bluuebunny/crossref_metadata_2025 huggingface dataset:
Attitudinal Changes Resulting from Repetitive Training of Operating Room Personnel Using High-Fidelity Simulation at the Point of Care
Authors: Paige John T. , Kozmenkq Valeriy , Yang Tong , Gururaja Ramnarayan Paragi , Hilton Charles W. , Cohn Isidore , Chauvin Sheila W.
Published: June 2020

We investigated the impact of repetitive training using high-fidelity simulation (HFS) at the point of care on the teamwork attitudes of operating room (OR) personnel. Members of the general surgical OR teams at an academic medical center participated in two half-day point-of-care HFS team training sessions. Module 1 targeted teamwork competencies; Module 2 included a preoperative briefing strategy. Modules were separated by 1 month. For each training, participants completed pre- and postsession questionnaires that included a 15-item self-efficacy tool targeting teamwork competencies using a 6-point Likert-type scale. Pre- and postsession mean scores were compared with a t test. Matched pre- and postsessions questionnaires were collected from 38 and 39 participants for Module 1 and Module 2, respectively. Mean item improvement from pre- to posttraining was 0.43 units (range, 0.23 to 0.69 units) for Module 1 and 0.42 units (range, 0.15 to 0.53 units) for Module 2. After Bonferroni adjustment, statistically significant improvement in scores from pre- to posttraining increased from four items after Module 1 to nine items after Module 2. Repetitive training of interdisciplinary OR teams through HFS at the point of care increases the effectiveness of promoting attitudinal change toward team-based competencies among participants.
Influence of Age on Choice of Therapy and Surgical Outcomes in Patients with Nonsmall Cell Lung Cancer
Authors: Bolton William D. , Rice David C. , Correa Arlene M. , Hofstetter Wayne , Komaki Ritsuko , Mehran Reza , Pisters Katherine , Roth Jack A. , Vaporciyan Ara A. , Walsh Garrett L. , Swisher Stephen G.
Published: June 2020

United States census data predict expansion of the elderly population until 2050 and nonsmall lung cancer (NSCLC) incidence is expected to rise accordingly. This study examines trends of lung cancer management and outcomes for pulmonary resection of primary NSCLC in the elderly. An institutional data set (n = 5950) was examined to determine patterns of management. A separate surgical dataset (n = 1756) was examined to determine surgical outcomes. “Elderly” was defined as 70 years old or older. Twenty-four per cent of patients in the institutional data set underwent surgery. Patients in the youngest age quartile (younger than 62 years) were more likely to undergo surgery, whereas the oldest quartile (older than 74 years) were less likely. In the surgical data set, 643 patients were elderly. No difference in combined 30-day/in-hospital mortality was noted (4 vs 2.9%). Five-year survival was 59.1 per cent for younger and 49.9 per cent for elderly patients. On multivariable analysis, age 70 years or older, male gender, increasing Charlson Comorbidity Index score, and pathologic stage were predictors of worse survival. Increasing age is an independent rick factor for surgical outcome and long-term survival after pulmonary resection for NSCLC, age appears to influence choice of initial treatment and extent of resection. Although surgery in the elderly carries higher risk, long-term cure can still be achieved in a significant number of patients.
Temporary Intravascular Shunts: When Are We Really Using Them According to the NTDB?
Authors: Ball Chad G. , Kirkpatrick Andrew W. , Rajani Ravi R. , Wyrzykowski Amy D. , Dente Christopher J. , Vercruysse Gary A. , Mcbeth Paul , Nicholas Jeffrey M. , Salomone Jeffrey P. , Rozycki Grace S. , Feliciano David V.
Published: June 2020

Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = –7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period ( P > 0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.
Nodular Fasciitis: Differential Considerations and Current Management Strategies
Authors: Grobmyer Stephen R. , Knapik Jacquelyn A. , Foss Robin M. , Copeland Edward M. , Hochwald Steven N.
Published: June 2020

Nodular fasciitis (NF) typically presents as an enlarging soft tissue mass with imaging characteristics that may be suggestive of soft tissue sarcoma or desmoid tumor. This presentation can make a correct diagnosis and management of patients with NF a challenge. We report our recent experience with two cases of NF that were both referred with a diagnoses of “soft tissue sarcoma.” Patient 1 was a 46-year-old woman who had undergone breast augmentation and was referred with a rapidly growing firm mass on the left chest wall beneath the breast implant. Computed tomography of the chest noted the mass to be 8 cm X 11 cm in size displacing the implant laterally with no radiological involvement of the bony structures of the chest. Core biopsy was suggestive of inflammation only. Given the clinical suspicion of malignancy, the patient underwent resection of the mass with implant removal. Final pathology showed NF. Patient 2 was a 65-year-old woman referred with an enlarging tender 3-cm infraclavicular mass and a clinical diagnosis of “soft tissue sarcoma.” Preoperative biopsy suggested NF. The patient underwent complete excision, which confirmed the diagnosis. These cases highlight the clinical issues associated with management of patients with NF. Current approaches to evaluation, diagnosis, and treatment of NF are discussed.
Changing Indications and Outcomes for Open Abdominal Aortic Aneurysm Repair since the Advent of Endovascular Repair
Authors: Joels Charles S. , Langan Eugene M. , Daley Charles A , Kalbaugh Corey A. , Cass Anna L. , Cull David L. , Taylor Spence M.
Published: June 2020

The indications for open abdominal aortic aneurysm (AAA) repair have changed with the development of endovascular techniques. The purpose of this study is to clarify the indications and outcomes for open repair since endovascular aneurysm repair (EVAR) and to compare contemporary AAA repair with the pre-EVAR era. Patients undergoing open AAA repair were identified; the demographics, outcomes, and indications for open repair were reviewed. Outcomes were compared based on indication for open repair in the EVAR era and between the pre-EVAR and EVAR eras. Open indications in the EVAR era included: age younger than 65 years with minimal comorbidities (AGE, n = 24 [9.8%]), unfavorable anatomy (ANAT, n = 146 [59.3%]), aortoiliac occlusive disease (AIOD, n = 38 [15.4%]), and miscellaneous (OTHER, n = 38 [15.4%]). Mortality (30-day and 5-year) was affected by indication: AGE = 0 and 0 per cent, ANAT = 4.1 and 49.7 per cent, AIOD = 13.5 and 32.3 per cent, and OTHER = 5.3 and 41.8 per cent. Age, sex, race, coronary artery disease, and peripheral artery disease were similar between the pre-EVAR and EVAR eras. EVAR-era patients had more diabetes mellitus, hypertension, and hyperlipidemia and longer operative time. Mortality was not different, but complication rates were lower in the pre-EVAR era (23.7 vs 43.5%, P = 0.025). Patients undergoing open AAA repair in the EVAR era have more comorbidities, longer operative times, and more complications. Outcomes for EVAR-era patients are affected by the indication for open repair. A preference for open repair in younger patients with minimal comorbidities is justified.
Management of Common Bile Duct Injury during Partial Gastrectomy
Authors: Dixon Jennifer A. , Morgan Katherine A. , Adams David B.
Published: June 2020

Injury to the common bile duct (CBD) during upper gastrointestinal surgery for peptic ulcer disease is a serious complication with an underestimated prevalence in light of the few cases reported in the surgical literature. Three cases of CBD injury were referred to a multidisciplinary specialized gastrointestinal unit for management over a 4-year period. Anomalous anatomy, adhesions, and potential duodenal shortening secondary to contracture all predispose the biliary ducts to intraoperative injury. The axial nature of the blood supply to the extrahepatic ducts and the tendency of bile itself to cause rapid collagen turnover and fibrosis, combined with the inflammation and subsequent fibrosis to the surrounding tissues caused by bile leakage, give the bile ducts a high propensity for stricture formation. Frequently presenting symptoms of CBD injury immediately after surgery include jaundice, elevated bilirubin values, elevated t-tube drainage, and symptoms of sepsis. The most common complaints noted in patients who present in a delayed manner are symptoms of cholangitis. Even when injuries are rapidly identified and corrected, the potential for lasting negative impact on quality of life is great in many cases. When CBD injury occurs, the pancreatic duodenal union can be concomitantly disrupted.
Traumatic Injuries Associated with Segways and Personal Transporters
Authors: Vincent Kyle B. , Block Ernest F. J. , Black Jonathan
Published: June 2020

Segways and other personal transporters are emerging as alternative modes of transportation that blur the distinction between pedestrian and vehicular traffic. We reviewed the records of four patients who were traumatically injured while piloting personal transporters. All required hospital admission for major blunt force trauma; three were admitted to the intensive care unit. Two intensive care unit admissions were for neurologic monitoring of severe intracranial hemorrhage. The other critically ill patient had an extensive chest wall injury and respiratory failure resulting in a tracheostomy. The fourth patient suffered an open lower extremity fracture requiring extensive reconstructive orthopedic surgery. Surgeons should be aware of the potential serious nature of associated injuries.
Long-Term Results of a Selective Surgical Approach to Management of Zollinger-Ellison Syndrome in Patients with MEN-1
Authors: Mortellaro Vincent E. , Hochwald Steven N. , Mcguigan James E. , Copeland Edward M. , Vogel Stephen B. , Grobmyer Stephen R.
Published: June 2020

The role of operation in patients with Multiple Endocrine Neoplasia Type 1 (MEN-1) and Zollinger-Ellison Syndrome (ZES) is controversial. Our institutional bias for this disease has, in general, been towards aggressive imaging and operative removal of localized gastrinomas. Few studies have reported long-term outcomes in patients with MEN-1 and ZES. A single institution retrospective review of all patients with MEN-1 and ZES from 1970 to present was performed. Twelve patients were identified (median age = 37 years at diagnosis). The median follow-up was 18 years from diagnosis of ZES. Common symptoms associated with gastrinoma in these patients were diarrhea (n = 6), abdominal pain (n = 4), and nausea/vomiting (n = 4). Most commonly identified sites of gastrinoma were: pancreas (n = 10), duodenum (n = 4), lymph nodes (n = 3), and liver (n = 1). Fifteen celiotomies were performed in total (median = 1; range 0-3). Operative procedures performed included: distal pancreatectomy (n = 4), acid reducing procedure (n = 4), enucleation of pancreatic gastrinoma (n = 3), duodenal resection (n = 3), pancreaticoduodenectomy (n = 1), and other (n = 7). One patient had a transient biochemical cure after operation lasting 3 years. Only one patient in this series had documented liver metastases of gastrinoma and no patients expired of metastatic gastrinoma. There was one postoperative patient death, secondary to respiratory arrest thought to be a result of aspiration or pulmonary embolus. Three patients died of nondisease related causes, and seven patients were alive at the time of last follow-up. Operations rarely result in biochemical cures in patients with MEN-1 and ZES. In our experience, resection of localized gastrinomas often did not require extended surgical resection and were associated with excellent long-term outcomes.
Infection Risk of Open Placement of Intraperitoneal Composite Mesh
Authors: Cobb William S. , Carbonell Alfredo M. , Kalbaugh Corey L. , Jones Yonge , Lokey Jonathan S.
Published: June 2020

Mesh contamination is the most feared postoperative complication after ventral herniorrhaphy. The morbidity is significant requiring additional operative procedures for debridement or complete removal of the prosthesis. From July 1998 to December 2007, a retrospective review was performed to evaluate the incidence of mesh infection in patients undergoing an elective, open intra-abdominal sublay technique of repair using a composite mesh of polypropylene and expanded polytetrafluoroethylene (Composix®, Davol®, Inc., Cranston, RI). There were 206 procedures involving open, intraperitoneal placement of Composix® mesh resulting in 21 mesh infections (10.2%). The majority of infections were secondary to Staphylococcus aureus contamination (76%), and over half were infected with MRSA. All patients, except two, required mesh removal. Reoperation for repair of the recurrent defect after mesh removal was necessary in 67 per cent. Two patients with MRSA infection subsequently reinfected their recurrent repair. Overall, the infected group required 44 additional procedures (mean of 2.1 procedures/patient). The infection risk was reduced with the lighter density, newer generation composite mesh (7.3% vs 14.5%). Mesh infection after ventral herniorrhaphy conveys significant morbidity. An open intraabdominal underlay of a composite mesh of polypropylene and ePTFE carries a real risk of contamination and should be reconsidered.
Incidence of Anastomotic Leak in Patients Undergoing Elective Colon Resection without Mechanical Bowel Preparation: Our Updated Experience and Two-year Review
Authors: Harris Lisa J. , Moudgill Neil , Hager Eric , Abdollahi Hamid , Goldstein Scott
Published: June 2020

Mechanical bowel preparation before elective colon resection has recently been questioned in the literature. We report a prospective study evaluating the anastomotic leak rate in patients undergoing elective colorectal surgery without preoperative mechanical bowel preparation. One hundred fifty-three patients undergoing elective colon resection from July 2006 to June 2008 were enrolled into this Institutional Review Board-approved study. All patients were operated on by a single surgeon at a single institution. No patients received mechanical bowel preparation. Of the 153 patients enrolled, 51.6 per cent had a colorectostomy, 32 per cent had an ileocolostomy, 10.4 per cent had a colocolostomy 5.2 per cent had an ileoanal anastomosis, and 0.6 per cent had an ileorectostomy performed. A total of eight patients (5.2%) developed an anastomotic leak. Of these patients, four required reoperation, three were managed with percutaneous drainage, and one was managed with antibiotics alone. Five of the eight patients who developed an anastomotic leak had significant preoperative comorbidities, including neoadjuvant radiation therapy, diabetes mellitus, end-stage renal disease, prior anastomotic leak, and tobacco use. Elective colon resection can be performed safely without preoperative mechanical bowel preparation. Vigilance for anastomotic leak must be maintained at all times, especially in patients with comorbidities that predispose to anastomotic leak.
Acute Care Surgery after Renal Transplantation
Authors: Benjamin Elizabeth R. , Jim Jeffrey , Kim Thomas J. , Meals Clifton , Gritsch H. Albin , Tillou Areti , Cryer H. Gill , Hiatt Jonathan R.
Published: June 2020

Emergent operation after renal transplantation (RT) has traditionally been associated with substantial morbidity and mortality. We reviewed 2340 adult patients who underwent RT at our tertiary care center and identified 55 patients who required acute care surgical consultation within 1 year of transplantation. Of these, 43 were treated operatively and 12 nonoperatively Primary diagnoses were intestinal problems in 29 patients (53%), including diverticulitis, ischemia, perforation, obstruction, and bleeding; cholecystitis in 10 (18%); fluid collections in six (11%), appendicitis and hernias in two each (4%); gastritis in one (2%); and no diagnosis in five (9%). Colonic pathology was treated with resection and diversion in 14 of 16 patients who underwent surgery. Acute allograft rejection preceded the surgical problem in five patients. Complications occurred in 13 per cent of patients, and mortality was 9 per cent. Colonic ischemia had a fulminating presentation and particular morbidity. We conclude that acute gastrointestinal emergencies after RT are rare and that early and aggressive intervention using an acute care surgical model yields excellent results.
Long-Term Outcome of Endoscopic Colorectal Stenting for Malignant and Benign Disease
Authors: Rayhanabad Jessica , Abbas Maher A.
Published: June 2020

Although the technical success rate of endoscopic stenting has been defined, there is a paucity of outcome data. The purpose of this study was to evaluate the long-term results of colorectal stenting for both malignant and benign disease. A retrospective review was conducted of patients who underwent stenting at a tertiary center over 4 years. One surgeon performed all stents under endoscopic and fluoroscopic guidance. A total of 49 stent procedures were performed in 36 patients (19 females, mean age 65 years). Mean follow-up was 15 months. Twenty-eight patients (78%) underwent stenting for malignant disease and eight patients (22%) for benign conditions. The most common reason for intervention was obstruction (81%). Technical success rate was 72 per cent. Carcinomatosis was associated with a higher technical failure rate. Procedural related complications occurred in two patients (6%). Long-term stent migration rate was 24 per cent and was more common in patients with benign disease and patients who received nonmetal stents or stents with diameter < 25 mm. Endoscopic reintervention was required in 33 per cent of patients with initial technical success. Long-term need for subsequent operative intervention was 14 per cent. Endoscopic stenting is a viable option for a select group of patients with colorectal disease. Patient's selection and stent choice influence outcome.
Predictors of Postoperative Urinary Retention
Authors: Shadle Benjamin , Barbaro Casey , Waxman Kenneth , Connor Scott , Von Dollen Kathryn
Published: June 2020

Postoperative urinary retention (PUR) rates vary greatly depending on the population studied. PUR leads to urinary tract instrumentation, which causes increased hospital costs and morbidity. We sought to determine our PUR rate and the risk factors that associated with it. One hundred seventy-six adult surgical inpatients were included in the study. Excluded were those receiving intraoperative catheterization, epidural anesthesia, and urologic procedures. The study population included 42 per cent spinal, 24 per cent laparoscopic abdominal, 20 per cent neck surgeries excluding the spine, and 14 per cent miscellaneous surgeries. Patient bladder volumes were determined using ultrasound scanning at three different intervals: a postvoid residual just before transfer to the operating suite, immediately on arrival in the recovery unit, and then immediately before transfer to the ward. Our overall rate of PUR was 5.7 per cent (10 of 176), defined as the need for catheterization during the postoperative hospitalization. Associated with PUR were advanced age ( P = 0.0292) and postoperative bladder volume ( P = 0.0246). Preoperative bladder volume, intraoperative fluid, and operative time did not reach statistical significance as being predictive of urinary retention. Our data suggest that PUR is associated with increased bladder volumes on arrival to the recovery room. A prospective study to determine whether identification of patients at risk will lead to decreased incidence of urinary tract infection is warranted.
Role of Water-Soluble Enema before Takedown of Diverting Ileostomy for Low Pelvic Anastomosis
Authors: Karsten Benjamin J. , King Justin B. , Kumar Ravin R.
Published: June 2020

The integrity of a low pelvic anastomosis is often studied radiographically before takedown of a diverting ileostomy. The aim of this study is to determine the impact of routine water-soluble enema studies (WSE) in our patient population with low pelvic anastomosis. We retrospectively reviewed the operative database for a county teaching hospital from 1998 to 2008. All patients with low pelvic anastomosis (ultralow colorectal, coloanal, and ileoanal pouch anastomosis) with diverting ileostomy who underwent subsequent takedown were identified. Fifty patients met inclusion criteria. Thirty-eight patients were evaluated by WSE and 12 were not. Twenty-five patients (66%) were noted to have normal WSE studies before ostomy takedown. Thirteen patients (26%) were noted to have abnormalities on WSE. Two stenoses were clinically significant. Water-soluble enema study was 100 per cent sensitive and 69 per cent specific for detecting significant pathology. Digital rectal examination (DRE), colonoscopy, and flexible sigmoidoscopy were also 100 per cent sensitive in detecting substantial pathology. Routine use of WSE failed to demonstrate a significant impact on patients with low pelvic anastomosis undergoing ileostomy takedown. Routine DRE and rigid proctoscopy can be used to evaluate low pelvic anastomosis. WSE can be used selectively on patients with abnormal findings.
Increased Incidence of Pancreatic Fistulas after the Introduction of a Bioabsorbable Staple Line Reinforcement in Distal Pancreatic Resections
Authors: Guzman Eduardo A. , Nelson Rebecca A , Kim Joseph , Pigazzi Alessio , Trisal Vijay , Paz Benjamin , Ellenhorn Joshua Di
Published: June 2020

Pancreatic fistula is a major cause of morbidity after distal pancreatic resection. When resections are performed with linear stapling devices, the use of bioabsorbable staple line reinforcement has been suggested to decrease the rate of pancreatic fistula. Our objective was to investigate the incidence of pancreatic fistula when using the Gore Seamguard® staple line reinforcement in stapled distal pancreatic resections. A retrospective review of 30 consecutive patients with stapled distal pancreatectomy was conducted. A broad definition of pancreatic fistula was used. Clinicopathologic factors and outcomes were compared between groups. Pancreatic fistula was diagnosed in 11 of 15 patients (73%) and three of 15 patients (20%) in the Seamguard® and non-Seamguard® groups, respectively ( P = 0.002). Pancreatic parenchymal transection at the neck of the gland was associated with pancreatic fistula, whereas laparoscopic procedures, splenic preservation, or additional organ resection were not. On multivariate analysis, the association between Seamguard® use and pancreatic fistula was significant ( P = 0.005). In conclusion, after introduction of the Gore Seamguard® bioabsorbable staple line reinforcement, we experienced a significant increase in the rate of pancreatic fistula. This experience raises concern about the efficacy of this device in limiting pancreatic fistula after stapled distal pancreatic resection.
Early Predictors of the Need for Emergent Surgery to Control Hemorrhage in Hypotensive Trauma Patients
Authors: Kaiser Meghann , Ahearn Patrick , Nguyen Xuan-Mai , Barleben Andrew , Cinat Marianne , Barrios Cristobal , Hoyt David , Malinoski Darren
Published: June 2020

Twenty-five to 30 per cent of hypotensive trauma patients require an emergent surgery, however, we have no reliable means to quickly determine that need. Our goal was to determine, via retrospective review, parameters available within minutes of arrival that predict the need for emergent surgery to control hemorrhage in hypotensive trauma patients. Inclusion criterion was initial systolic blood pressure (SBP) < 90 mm Hg in the emergency department (ED). Patients who were dead on arrival or underwent ED thoracotomy were excluded. Emergent surgery was defined as sternotomy, thoracotomy, laparotomy, or major neck vascular repair on day of admission. Potential clinical predictors were analyzed in a binary logistic regression model. Six hundred and thirty-nine hypotensive patients were identified and 193 excluded, leaving 446 with a mean age of 33 ± 19 years and Injury Severity Score of 22 ± 17. Thirty-two per cent suffered penetrating trauma, 30 per cent needed emergent surgery, and 19 per cent died. Independent predictors were: prolonged extrication (odds ratio (OR) 2.3), no loss of consciousness (OR 2.8), intubation (OR 1.7), central line placement (OR 1.7), and blood transfusion (OR 2.1, all P < 0.05). We concluded that hypotensive trauma patients without head injuries who require prolonged extrication, intubation, central venous access, and blood transfusion in the ED are more likely to need emergent surgery.
Extreme Thrombocytosis in Trauma Patients: Are Antiplatelet Agents the Answer?
Authors: Saadi Zainab , Inaba Kenji , Barmparas Galinos , Salim Ali , Talving Peep , Plurad David , Green Donald , Demetriades Demetrios
Published: June 2020

The purpose of this study was to review the incidence of extreme thrombocytosis (ExT) (platelet count 1,000,000/μL or greater) in trauma patients and to examine the role of antiplatelet agents in its treatment. The Los Angeles County Medical Center trauma registry was used to obtain injury demographics, medications, and daily platelet counts for injured patients 16 years of age or older admitted between July 2005 and February 2008. Of 6,985 total trauma patients admitted during the study period, 95 developed ExT (1.4%). Average age was 29 years (range, 16-63 years), 89 per cent were male, 44 per cent had penetrating trauma, and mean Injury Severity Score was 24 (range, 1-57). Of the 95 patients with ExT, 41 were treated with aspirin (43%) and 54 were not (57%). The two groups did not differ with regard to basic demographics, injury patterns, vitals on admission, or splenectomy rate (34 vs 20%, P = 0.13). After adjusting for maximum platelet counts and duration of ExT, there was no difference between the treated and untreated groups in terms of mortality, complications, and intensive care unit or hospital lengths of stay. The incidence of ExT is approximately 1.4 per cent in trauma patients. Antiplatelet therapy does not affect ExT patient outcome. Further prospective studies are warranted.
Pancreatic Neuroendocrine Tumors: Presentation, Management, and Outcomes
Authors: Nissen Nicholas N. , Kim Amanda S. , Yu Run , Wolin Edward M. , Friedman Marc L. , Lo Simon K. , Wachsman Ashley M. , Colquhoun Steven D.
Published: June 2020

Pancreatic neuroendocrine tumors (pNETs) are an uncommon pancreatic neoplasm. We reviewed the presentation, management, and outcome of patients with pNETs treated at a single center by a multidisciplinary approach between 2004 and 2008. Over this time period, 154 patients with carcinoid and neuroendocrine tumors were treated, which included 46 patients (30% of total) with pNETs. The most common presentations included abdominal pain (20 of 46 [43%]), systemic symptoms such as hypoglycemia (15 of 46 [33%]), and incidental mass (7 of 46 [15%]). Fourteen patients had functional tumors. At the time of diagnosis, 22 patients (48%) presented without metastases and 24 (52%) had metastatic disease. Median follow up for the entire group was 42 months. All patients with nonmetastatic pNET underwent pancreatic resection with 95 per cent postoperative survival. Overall survival in this group at 3 years was 86 per cent and disease-free survival was 81 per cent. In patients presenting with metastatic pNET, multiple treatment modalities were used, including liver resection or ablation (n = 15), hepatic chemoembolization (n = 17), pancreatic resection (n = 12), and systemic treatments (n = 7). Three-year survival was 70 per cent. Pancreatic resection results in greater than 80 per cent 3-year survival in nonmetastatic pNET. In patients presenting with metastatic pNET, excellent survival rates are also achievable using a multidisciplinary multimodal approach.
Methicillin-Resistant Staphylococcus Aureus in a Surgical Intensive Care Unit
Authors: Recinos Gustavo , Naba Kenjii , Dubose Joseph , Barmparas Galinos , Teixeira Pedro G.R. , Talving Peep , Belzberg Howard , Demetriades Demetrios
Published: June 2020

The rate of methicillin-resistant Staphylococcus aureus (MRSA) infections has increased significantly over the last years, especially from community-associated MRSA (CA-MRSA) sources. The true prevalence of these multidrug-resistant infections among the trauma patient population, however, is not well defined. A retrospective review of our surgical intensive care unit (SICU) database from April 2003 to April 2007 was performed to identify all trauma patients surviving 48 hours or more that had a positive culture result during their SICU stay. The results of the cultures were examined. A total of 582 SICU patients with 2,860 cultures were assessed for MRSA infection. Among these, 368 cultures (12.9%) in 36 patients were reported as MRSA positive. Thirteen of these patients fulfilled the criteria for a CA-MRSA infection. When outcomes were analyzed, no significant difference in mortality (8.7% vs 15.4%, P = 0.540) or hospital related charges ($364,231 ± 323,719 vs $242,458 ± 276,630, P = 0.091) was noted. Patients with a hospital-acquired MRSA infection, however, had longer hospital lengths of stay (42.7 ± 47.1 vs 25.3 ± 31.1, P = 0.037) than their community-associated counterparts. MRSA constitutes an important source of infection among critically ill trauma patients. CA-MRSA organisms may play an increasing pathogenic role in this population.
Aggressive Resection of Hepatocellular Carcinoma with Right Atrial Involvement
Authors: Florman Sander , Weaver Michael , Primeaux Paul , Killackey Mary , Sierra Rafael , Gomez Santiago , Haque Salima , Regenstein Fredric , Balart Luis
Published: June 2020

Hepatocellular carcinoma with extension into the right heart is a recognized, albeit rare occurrence. Patients who present with tumors extending into the heart have generally been considered inoperable and had limited survival, many sustaining tumor embolism and/or sudden death. Resection has been fraught with intraoperative and perioperative mortality as well as considerable postoperative morbidity. We report an exceptional case of a patient with such a tumor successfully treated with an aggressive surgical approach and review the limited published experience.
Trauma Laparotomy: Evaluating the Necessity of Histological Examination
Authors: Laituri Carrie , Teixeira Andre , Lube Matthew W. , Seims Aaron , Cravens Jeremy
Published: June 2020

Trauma laparotomy is the most commonly performed procedure in the acute care setting. As current practice, removed specimens are sent for histological examination. A retrospective review of all trauma laparotomies with specimens removed and sent to pathology during a 12-month period was performed in a Level I trauma center. One hundred five procedures of 244 trauma laparotomies yielded specimens sent for examination. Eighty-six patients were male and 19 patients were female with an average age of 34 ± 14 years. Fifty-six per cent of the injuries resulted from penetrating trauma and 44 per cent were from blunt trauma. Gunshot wound and motor vehicle crash were the most common penetrating and blunt injuries, respectively. One hundred thirteen specimens were sent to pathology. Forty-three per cent of the specimens were spleen, 24 per cent small bowel, 16 per cent large bowel, 4 per cent kidney, 2 per cent omentum, 3 per cent appendix, 3 per cent pancreas, and 1 per cent for gallbladder and lung. One hundred twelve of 113 grossly normal specimens had normal pathology. One grossly normal specimen exposed abnormal pathology revealing benign appendiceal mucocele. Therefore, 99.1 per cent of grossly normal specimens sent for histological examination after trauma laparotomy were normal. Based on our review, in select patients routine histological examination of tissues removed for traumatic injury is unnecessary.
Minor Hepatic Resection Using Heat Coagulative Necrosis
Authors: Sandonato Luigi , Cipolla Calogero , Fulfaro Fabio , Re Giuseppe Lo , Latteri Federica , Terranova Angela , Mastrosimone Achille , Bova Valentina , Cabibbo Giuseppe , Latteri Mario Adelfio
Published: June 2020

Intra- and postoperative bleeding represents an extremely serious and frequent complication of hepatic surgery. In this study, we evaluated the effectiveness of a radiofrequency (RF) device using heat to cause coagulative necrosis of the hepatic parenchyma to control hemostasis in minor hepatic resection. Between December 2005 and November 2007, a study was conducted of 21 patients undergoing 22 hepatic resections with the RF-assisted technique. Sixteen of these were affected by hepatocellular carcinoma and five had liver metastases from colorectal cancer. Intraoperative blood loss, the need for blood transfusion, the complication rates, operating times, and the duration of postoperative hospitalization were evaluated. Four segmentectomies and 18 tumorectomies were performed. The average blood loss was of 15.7 mL (range, 0-40 mL); the average operating time was 25.7 minutes (range, 12-43 minutes); the mean postoperative hospital stay was 8.2 days (range, 3-49 days) with a median of 6.0 days. The authors concluded that the RF-assisted technique can be a useful method not only for reducing blood loss and avoiding blood transfusions, but also for reducing operating time and postoperative hospitalization for minor liver resections.
Management of Complex Abdominal Wall Defects Using Acellular Porcine Dermal Collagen
Authors: Chavarriaga Luis Felipe , Lin Edward , Losken Albert , Cook Michael W. , Jeansonne Louis O. , White Brent C. , Sweeney John F. , Galloway John R. , Davis S. Scott
Published: June 2020

Multiple techniques have been used for the repair of complex abdominal wall defects after recurrent incisional hernias with varying rates of success. Primary repair has been associated with high recurrence rates, and prosthetic mesh placement is contraindicated in contaminated surgical fields. The development of biologic prostheses has changed the approach to these difficult problems. This study evaluates the management of complex abdominal wall defects using acellular porcine dermal collagen. Between August 2006 and May 2007, 18 patients underwent abdominal wall reconstruction for complex defects with acellular porcine dermal collagen (CollaMend™; Bard Inc., Warwick, RI). Patient demographics, preoperative risk factors, previous herniorrhaphy attempts, postoperative complications, recurrences, and long-term results were retrospectively reviewed. Records were reviewed at a mean follow up of 7.3 months; the recurrence rate was 44.4 per cent. A total of 38.9 per cent (seven of 18) developed a postoperative wound complications, including infection in 22.2 per cent (four of 18). All of the patients with infection required prosthesis removal as a result of encapsulation rather than incorporation of the biologic prosthesis. Acellular porcine dermal collagen has the potential for reconstruction of abdominal wall defects with postoperative wound occurrences comparable with other biologic materials. Encapsulation of the material was a major problem in cases with wound infection that required graft removal rather than local wound measures. Hernia recurrence and dehiscence of the graft were problems in noncompromised surgical fields.
Early Results of Fissurectomy and Advancement Flap for Resistant Chronic Anal Fissure without Hypertonia of the Internal Anal Sphincter
Authors: Patti Rosalia , Famà Fausto , Tornambè Antonino , Restivo Margherita , Di Vita Gaetano
Published: June 2020

The aim of this study was to assess the efficacy of fissurectomy with skin advancement flap in healing chronic anal fissures without hypertonia of the internal anal sphincter. Twenty-six consecutive patients who failed healing after well-practiced topical medical therapy were enrolled. Anorectal manometry was performed preoperative and 6 months postoperatively. All patients were treated with fissurectomy and advancement flap through healthy skin tissue. All patients healed completely within 30 days from operation. The intensity and the duration of pain post-defecation was reduced significantly with respect to the preoperative values starting from the first defecation. One patient suffered urinary retention, two patients suffered infections, and two partial breakdowns were recorded. At 6 months the maximum resting pressure values were similar to those were detected preoperatively. One month after surgery, anal incontinence was reported in seven patients, four of whom complained about it preoperatively. At 12 months, only three subjects reported incontinence. No patients needed reoperation and no recurrences were detected. The fissurectomy, in combination with advancement flap, is a safe sphincter-saving procedure for the treatment of chronic anal fissures without hypertonia of internal anal sphincter that fails medical conservative treatment.
Percutaneous versus Open Tracheostomy in the Pediatric Trauma Population
Authors: Raju Ashish , Joseph D'Andrea K. , Diarra Cheickna , Ross Steven E.
Published: June 2020

The purpose of this study was to determine the safety and efficacy of percutaneous versus open tracheostomy in the pediatric trauma population. A retrospective chart review was conducted of all tracheostomies performed on trauma patients younger than 18 years for an 8-year period. There was no difference in the incidence of brain, chest, or facial injury between the open and percutaneous tracheostomy groups. However, the open group had a significantly lower age (14.2 vs. 15.5 years; P < 0.01) and higher injury severity score (26 vs. 21; P = 0.015). Mean time from injury to tracheostomy was 9.1 days (range, 0 to 16 days) and was not different between the two methods. The majority of open tracheostomies were performed in the operating room and, of percutaneous tracheostomies, at the bedside. Concomitant feeding tube placement did not affect complication rates. There was not a significant difference between complication rates between the two methods of tracheostomy (percutaneous one of 29; open three of 20). Percutaneous tracheostomy can be safely performed in the injured older child.
Post-Operative Nausea and Vomiting (PONV) after Thyroid Surgery: A Prospective, Randomized Study Comparing Totally Intravenous versus Inhalational Anesthetics
Authors: Vari Alessandra , Gazzanelli Sergio , Cavallaro Giuseppe , De Toma Giorgio , Tarquini Sergio , Guerra Carolina , Stramaccioni Elisa , Pietropaoli Paolo
Published: June 2020

The incidence of postoperative nausea and vomiting (PONV) after thyroidectomy and the association of Propofol versus Sevoflurane use for anesthesia maintenance were investigated during a randomized, prospective study. One hundred and ninety-eight patients underwent thyroidectomy receiving either Sevoflurane (0.5-1.3% end-tidal) or Propofol (50-200 mg/kg/min) for anesthesia maintenance. All patients received Propofol for induction of anesthesia, Succinylcholine or Vecuronium, Nitrous Oxide, and Fentanyl. Prophylactic antiemetics were not administered. The combined incidence of PONV was 54.4 per cent over the 24-hour postoperative evaluation period. PONV was more common in patients receiving Sevoflurane than Propofol for maintenance of anesthesia (64.6% vs 43.8%). In women (n = 117), the incidence of PONV resulted higher when receiving inhalational Sevoflurane than Propofol for maintenance (70.6% vs 42.4%). However, in men (n = 81), there was no significant difference in PONV between anesthetic regimens (47.4% with Sevoflurane vs 49.6% with Propofol). Patients undergoing thyroid surgery are at high risk for the development of PONV. Propofol for maintenance of anesthesia, although more expensive than Sevoflurane, may reduce the rate of PONV.
Clinical Presentation and Treatment Considerations in Children with Acute Omental Torsion: A Retrospective Review
Authors: Vázquez Bianca J. , Thomas Robert , Pfluke Jason , Doski John , Cofer Barry , Robertson Frank , Kidd Joseph
Published: June 2020

Omental torsion is an underdiagnosed cause of abdominal pain in children. It resembles appendicitis, and the diagnosis is often made surgically. We review the presentation, treatment, and outcomes in the largest reported series to date. We recorded demographics, diagnostics, treatment, and histopathology in 18 children with omental torsion between May 2000 and 2007. We found a 4:1 male to female ratio and 85 per cent met criteria for obesity based on Centers for Disease Control and Prevention body mass index-for-age growth chart calculations. Fourteen of 18 (78%) presented with right lower quadrant pain concerning for appendicitis and seven of 18 (39%) with fever, nausea, or vomiting. Mild leukocytosis was found in 78 per cent of patients. All but one was taken to surgery with a diagnosis of appendicitis. Partial omentectomy, either open (50%) or laparoscopic (50%), was performed in all cases. The appendix, resected in 17 patients, was grossly normal. However, 30 per cent of specimens had histopathologic findings of appendicitis. Hospital discharge, after symptom resolution, averaged 33 hours. Surgeons should have a high index of suspicion for omental torsion when evaluating obese children for right lower quadrant pain. Both surgical approaches provide the diagnosis and treatment with minimal morbidity and rapid recovery. We advocate simultaneous appendectomy because appendicitis is often encountered with the torsion.
Buprenorphine Maintenance Therapy Hinders Acute Pain Management in Trauma
Authors: Harrington Colin J. , Zaydfudim Victor
Published: June 2020

Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the μ-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the κ-opioid receptor. These properties make buprenorphine an effective maintenance treatment for opioid-dependent patients. These same properties, however, can interfere with the management of acute pain in patients on maintenance buprenorphine therapy. We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients.
Optimizing Outcomes in Emergency Room Thoracotomy: A 20-Year Experience in an Urban Level I Trauma Center
Authors: Gomez Gerardo , Fecher Alison , Joy Theresa , Pardo Ivanesa , Jacobson Lewis , Kemp Heather
Published: June 2020

Emergency room thoracotomy (ERT) has remained a last resort tool of resuscitation in the management of patients with major trauma. The medical records of all patients undergoing ERT for penetrating chest trauma from January 1, 2000 through April 30, 2008 were retrospectively reviewed. The data from this study were added to data collected in two previous studies conducted at our institution for meta-analysis. A total of 102 ERTs were performed. There were 28 Class I patients (27.4%), 58 Class II (56.8%), six Class III (5.8%), and 11 Class IV (10.7%). The number of ERTs performed on Class I patients has decreased from 58.3 per cent in the 1995 group to 35.4 per cent in the 1999 group. There was an overall survival of 7.8 per cent in the current period of review. Overall survival in the 1995 group was 2.5 per cent, 1999 was 2.7 per cent, and 2008 was 7.8 per cent. The majority of the survival benefit occurs in patients who have electrical activity and a blood pressure when examined in the emergency department (Class III and IV). We intend to do future prospective research to further clarify the Class II patients when evaluating the type of rhythm shown on electrocardiogram tracing to move away from the generic pulseless electrical activity category.
Management of Enteroatmospheric Fistulae in the Open Abdomen
Authors: Ramsay Philip T. , Mejia Vicente A.
Published: June 2020

There are few complications dreaded more by the general surgeon than the development of an enteroatmospheric fistula in the face of the open abdomen. The open abdomen has become a valuable tool in the treatment of trauma and complex surgical patients. The development of enteroatmospheric fistulae leads to increased cost, morbidity, and mortality. In our case series, we describe the use of Malecot catheters and early mobilization of skin and subcutaneous tissue flaps to manage enteroatmospheric fistulae. All of our patients were discharged from the hospital and did not develop any complications from the procedure. All of our patients’ fistulae ultimately closed. This procedure could lead to decreased cost and morbidity.
Analysis of Demographic and Tumor Characteristics of an Inner City Breast Cancer Patient Population Compared with Patients Treated in National Surgical Adjuvant Breast and Bowel Project Trials
Authors: Colfry Alfred J. , Humphries Timothy , Fuhrman George M.
Published: June 2020

In June of 2008 we initiated a breast clinic designed to serve patients regardless of funding status. We analyzed age, race, tumor size, nodal status, estrogen, progesterone, and her-2-neu status. We compared our results to NSABP B-06 (nodal status), B-15 (estrogen, progesterone, and Her-2-neu receptor status), B-18, and B-27 (age, race, and tumor size) to determine whether our patient population was similar to patients included in these trials. Forty-nine patients with newly diagnosed breast cancer were treated during our first year (53 total cancers). Eight patients had noninvasive cancer; 45 had invasive disease. The mean age was 52.2 ± 12.2 years compared to a mean age of 48.4 ± 9.8 years in the B-06 trial ( P = 0.005). Thirty six patients were African American (74%) compared to 10% and 12% in the NSABP B-18 and B-27 trials ( P < 0.00001). A total of 23 of our patients with invasive cancer had involved axillary lymph nodes which was statistically more common than the 35.3% of node positive patients in the B-06 trial ( P = 0.03). Tumor size (3.6 ± 3.3 cm), estrogen (54.4%), and progesterone (52.8%) receptor status were similar to NSABP trials. Only 6 (13.3%) of our patients were considered Her-2-neu positive compared to 29.4 % in the B-15 trial which was significantly less prevalent ( P = 0.02). Significantly different demographic and tumor characteristics were identified in our inner city breast cancer patient population compared to NSABP patients. These results question the validity of using recommendations from large cooperative group trials in the development of treatment plans for our inner city patient population.