively, P = 0.012). The TAPP group had significantly lower visual analogue scale scores, fewer analgesics consumption, and faster recovery than the Lichtenstein group ( P < 0.05). Chronic pain was more prevalent in the Lichtenstein group than the TAPP group (15.9% vs 3.4%, respectively, P = 0.031). The recurrence rate was 4.8 per cent for the Lichtenstein group and 1.7 per cent for the TAPP group, with no significant difference ( P = 0.62). Both the Lichtenstein and TAPP procedures are safe and effective methods for repairing recurrent inguinal hernia with low incidence rates of life-threatening complications and recurrence. The TAPP procedure is superior to the Lichtenstein repair in terms of reduced postoperative pain, shorter sick leave, faster recovery, and better cosmetic results. Careful selection of the surgical procedures and implementation of technical essentials are necessary.
Impact of Multiprofessional Rounds on Critical Care Outcomes in the Surgical Trauma Intensive Care Unit
Authors: Nahouraii Michael R. , Karvetski Colleen H. , Brintzenhoff Rita A. , Sachdev Gaurav , Evans Susan L. , Huynh Toan T.
Published: June 2020

Multiprofessional rounds (MPR) represent a mechanism for the coordination of care in critically ill patients. Herein, we examined the impact of MPR on ventilator days (Vent-day), ICU length of stay (LOS), hospital LOS (HLOS), and mortality. A team developed guidelines for MPR, which began in February 2016. Patients admitted between November 2015 and March 2017 with Acute Physiology and Chronic Health Evaluation (APACHE) IV and injury severity scores were included. Outcome data consisted of Vent-day, Vent-day observed/expected ratio (O/E), ICU LOS, ICU LOS O/E, HLOS, HLOS-O/E, and mortality. Linear regression models are constructed to assess statistical significance. A total of 3372 patients were included. Among surgical patients (n = 343 pre-MPR, n = 1675 post-MPR), MPR was associated with decreases in Vent-day O/E (0.74 pre, 0.59 post, P = 0.03), ICU LOS O/E (0.67 pre, 0.61 post, P = 0.01), and HLOS-O/E (1.47 pre, 1.22 post, P = 0.0005). No mortality difference was observed. For trauma patients (n = 221 pre, n = 1133 post), MPR resulted in a reduction in Vent-days (2.2 days pre, 1.6 days post, P = 0.05). However, no differences were observed for Vent-day O/E, ICU LOS O/E, HLOS-O/E, and mortality. Implementation of MPR was associated with improved outcomes for surgical trauma ICU patients. Sustainability of MPR remains a challenge and requires education and engagement.
Nissen Fundoplication–Preserving Laparoscopic Sleeve Gastrectomy
Authors: Smith Craig R. , Gardner Jeffrey T. , Vaughn Lexie H. , Kelly Robert J. , Whipple Oliver C.
Published: June 2020

Gastroesophageal reflux disease (GERD) is significantly more prevalent in obese patients. Nissen fundoplication alleviates symptoms in those refractory to dietary changes and optimal medical management. The need for concomitant treatment of GERD and obesity is becoming more prevalent. The objective of this study was to determine whether Nissen-preserving laparoscopic sleeve gastrectomy (SG) is a safe and effective weight loss option for patients with pre-existing Nissen fundoplication. The study was conducted at the Hospital Corporation of America, Memorial Health, Savannah, Georgia, academic institution. We retrospectively reviewed five patients who underwent laparoscopic Nissen-preserving SG between 2011 and 2017. We compared pre- and postoperative subjective GERD symptoms, occurrence of any immediate postoperative complications, change in BMI, and excess weight loss. Of the five patients, four were female and one was male. The mean age was 50.6 years. The mean preoperative BMI was 44.8 ± 5.4, one-month postoperative BMI was 41.2 ± 6.1 (P < 0.001), and six-month postoperative BMI was 37.5 ± 8.1 (P < 0.009), with mean excess weight loss at six months of 33.9 ± 23 per cent. There were no immediate postoperative complications. Subjective GERD symptoms were unchanged in two patients and improved in the other three. We demonstrate the early feasibility of Nissen-preserving SG for surgical weight loss in patients with existing Nissen fundoplication. Although our results are early, we feel encouraged by mean excess weight loss to date and control of GERD symptoms.
Appendiceal Malignancy: The Hidden Risks of Nonoperative Management for Acute Appendicitis
Authors: Westfall Kristen M. , Brown Rebecca , Charles Anthony G.
Published: June 2020

One potential harm of nonoperative management for acute appendicitis is missed appendiceal cancer, a rare and often aggressive malignancy due to the frequency of late stage of diagnosis. Previous studies have reported an increasing incidence of appendiceal neoplasms in the population. This is a retrospective case–control study of 1007 adult patients, who presented to the University of North Carolina-Memorial Hospital (UNC-MH) between 2011 and 2015 with clinical signs and symptoms of appendicitis. We evaluated the incidence of primary appendiceal cancer in this population and determined factors that predict appendiceal cancer diagnosis using multi-variate logistic regression analysis. The overall incidence of appendiceal neoplasm for adult patients presenting to UNC-MH with appendicitis from 2011 to 2015 was 2.3 per cent (23/1007). The incidence in patients without appendiceal perforation on pathology was 1.9 per cent (16/832). Age (odds ratio (OR) 1.03), number of days of abdominal pain (OR 1.16), self-reported fever (OR 2.08), appendiceal width (OR 1.95), and appendiceal wall thickness (OR 1.30) were predictors of appendiceal neoplasm diagnosis in patients that present with acute appendicitis. We recommend that an operative approach to acute appendicitis should remain the standard of care because operative management may not only be diagnostic but potentially therapeutic.
The Welsh Clan that Transformed Orthopedic Surgery
Authors: Nakayama Don K.
Published: June 2020

Modern orthopedic surgery arose from Hugh Owen Thomas (1834–1891) and Sir Robert Jones (1857–1933), uncle and nephew, two descendants of a family of bonesetters from North Wales and Liverpool, respectively. Thomas combined a formal medical education with his hereditary vocation into treatments that have endured for more than a century. The epitome is the Thomas splint, which was credited with a decrease in the mortality from open femur fractures to 20 from 80 per cent during World War I and is still in use for the emergency transport of lower extremity injuries. Jones was 15 when he became Thomas’ apprentice. By the end of the century, he was a leading figure in orthopedic surgery, at the forefront of the treatment of childhood deformities and the clinical use of X-rays. Enlisting in the Royal Army Medical Corps with the onset of World War I, he saw the need for a system of orthopedic care to treat soldiers with injured limbs that threatened to flood the country with crippled, disabled men. The centerpiece was the military orthopedic center, where surgeons devised integrated programs of surgery, physical therapy, and “curative workshops” to return war-injured soldiers to productive lives. With British surgeons conscripted to work at the Western Front, hundreds of American surgeons with little prior experience in orthopedics volunteered to work in the centers and thus received intensive training under Jones. Orthopedic surgery, traditionally part of the broader practice of surgery, thus emerged from the war as a full-time endeavor and a distinct surgical specialty.
State of Rib Fracture Care: A NTDB Review of Analgesic Management and Surgical Stabilization
Authors: Cheema Fareed A. , Chao Edward , Buchsbaum Joseph , Giarra Katie , Parsikia Afshin , Stone Melvin E. , Kaban Jody M.
Published: June 2020

Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% vs 2.6%, P < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% vs 2.8%, P < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% vs 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture–related pain to elucidate optimal treatment.
Injury Patterns in Near-Hanging Patients: How Much Workup is Really Needed?
Authors: Berke David M. , Helmer Stephen D. , Reyes Jared , Haan James M.
Published: June 2020

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CTand magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS) versus normal GCS (55% vs 10.5%, respectively). Patients who present after near-hanging have a low incidence of associated injuries. Workup can be restricted to patients with abnormal GCS scores and for specific signs and symptoms or high-risk energy mechanisms. The trauma team can be activated for signs of trauma.
Parastomal Hernia Repair Outcomes: A Nine-Year Experience
Authors: Lin You Wei , Keller Patrick , Davenport Daniel L. , Plymale Margaret A. , Totten Crystal F. , Roth John Scott
Published: June 2020

Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/ absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board–approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) versus III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH vs LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.
Effect of Surgical Approach on Node Harvest in Robotic Gastrectomy
Authors: Watson Michael D. , Trufan Sally J. , Gower Nicole L. , Hill Joshua S. , Salo Jonathan C.
Published: June 2020

There has been increasing utilization of minimally invasive surgical approaches. This study evaluates the effect of surgical approach on total lymph node harvest in gastrectomy. Patients undergoing gastrectomy for gastric adenocarcinoma between 2007 and 2018 were reviewed retrospectively. Data collected included age, gender, race, BMI, neoadjuvant therapy, tumor stage, surgical approach, and total number of lymph nodes harvested. The total number of harvested lymph nodes for open, laparoscopic, and robotic gastrectomy was compared using the Kruskal-Wallis test for univariate analysis and a Poisson regression model for multivariable analysis. One hundred four patients were identified. Median node harvest for open, laparoscopic, and robotic approaches were 16, 17, and 36, respectively. Multivariable analysis controlling for gender, BMI, pathological T stage, and year of operation demonstrates that surgical approach is statistically significantly associated with lymph node harvest ( F = 83.4, P < 0.0001). In multivariable analysis, robotic approach was associated with greater lymph node harvest than both open ( P < 0.0001) and laparoscopic ( P < 0.0001) approaches, whereas laparoscopic approach was associated with greater lymph node harvest than open ( P < 0.0001) approach. These data demonstrate that for patients undergoing gastrectomy for gastric adenocarcinoma at our institution, robotic approach is associated with greater lymph node harvest than both laparoscopic and open approaches.
Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience
Authors: Martinez Manuel , Cole Joshua , Dove James , Blansfield Joseph , Shabahang Mohsen , Wild Jeffrey , Widom Kenneth , Torres Denise , Factor Matthew
Published: June 2020

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher read-mission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.
Value Improvement and Resource Utilization in Complex Abdominal Wall Reconstruction
Authors: Mayfield Cory K. , Gould Daniel J. , Wong Alex , Patel Ketan M. , Carey Joseph
Published: June 2020

Although recommendations help guide surgeons’ mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.
Central versus Distal Pancreatectomy for Benign or Low-Grade Malignant Lesions in the Pancreatic Neck and Proximal Body
Authors: Li Yangjun , Li Yujie
Published: June 2020

The purpose of this meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). PubMed, Web of Knowledge, and Ovid's database were searched for studies published in English language between January 1990 and December 2018. A meta-analysis was performed to compare the clinical outcomes of CP versus DP. Nineteen trials with 1440 patients were analyzed. Although there were no significant differences in the rate of intra-operative blood transfusion between two groups, CP costs more operative time as well as had more intraoperative blood loss than DP. Furthermore, the overall complication rate, pancreatic fistula rate, and the clinically significant pancreatic fistula rate were significantly higher in the CP group. On the other hand, CP had a lower risk of endocrine (odds ratio: 0.17; 95% confidence interval: 0.10, 0.29; P < 0.05) and exocrine insufficiency (odds ratio: 0.22; 95% confidence interval: 0.10, 0.48; P < 0.05). CP was associated with a higher pancreatic fistula rate, and it should be performed in selected patients who need preservation of the pancreas, which is of utmost importance.
Platelet's Rule of Change and Clinical Significance before and after Splenectomy
Authors: Guo Binbin , Pan Jinfang , Shen Yi , Zhang Qi , Wang Zhen , Huang Long , Yu Qingsheng
Published: June 2020

Portal vein system thrombosis (PVST) is a form of venous thrombosis, which behaves as a common and potentially life-threatening complication after splenectomy. Numerous studies have been made to investigate the mechanism and the risk factors of PVST. However, the research on the prevention and treatment of PVST associated with platelet's (PLT) rule of change is rare. This work mainly investigates the PLT's rule of change and its correlativity with the formation of PVST after splenectomy. The retrospective study included 117 patients who underwent splenectomy from August 2014 to June 2018 and monitored by blood routine, D-dimer (D-D), and portal vein system ultrasound routinely after splenectomy. The changes of PLT and D-D were recorded and compared before and after each operation. We analyzed the changes of PLTand D-D as well as the incidence of PVST postoperatively. Most of the patients’ PLT increased significantly after splenectomy. On the first day after operation, there were 80 patients’ (68.38%) PLTrecovered to normal or above normal. The proportion of patients with abnormally high PLT value on the seventh and fourteenth day were 60.68 per cent and 81.20 per cent, respectively. Thereinto, there were 67 patients’ (57.26%) PLT beyond 500 x 109/L on the 14th day. The D-D of all patients exceeded the normal range on the first, seventh, and fourteenth day after operation, and the difference was statistically significant ( P < 0.05), which behaved similar like PLT. Meanwhile, our color Doppler ultrasonography showed that the incidence of PVST was 70.79 per cent. Among the patients with PVST, 82 (100%) patients’ PLT was increased after operation. The PLT of patients increased obviously after splenectomy. The increased blood viscosity caused by the consecutive elevation of PLT may result in a higher PVST incidence. Early intervention and treatment are needed clinically for PVST after splenectomy.
Enhancing the Preoperative Experience and Satisfaction of Surgical Patients at an Academic Medical Center through Implementation of a Smartphone Application
Authors: Ramakrishnan Divya , Garson Les , Mensah Paulette , De Los Santos Joe , Elfenbein Dawn M.
Published: June 2020

Preoperative education improves patient satisfaction and postsurgical outcomes, but the use of mobile applications to provide preoperative education in a large population has not been extensively studied. The objective of this study was to determine whether patient use of a text messaging application would lead to a high patient satisfaction rating. Patients undergoing general surgical procedures at our institution were invited to use the application. Each patient received educational messages and was sent a feedback survey postoperatively. Seven hundred twenty-three patients were invited to register with the application, and 402 patients (56%) did so. One hundred sixty-eight (42%) patients who registered filled out the postoperative survey. Of the surveyed patients, 94 per cent stated that they used smart phones daily or a few times a week. The use of the application in our patient population led to good or excellent patient satisfaction scores. Further investigations to determine whether this technology reduces postoperative visits or improves outcomes are ongoing.
Advancing the Use of Laparoscopy in Trauma: Repair of Intraperitoneal Bladder Injuries
Authors: Arnold Michael R. , Lu Caroline D. , Thomas Bradley W. , Sachdev Gaurav , Cunningham Kyle W. , Vaio Raymond , Heniford B. Todd , Sing Ronald F.
Published: June 2020

Traumatic intraperitoneal bladder rupture (IBR) requires surgical repair. Traditionally performed via laparotomy, experience with laparoscopic bladder repair (LBR) after blunt trauma is limited. Benefits of laparoscopy include decreased length of stay (LOS), less pain, early return to work, fewer adhesions, and lower risk of incisional hernia. The aim of this series is to demonstrate the potential superiority of LBR in select trauma patients. This is a retrospective review performed of all IBR patients from 2008 to 2016. Demographics, clinical management, outcomes, and follow-up were compared between LBR and open bladder repair (OBR) patients. Twenty patients underwent OBR, and seven underwent LBR. There was no significant difference in gender, age, or Injury Severity Score. There were no deaths or reoperations in either group. Average hospital length of stay and ICU days were similar between groups. There was one patient with UTI and one with readmission in each group. There were two incisional hernias and two bowel obstructions in the OBR group, with one patient requiring operative intervention. No such complications occurred in the LBR group. LBR for traumatic IBR can be safely performed in select patients, even in those with multiple extra-abdominal injuries.
Unexpected ICU Admission is Associated with Pulmonary Complications but Not Increased Mortality; Rescue is Essential for Optimal Patient Outcome
Authors: Duverseau Marc O. , Suma Dominic , Galvin Shelley L. , Conquest Anne M. , Schurr Michael J.
Published: June 2020

ICU beds are in demand in large regional referral hospitals; therefore, nonintubated polytrauma patients are often admitted to general care (GC) wards. We hypothesized that trauma patients with Injury Severity Score (ISS) greater than 15 and unexpected ICU admission (U-ICU) after initial admission to GC had increased morbidity and mortality. We also hypothesized that those requiring U-ICU could be predicted based on admission parameters. This was a retrospective review of patients aged at least 18 years, admitted to GC with blunt trauma and ISS greater than 15 from April 2015 to March 2017. Demographics were collected along with injury patterns and complications. Statistics included chi-squared, Fisher's exact, Mann-Whitney, and t tests. Of 986 patients, 502 (50.9%) were directly admitted to GC. Prevalence of U-ICU was 9.8 per cent (49/502 patients). The only admission predictor of U-ICU was a history of myocardial infarction (8/49, 16.3%, vs 21/453, 4.6%, P = 0.001). Those with U-ICU had increased incidence of pneumonia, acute respiratory distress syndrome, and endotracheal intubation compared with GC, but there was no difference in overall mortality (3/49, 6.1% vs 18/453, 4.0%, P = 0.45). Half of all severely injured, nonintubated patients can be managed on the GC ward; however, 9.8 per cent of patients will require U-ICU admission for pulmonary complications. Admission history of myocardial infarction predicts those at risk. Severely injured patients with U-ICU admission have significant cardiopulmonary complications, but can be rescued with no increase in overall mortality.
Institutional First 100 Case Experience and Outcomes of Robotic Hepatectomy for Liver Tumors
Authors: Sucandy Iswanto , Giovannetti Andres , Ross Sharona , Rosemurgy Alexander
Published: June 2020

The nascent robotic approach for hepatic resections is gaining momentum in the United States because it offers solutions to the known limitations of laparoscopic approach. Herein, we report our initial experience and short-term outcomes of the first 100 robotic hepatectomies. With Institutional Review Board approval, all patients undergoing robotic hepatectomy were prospectively followed up. Patient demographics, operative outcomes, complications, and 30-day readmissions were collected and analyzed. Data are presented as median (mean ± SD). One hundred consecutive patients underwent robotic hepatectomy. Patients were aged 62 (63 ± 13.6) years, 66 per cent were women, and BMI was 29 (29 ± 6.4) kg/m2. In all, 76 per cent of the hepatectomies were undertaken for malignancy [metastatic colorectal cancer (28%), hepatocellular carcinoma (21%), and intrahepatic cholangiocarcinoma (15%)], and 20 per cent for benign lesions; 66 per cent of patients underwent nonanatomical partial hepatectomies, 17 per cent right hepatectomies, 16 per cent left hepatectomies, and 1 per cent trisegmentectomy. Operative time was 233 (268 ± 109.3) minutes, and the estimated blood loss was 123 (269 ± 322.1) mL. Conversion to “open” approach was necessary in one patient. The length of stay was 3 (5 ± 4.6) days. There were no intraoperative complications. Twelve patients experienced postoperative complications. Six patients required readmission to the hospital within 30 days of discharge. Robotic hepatectomy is safe and feasible with favorable short-term outcomes. The robotic system enhances application of minimally invasive surgery for complex hepatobiliary operations.
Article Commentary: Cancer Immunotherapy for the General Surgeon
Authors: Fromer Marc W. , Scoggins Charles R.
Published: June 2020

Progress in the arena of cancer immunotherapy has been immense in recent years. The fact remains that most of the cancer resections in the United States are performed by general surgeons and not oncologic specialists. A busy practice in general surgery will invariably make it difficult to keep pace with such rapid advancement. This review offers a concise summary of the major concepts and trials that have driven the immunotherapy revolution and their implications for surgeons who deliver cancer care.