bluuebunny/crossref_metadata_2025 huggingface dataset:
Preoperative Evaluation of Endoscopic Ultrasonography and Portography in Selecting Devascularization Surgery for Esophagogastric Varices
Authors: Hsieh Jan-Sing , Jan Chang-Ming , Lu Chien-Yu , Chen Fang-Ming , Wang Jaw-Yuan , Huang Tsung-Jen
Published: June 2020

This study assesses the role of endoscopic ultrasonography (EUS) and portography in selection of mode of devascularization surgery for esophagogastric varices (EGV) in patients with portal hypertension and reports our experience in the treatment of EGV with modified devascularization surgery. Forty-two cirrhotic patients with EGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used as the guiding mode for therapy of EGV. In addition to devascularization and splenectomy, esophageal transection (ET) was performed in 26 patients with upward-flow varices (UFV), whereas 16 patients with downward-flow varices (DFV) underwent proximal gastrectomy instead of ET. In both UFV and DFV groups, grade II of intramural varices and extramural collaterals were most commonly observed on EUS imaging. There was no significant difference of EUS grading between these two groups ( P > 0.05). The incidence of postoperative complications, mortality, and recurrent varices were not significantly different between these two groups. The overall 5-year survival rate for UFV group was 69.2 per cent, whereas that for the DFV group was 68.7 per cent ( P > 0.05). Our study shows that devascularization surgery is highly effective for the prevention of recurrent bleeding from EGV, and it provides an alternative treatment modality. Combined PTP and EUS are very helpful in determining adequate modalities of devascularization surgery.
The Effect of Malnutrition on Morbidity after Surgery for Chronic Pancreatitis
Authors: Schnelldorfer Thomas , Adams David B.
Published: June 2020

Protein-energy malnutrition is a notable problem in the management of patients with chronic pancreatitis. The effect of malnutrition on pancreatic surgery is not well known. The records of 313 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 152), pancreaticoduodenectomy (PD, n = 78), or distal pancreatectomy (DP, n = 83) for chronic pancreatitis were retrospectively reviewed and analyzed. Subjective Global Assessment, Nutritional Risk Index, and Instant Nutritional Assessment were used to assess the nutritional state. An average of all three nutritional indexes was established, and patients were categorized into well nourished (n = 101) as well as mild (n = 91), moderate (n = 94), and severe malnourished (n = 27). Poor nutritional state was associated with an increase in postoperative complication rate (LPJ: well nourished 14%, mild 25%, moderate 31%*, severe 50%*; PD: well nourished 44%, mild 44%, moderate 60%, severe 88%*; DP: well nourished 17%, mild 13%, moderate 30%, severe 55%*; * P < 0.045 vs well nourished). Low serum albumin levels also increased operative morbidity. The increase in morbidity was reflected by a higher rate of infectious complications as well as increased ICU stay. Body mass index and weight loss did not contribute to change in outcome. Malnutrition was associated with a higher incidence of postoperative complications after surgery for chronic pancreatitis. An increase in operative morbidity might be related to decreased protein synthesis and impaired immunocompetence.
Acute Abdomen Secondary to Ascaris lumbricoides Infestation of the Small Bowel
Authors: Schulze Scott M. , Chokshi R.J. , Edavettal M. , Tarasov E.
Published: June 2020

Ascariasis is a helminthic infection commonly found in tropical climates. It often propagates in communities of low socioeconomic status secondary to contamination of the soil and water supply with human feces. We present a case report of a 42-year-old Asian-Indian female presenting with a long-standing history of severe recurrent postprandial epigastric pain, requiring multiple hospital admissions. Ultrasound, computed tomography (CT), and nuclear biliary scan were negative. She underwent esophagogastroduodenoscopy that suggested ischemia. Magnetic resonance angiography (MRA) and mesenteric angiography were inconclusive. As conservative treatment had been unsuccessful, a small bowel series was performed. The radiographs demonstrated characteristic findings of Ascaris lumbricoides infestation. Although the prevalence, diagnosis, and subsequent treatment of an acute abdomen secondary to Ascaris lumbricoides infestation is commonly seen in developing countries, clinicians in developed countries may not consider this entity when faced with a patient with similar symptoms. We frequently care for immigrants from developing countries and our own citizens who visit the countries where ascariasis is endemic. Therefore, heightened awareness of Ascaris lumbricoides infection (ALI) presenting as an acute abdomen is necessary. The diagnosis requires an experienced radiologist and knowledge by the clinician of treatment options and of when a surgeon should be involved.
The Utility and Timing of Surgical Intervention for Parapneumonic Empyema in the Era of Video-Assisted Thoracoscopy
Authors: Hope William W. , Bolton William D. , Stephenson James E.
Published: June 2020

Empyema, a pyogenic or suppurative infection of the pleural space, continues to cause significant morbidity and mortality in patients with pneumonia. The advent of video-assisted thoracoscopy has placed the treatment algorithm of empyema in flux. We retrospectively reviewed all patients who underwent surgical treatment for parapneumonic empyema from January 1, 1999, through December 31, 2003. Data collected included demographic information, preoperative CT scanning/thoracostomy tube placement, morbidity/mortality, days from admission to surgery, and postoperative length of stay. We compared patients undergoing video-assisted thoracoscopy to those requiring conversion to open thoracotomy and those who had initial open thoracotomy. Morbidity and mortality rates were similar among all groups. Conversion rate to open thoracotomy was 21 per cent. We found patients operated on within 11 days of admission had a shorter postoperative length of stay with similar morbidity and mortality. Our data supports early aggressive surgery treatment for parapneumonic empyema.
Adult Gastric Duplication Cysts: A Case Report and Review of Literature
Authors: O'Donnell Paul L. , Morrow J. Bradley , Fitzgerald Timothy L.
Published: June 2020

In this report, we present the rare case of a 53-year-old white female with a gastric duplication cyst. Diagnosis was made with a combination of CT scan and endoscopic ultrasound. The cyst was removed by using a seromuscular incision and enucleation. A review of English literature was performed to help define the etiology, workup, and treatment of adult patients. Theories of origin include embryologic enteric diverticula, incomplete notochordal plates separation, and embryonic longitudinal folds that fuse with a bridge. The essential features of duplication are that the cyst wall is contiguous with the stomach, is surrounded by smooth muscle, has a common blood supply, and is lined with epithelium. Few duplication cysts are diagnosed after the age of 12 and in adults present a diagnostic dilemma. In the past, preoperative diagnosis of gastric duplications was the exception, but with advances in imaging, most importantly endoscopic ultrasound, the diagnosis is established before surgery in a majority of the cases. Gastric duplication cysts have been removed using various methods; however, as enucleation can be performed easily with little disruption of normal anatomy, it should be considered the procedure of choice.
Synchronous Diverticular Perforation: Report of a Case
Authors: Krajewski Eduardo , Szomstein Samuel , Weiss Eric G.
Published: June 2020

Synchronous colonic events are rare. Diverticulitis is the most common and lethal cause of colonic perforation. The first case in the literature of a synchronous diverticular perforation is presented. The patient was admitted with peritonitis. An exploratory laparotomy showed cecal and sigmoid perforations. Resection and primary anastomosis with a protective loop ileostomy was performed. Microscopic evaluation confirmed the presence of cecal and sigmoid perforated diverticuli. Diverticular disease is present in up to two-thirds of patients 80 years of age and older. Right-sided free colonic perforation is rare. Resection and primary anastomosis is feasible in the treatment of perforated diverticular disease. In this report, we emphasize the importance of a thorough abdominal exploration at the time of surgery.
Not All Inflammation in the Right Lower Quadrant is Appendicitis: A Case Report of Escherichia coli O157:H7 with a Review of the Literature
Authors: Rosen Seth A. , Wexner Steven D. , Woodhouse Sherry , Colquhoun Patrick , Weiss Eric G. , Nogueras Juan J. , Efron Jonathan , Vernava Anthony
Published: June 2020

Although significant work has been presented on this subject in pediatric, infectious disease, and epidemiologic literature, there is a noteworthy lack of information on Escherichia coli O157:H7 in any surgical journals. As this disease can present with signs and symptoms often ascribed to the acute abdomen, it is imperative that the general surgeon, pediatric surgeon, and colorectal surgeon are all familiar with this infection and its clinical ramifications. A case report followed by a review of the literature is presented.
Superselective Catheterization and Embolization as First-Line Therapy for Lower Gastrointestinal Bleeding
Authors: Neuman Heather B. , Zarzaur Ben L. , Meyer Anthony A. , Cairns Bruce A. , Rich Preston B.
Published: June 2020

Emergent operative intervention for lower gastrointestinal bleeding (LGIB) is associated with significant morbidity and mortality. Advances in endovascular techniques have made superselective catheterization and embolization (SSCE) of small visceral arterial branches possible. We hypothesized that SSCE for LGIB would be an effective first-line therapy and associated with low mortality. We identified all patients that underwent visceral angiography at our institution from 1997 to 2003. Records from all patients with documented LGIB and in whom SSCE was used as first-line therapy were reviewed. Twenty-three patients (69 ± 11 years) were treated with SSCE as an initial intervention for LGIB. A definitive bleeding site was identified in 95 per cent of cases (22/23). Eleven patients (48%) developed an early complication [recurrent bleeding (n = 5; two required surgery), asymptomatic ischemic colonic mucosa (n = 3), acute renal insufficiency (n = 1; resolved), and femoral pseudo-aneurysm (n = 2; one treated operatively)]. Long-term (mean 19 months) follow-up was available for 17 patients. Five patients (22%) experienced recurrent LGIB, and three patients had evidence of colonic ischemic. One patient required endoscopic dilation of a stricture, and three underwent surgical resection. There was no mortality in our series. In this series, SSCE was an effective first-line therapy for LGIB. Rebleeding and ischemia rates were low.
Large Gastric Mesenteric Cyst: Case Report and Literature Review
Authors: Hassan Mohammed , Dobrilovic Nick , Korelitz Joel
Published: June 2020

The case is a 33-year-old white female presenting with a 3-day history of abdominal pain. On initial examination, she was found to have significant right lower quadrant tenderness. Workup included computed tomography, which demonstrated a large cystic mass appearing to be of ovarian origin. The patient required an exploratory laparotomy, at which time she was found to have a large cyst involving the lesser curvature of her stomach. The cyst was successfully resected, and the patient had a rapid postoperative recovery with complete resolution of symptoms. Histopathologic evaluation of the specimen identified a mesenteric cyst. Mesenteric cysts are uncommon; gastric involvement is exceedingly rare. A review of the literature is presented.
Coronary Artery Bypass via Resternotomy after Pectus Excavatum Repair
Authors: Mohan Pradeep S. , Stark Rochelle D. , Costic Joseph T. , Seinfeld Fredric I. , Laub Glenn W.
Published: June 2020

Pectus excavatum is a chest wall deformity that commonly warrants pediatric surgical correction for cosmesis or respiratory impairment via sternotomy. The repair typically consists of sternal wedge osteotomy and subsequent placement of a Steinman pin across the sternum with fixation to the ribs bilaterally. Coronary artery bypass grafting (CABG) after surgical repair of the sternum with a metal implant poses an intriguing surgical challenge. Literature review reveals only one such previously described case. We present a case of coronary revascularization in an adult who previously underwent pectus excavatum repair with ligation of the internal mammary arteries. Our coronary revascularization was accessed through a resternotomy after surgical removal of the metal implant previously placed during the pectus excavatum repair. Autologous greater saphenous vein was used as a conduit for bypass. The patient did well postoperatively and was discharged on postoperative day 4. The pectus repair remained intact even after the median sternotomy was performed. This was confirmed at the 1-year follow-up for the patient. Resternotomy after pectus excavatum repair with a prosthetic implant poses a challenge to cardiothoracic surgeons. Many such repairs have been described in the pediatric population. As our society ages and coronary artery disease becomes more prevalent, this unique situation may be more commonly encountered. We present an approach to coronary artery bypass grafting via median resternotomy after pectus excavatum repair.
Full-Thickness Chest Wall Resection for Recurrent Breast Carcinoma: An Institutional Review and Meta-analysis
Authors: Pameijer Colette R.J. , Smith David , Mccahill Laurence E. , Bimston David N. , Wagman Lawrence D. , Ellenhorn Joshua D.I.
Published: June 2020

Locoregional recurrence of breast cancer can occur in up to 30 per cent of patients and has often been considered to indicate a poor prognosis. We reviewed our experience with full-thickness chest wall resection for recurrent breast cancer and conducted a meta-analysis of the English literature to determine patient characteristics and outcomes. Twenty-two women with isolated chest wall recurrence of breast cancer were treated between 1970 and 2000 at our institution. We reviewed their preoperative demographics, operative management and outcome, and combined our results with seven other English language studies. A majority of women (90%) underwent a mastectomy as initial management of their breast cancer. Only 18 per cent of patients had meta-static disease at the time of chest wall resection, and 71 per cent of patients had an R0 resection. The 5-year disease-free survival at City of Hope National Medical Center (COH) was 67 per cent and was 45 per cent for the entire group of 400 patients. The 5-year overall survival was 71 per cent for the COH group and 45 per cent for the entire group. Several studies reported prognostic factors, the most common being a better prognosis in patients with a disease-free interval greater than 24 months. Full-thickness chest wall resection for patients with isolated local recurrence of breast cancer can provide long-term palliation and even cure in some patients.
Outcomes of Surgical and Sonographic Assessment of Breast Masses in Women Younger than 30
Authors: Vargas Hernan I. , Vargas M. Perla , Eldrageely Kamal , Gonzalez Katherine D. , Burla Melissa L. , Venegas Rose , Khalkhali Iraj
Published: June 2020

Assessment of breast masses in young women is challenging due to normal glandular variance. Our purpose is to define the outcomes of specialized physical exam, selective breast sonography (BUS), and biopsy in women younger than 30. Five hundred forty-two patients younger than 30 referred with a palpable breast mass were studied. Patients’ mean age was 24.8. Surgeon's physical exam confirmed a dominant mass in 44 per cent of cases. Thirty-seven per cent had normal clinical exams. Median tumor size was 2.2 cm. On multivariate analysis, a mass on surgeon's clinical exam ( P < 0.0001), and BUS ( P = 0.0001) predicted the presence of a true mass. Fifty-three per cent of self-detected abnormalities were true masses compared to 18 per cent when detected by the primary care provider (PCP) ( P < 0.001). Most common diagnoses were fibroadenoma (72%), breast cysts (4%), or fibrocystic changes (3%). Malignancy occurred in 1 per cent. In summary, breast mass is a common reason for surgical consultation. Normal glandular nodularity is often mistaken for a mass. However, a judicious approach of physical exam by a surgeon using selective BUS and image guided core biopsy provides an efficient and safe approach for diagnosis. Breast malignancy is a rare but serious cause of breast mass in young women.
Device-Related Reoperations after Laparoscopic Adjustable Gastric Banding
Authors: Lyass Sergey , Cunneen Scott A. , Hagiike Masanobu , Misra Monali , Burch Miguel , Khalili Theodore M. , Furman Gary , Phillips Edward H.
Published: June 2020

Laparoscopic adjustable gastric banding (LAGB) is considered a relatively safe weight loss procedure with low morbidity. When complications occur, obstruction, erosion, and port malfunction require reoperation. We retrospectively reviewed our experience with 270 consecutive patients who underwent LAGB. Device-related reoperations were performed in 26 (10%) patients. Reoperations were related to the band in 13, to port/tubing in 11, and related to both in 2 patients. Of the 15 band-related problems, it was removed in 5 (2%): slippage (3), intra-abdominal abscess (1), and during emergent operation for bleeding duodenal ulcer (1). Revision or immediate replacement was performed in 10 (4%): slippage (5), obstruction (4), and leak from the reservoir (1). Port/tubing problems were the reason for reoperations in 13 (5%): infection (5), crack at tubing-port connection (6), and port rotation (2). Port removal for infection was followed later by port replacement (average 9 months). Overall, slippage occurred in 8 (3%), obstruction in 4 (1.5%), leak from reservoir in 7 (3%), and infection in 5 (2%) patients. Fifteen device-related problems occurred during our first 100 cases and 12 subsequently ( P = 0.057). Permanent LapBand loss was only 5 per cent, leading to overall rate of 95 per cent of LapBand preservation as a restrictive device.
Use of Recombinant Factor VIIa for Adjunctive Hemorrhage Control in Trauma and Surgical Patients
Authors: Benharash Peyman , Bongard Fred , Putnam Brant
Published: June 2020

Recombinant factor VIIa (rFVIIa) has recently been described for patients with ongoing massive bleeding in a number of different clinical scenarios. A retrospective chart review was conducted at a public level I trauma center in order to describe the use of rFVIIa in trauma and surgical patients with massive bleeding despite surgical control. Fifteen trauma and general surgical patients underwent major operative procedures and developed coagulopathy requiring massive blood product transfusion. All patients had continued life-threatening hemorrhage despite surgical control of bleeding. The mean base deficit was 6 and arterial lactate was 9.0 mmol/L. An initial dose of rFVIIa was given intravenously, followed by a second dose if there was evidence of at least a partial response. Twelve of 15 patients who had been expected to die from hemorrhage survived for greater than 48 hours, and 7 survived to hospital discharge. A partial or complete hemostatic response to rFVIIa was noted in 12 of 15 patients. The number of blood products received after administration of rFVIIa was significantly reduced and the International Normalized Ratio (INR) decreased. Our experience demonstrates that rFVIIa may reduce or completely arrest coagulopathic bleeding in trauma and surgical patients after vascular control.
Administration of Nesiritide in Patients after Coronary Artery Bypass Surgery Induces Brisk Diuresis
Authors: Benharash Peyman , Omari Bassam
Published: June 2020

Recombinant human brain natriuretic peptide, nesiritide, has recently been used in limited studies to enhance postoperative diuresis. A retrospective chart review was conducted at a university hospital to assess the efficacy of nesiritide in cardiac surgery patients with fluid overload refractory to diuretics and dopamine. Nine out of 137 patients who underwent coronary artery bypass grafting at the institution from May 2003 to July 2004 exhibited fluid overload despite diuretics and dopamine. Those who did not respond to the therapy, as manifested by oliguria and heart failure, were started on nesiritide. Urine output, weight change, central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), and serum creatinine were the main outcome measures. Within 6 hours after initiation of nesiritide, the average urine output increased from 28 to 130 mL/h. Serum creatinine levels were not significantly different after 24 hours. The mean CVP decreased from 14 to 10 within 12 hours while the PAWP decreased from 24 to 17 mm Hg. Systemic pressures did not change. One patient had to eventually undergo hemodialysis for complications of renal failure. Our experience demonstrates that infusion of nesiritide in patients with heart failure and fluid overload improves diuresis and hemodynamics without major side effects.
Appendectomy during Early Pregnancy: What is the Preferred Surgical Approach?
Authors: Carver Thomas W. , Antevil Jared , Egan John C. , Brown Carlos V.R.
Published: June 2020

Appendectomy is the most common nongynecologic surgery performed during pregnancy. Although many surgeons offer laparoscopic appendectomy (LA) as an alternative to open appendectomy (OA) during early pregnancy, few studies have compared the effects of LA versus OA on the fetus and the outcome of the pregnancy. Twenty-eight consecutive females undergoing appendectomy for presumed appendicitis in the first two trimesters of pregnancy between January 2000 and December 2002 were identified retrospectively. Demographic information, weeks of pregnancy at operation, and surgical approach (LA or OA) were recorded. Study outcomes included operative and pregnancy-related complications, length of hospitalization, final outcome of pregnancy, and infant birth weight. Seventeen LA and 11 OA were performed. There were no significant differences in surgical or obstetrical complications, length of hospitalization, or birth weight between the two groups. Two cases of postoperative fetal demise were noted in the LA group. Although not statistically significant, the two fetal losses in the laparoscopic group are concerning. The current study did not demonstrate any advantages to the laparoscopic approach. Pending further investigation, the open approach may be preferred for appendectomy in pregnant patients during the first two trimesters of pregnancy.
Extensive Mobile Thrombus of the Internal Carotid Artery: A Case Report, Treatment Options, and a Review of the Literature
Authors: Hill Stephen L. , Brozyna Witold
Published: June 2020

The presence of a carotid stenosis, a floating thrombus, and a patient with clinical and CT evidence of a stroke represents a significant therapeutic dilemma to the clinician. The evidence of a stroke precludes any active treatment of the carotid stenosis safely, while the floating thrombus demands immediate attention. We recently were involved with just such a patient and chose a conservative approach of anticoagulation followed by operative intervention several weeks later.
T4 Rectal Cancer: Analysis of Patient Outcome after Surgical Excision
Authors: Amshel Craig , Avital Shmuel , Miller Allison , Sands Laurence , Marchetti Floriano , Hellinger Michael
Published: June 2020

Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5½-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive individuals. Out of the six patients who died in this review, five (83%) received chemoradiotherapy. Operations for advanced primary rectal cancer with involvement of adjacent organs are major procedures associated with high morbidity. Patients without nodal disease may have long-term survival despite the locally advanced tumor. Interestingly, neoadjuvant therapy, adjuvant, or both, did not increase survival.
Amelioration of Gastroesophageal Reflux Symptoms following Roux-en-Y Gastric Bypass for Clinically Significant Obesity
Authors: Nelson Lana G. , Gonzalez Rodrigo , Haines Krista , Gallagher Scott F. , Murr Michel M.
Published: June 2020

Symptoms of gastroesophageal reflux disease (GERD) are frequent in patients with clinically significant obesity and are reported to improve after Roux- en-Y gastric bypass (RYGB). The purpose of this study is to determine timing and duration of improvement of GERD symptoms in patients undergoing RYGB. Prospectively collected data from patients who underwent RYGB from January 1998 to August 2004 were analyzed. Patients answered a standardized questionnaire pre- and postoperatively inquiring about frequency of GERD symptoms (none, one episode/week, one episode/day, more than one episode/day) and medication use. Of 606 patients undergoing RYGB, 239 patients (39%) reported GERD symptoms preoperatively (mean age 43 ± 1 years; body mass index 51 ± 1 kg/m2). Of these, 89 per cent of patients reported improved at 3 months post-op and 94 per cent of patients 9 months post-op ( P < 0.001). Medication usage decreased from 30 per cent to 3 per cent by 3 months and 5 per cent beyond 9 months ( P < 0.001). Percentage of excess weight loss was 18 ± 1 per cent and 75 ± 2 per cent at 3 and 9 months, respectively. Symptoms of GERD significantly improve and use of antireflux medications is reduced after RYGB independent of weight loss. RYGB may be the treatment of choice for GERD in obese patients.
Selective Use of Intraoperative Touch Prep Analysis of Sentinel Nodes in Breast Cancer
Authors: Forbes Rachel C. , Pitchford Clovis , Simpson Jean F. , Balch Glen C. , Kelley Mark C.
Published: June 2020

Imprint cytology (touch prep) is often used for intraoperative examination of sentinel nodes in breast cancer. This allows axillary lymph node dissection (ALND) to be performed immediately for tumor-positive nodes. We evaluated the accuracy of touch prep examination of sentinel nodes and its role in the surgical treatment of breast cancer. We analyzed 169 breast cancer patients who underwent 170 lymphatic mapping procedures with intraoperative touch prep examination. Results from the touch prep were correlated with histopathology and clinical variables. There were 115 true-negative, 35 true-positive, 15 false-negative, and 5 false-positive results. Touch prep had a sensitivity of 70 per cent and specificity of 96 per cent. Positive predictive value, negative predictive value, and diagnostic accuracy were all 88 per cent. The false-negative rate was 30 per cent and correlated with the size of the nodal metastasis and number of involved nodes, but not other patient factors. Touch prep is useful for the evaluation of sentinel nodes in breast cancer, but it has a lower sensitivity than initially reported, particularly in patients with micrometastases. False positive results occur, although they may be reduced after experience with the technique. We recommend that suspicious findings on touch prep should be confirmed by frozen section and that ALND only be performed for histologically documented metastases. We currently perform touch prep only in patients who are at high risk of nodal metastasis or will undergo mastectomy. This improves operative efficiency and limits the impact of false positive and negative results without dramatically increasing the number of patients who require a second surgical procedure.
Secondary Abdominal Compartment Syndrome: Risk Factors and Outcomes
Authors: Britt R.C. , Gannon T. , Collins J.N. , Cole F.J. , Weireter L.J. , Britt L.D.
Published: June 2020

Secondary abdominal compartment syndrome (ACS), defined as intra-abdominal hypertension with associated pulmonary, renal, or hemodynamic compromise in the absence of preceding abdominal operation or injury, can markedly increase surgical morbidity and mortality. We performed a retrospective chart review of the physiologic parameters and outcomes of 10 patients with secondary ACS. Ten patients developed secondary ACS after aggressive resuscitation, at an average of 20.2 hours. Four of the patients sustained burns greater than 40 per cent, three of the patients had penetrating extremity trauma, one patient had blunt abdominal trauma, one patient was struck by lightning, and one patient developed a retroperitoneal bleed while on heparin. The average bladder pressure was 40.6. The average volume given in the first 24 hours was 33,001 cc (range, 12,400 to 69,000). The average base deficit at admission was -12 (range, +1 to -25). Seven of the 10 patients had decreased urine output. Nine of the 10 patients had decreased tidal volumes on pressure control ventilation. All 10 patients were hypotensive, with 7 of the 10 requiring vasopressors. Overall mortality was 60 per cent, with 43 per cent mortality for those decompressed. Prompt recognition and treatment are mandatory for survival of ACS. We recommend routine bladder pressure monitoring for patients with ongoing resuscitation greater than 500 cc/hr.
Blowdart Injury Resulting in Brown-Séquard plus Syndrome
Authors: Jones Frank K. , Babalola Femi , Eltayeb Osama , Teixeira Andre
Published: June 2020

This report presents an interesting and unusual case of an injury sustained from a blowgun dart. The dart penetrated zone 2 of the neck, resulting in a neurological deficit consistent with a variant of Brown-Séquard syndrome referred to as “Brown-Séquard plus syndrome.”
The Human Papillomavirus as a Possible Cause of Squamous Cell Carcinoma: A Case Study with a Review of the Medical Literature
Authors: Zhao Xian , Rasmussen Sara , Perry John , Kiev Jon
Published: June 2020

Human papillomavirus is a possible risk factor in the development of squamous cell carcinoma. We report the case of a 21-year-old African-American male who presented with coughing and shortness of breath. He had been treated with multiple cauteries and ablations for problems associated with HPV since childhood. A CT scan revealed bilateral cavitary lung lesions. These lesions were resected through staged thoracotomies and revealed synchronous squamous cell carcinomas.
Safety of Mediastinoscopy in Anatomical Variations of the Mediastinum: The Situs Inversus Syndrome
Authors: Mahmoud Ahmed , Pham Hien , Matolo Nathaniel , Shrivastava Deepak
Published: June 2020

Mediastinoscopy has been widely used by thoracic surgeons to evaluate the superior mediastinum since 1959. Large series of mediastinoscopy have been reported with very low morbidity and no mortality. Proper attention to surgical techniques and mediastinal anatomy are essential to maintain the safety of the procedure. Situs inversus totalis is exceedingly rare, but variations in mediastinal anatomy in this group of patients can render the procedure challenging for the thoracic surgeon. A case of mediastinoscopy in a situs inversus patient is presented with emphasis on anatomical variations of the mediastinum and technical pitfalls of the procedure in this rare group.
Metastatic Myxoid Liposarcoma in the Mesentery: What is Debated? Case Report and a Review of the Literature
Authors: Tomita Hiroyuki , Yamaguchi Kazuya , Matsuo Masayuki , Ohno Takatoshi , Nishimoto Yukata , Hirose Yoshinobu
Published: June 2020

Myxoid liposarcoma, unlike other types of liposarcoma, has an unusual propensity to metastasize to extrapulmonary sites including the abdominal cavity. Metastatic myxoid liposarcoma is an important condition because it may indicate distant micrometastatic disease. We report the case of a 47-year-old woman with a metastatic myxoid liposarcoma in the mesentery. Surgical excision with a tumor-free margin was achieved, but cardiac and liver metastases developed. We review the available literature and discuss what is still debated about this disease.
Stromal Tumors of the Small Bowel Causing Unexplained Melena: Report of Two Cases
Authors: Basso L. , Basile U. , Gabriele R. , Izzo L. , Silvestri A. , De Toma G.
Published: June 2020

Gastrointestinal stromal tumors (GISTs) of the small bowel are relatively rare and, therefore, both difficult to diagnose and treat. The authors present two cases of such tumors and review the various options for diagnosis and treatment.
Outcomes of Clinical and Surgical Assessment of Women with Pathological Nipple Discharge
Authors: Vargas Hernan I. , Vargas M. Perla , Eldrageely Kamal , Gonzalez Katherine D. , Khalkhali Iraj
Published: June 2020

There is no consensus about the diagnostic approach to pathologic nipple discharge (PND). We hypothesize that lactiferous duct excision (microdochectomy) or image-guided biopsy are safe and effective means of diagnosis of PND. Eighty-two patients with PND underwent history and physical exam followed by breast sonography and mammogram. Image-guided biopsy was done if imaging studies were positive, whereas microdochectomy was done if normal. Discharge was unilateral (96%), bloody (79%), and spontaneous (62%). The sensitivity, specificity, positive and negative predictive values for the detection of neoplasia were 0.07, 1.0, 1.0, and 0.4 for mammography and 0.26, 0.97, 0.91, and 0.48 for sonography, respectively. Tissue diagnosis revealed papillary lesion (57%), mammary duct ectasia (33%), breast cancer (5%), and inflammatory/infectious (5%) causes. Hemorrhagic discharge associated with pregnancy or infections was managed successfully without surgery. After a median follow-up of 18 months, no PND recurrence was seen, but one patient developed cancer in a different location after diagnosis of atypical ductal hyperplasia. In conclusion, imaging studies provide confirmatory information and a biopsy target when positive. Negative imaging does not reliably exclude neoplasia or malignancy. Microdochectomy provides a sensible and effective approach in the workup of patients with PND.
Open Reconstruction of Sizeable Ventral Hernias in the Laparoscopic Era
Authors: Pavlakis Emmanouil , Avgerinos Efthimios , Filippou Dimitrios , Pikoulis Emmanouil , Tsatsoulis Panagiotis , Skandalakis Panagiotis
Published: June 2020

The purpose of this study was to review our 15 years of experience in the repair of sizeable ventral hernias with a standardized open surgery technique, to evaluate the clinical outcome, and to assess the decreasing role of traditional surgical techniques in the laparoscopic era. A retrospective study has been conducted, including 200 patients operated for ventral hernia defects with a standardized underlay mesh implantation technique between 1990 and 2004. Their mean age was 62.6 (range 21–88) years and their mean BMI (body mass index) was 33.4 (range 22–69). Out of them, 56 per cent presented one to four major risk factors and 31.5 per cent had previously undergone ventral hernia repair surgery. The mean size of hernial defect was 135.2 (range 24–684) cm2. The mean follow-up was 43 (range 3–174) months. The overall major complication rate was 3.8 per cent and overall recurrence rate was 9.6 per cent. Our retrospective study confirms the safety and efficacy of open reconstruction in complex hernias. Prospective randomized homogenous trials with long-term follow-up are needed to provide us a better evidence-based approach. Minimal invasive surgery is favored but open reconstruction should still be considered as an alternative for sizeable ventral hernias management. A careful selection among patients for selecting the optimal technique is necessary.
Acute Pain and Narcotic Use Does Not Impair the Ability to Provide Informed Consent: Evaluation of a Competency Assessment Tool in the Acute Pain Patient
Authors: Lucha Paul A. , Kropcho Luisa , Schneider James J. , Francis Michael
Published: June 2020

Patients evaluated in acute pain will often have narcotics withheld until after the patient has been evaluated by a surgeon and has given informed consent. Concern that the patient would have impaired judgment due to narcotic effects often prevents the administration of timely pain relief. The Hopkins Competency Assessment Tool (HCAT) is a validated instrument for both psychiatric and medical patients; it has not been validated to evaluate drug effects on judgment. Thirty consecutive patients agreed to participate in the trial over a 12-month period. The HCAT was administered prior to the planned major elective procedure and repeated on each postoperative day up to and including postoperative day 5. Narcotic use (as morphine equivalents), HCAT scores, demographic data, and surgical procedures were recorded. The average age of our patients was 53 years. Twenty-seven patients passed the initial HCAT, and one patient failed subsequent exams. No correlation was seen between HCAT score and narcotic dose. Narcotic administration sufficient for pain control does not impair the ability to provide informed consent. The only patient who failed the HCAT after an initial passing score was somnolent on the narcotic dose.
Radical Resection in Signet Ring Carcinoma of the Ampulla of Vater: Report of an 11-Year Survivor
Authors: Bloomston Mark , Walker Michael , Frankel Wendy L.
Published: June 2020

Carcinomas of the ampulla of Vater are uncommon tumors but have a better prognosis than typical pancreatic cancers. They tend to be well or moderately differentiated while the poorly differentiated variants are still quite aggressive. Signet ring features associated with poor differentiation traditionally confer a dismal prognosis in other gastrointestinal malignancies, particularly gastric cancer. Signet cell ring morphology has only been described in a few ampullary carcinomas with all cases reporting short follow-up. We describe a 58-year-old woman who presented with painless jaundice and a prominent ampulla of Vater by endoscopy. She underwent pancreaticoduodenectomy and was found to have a 1.0 x 0.8 cm poorly differentiated carcinoma with prominent signet ring cell features arising from the ampulla of Vater and invading into the periampullary duodenum but sparing the pancreatic parenchyma. No distant or nodal metastases were seen (pT2N0M0). No adjuvant therapy was given, and the patient remains free of disease with 134 months of follow-up.
Laparoscopic Nissen fundoplication offers High Patient Satisfaction with Relief of Extraesophageal Symptoms of Gastroesophageal Reflux Disease
Authors: Rakita Steven , Villadolid Desiree , Thomas Ashley , Bloomston Mark , Albrink Michael , Goldin Steven , Rosemurgy Alexander
Published: June 2020

Nissen fundoplication is applied for patients with gastroesophageal reflux disease (GERD), usually because of symptoms of esophageal injury. When presenting symptoms are extraesophageal, there is less enthusiasm for operative control of reflux because of concerns of etiology and efficacy. This study was undertaken to evaluate the efficacy of laparoscopic Nissen fundoplication in palliating extraesophageal symptoms of GERD. Patients were asked to score their symptoms before and after laparoscopic Nissen fundoplication on a Likert scale (0 = never/none to 5 = always/every time I eat). A total of 322 patients with extraesophageal symptoms (asthma, cough, gas/bloat, chest pain, and odynophagia) of 4 to 5 were identified and analyzed. After fundoplication, all extraesophageal symptom scores improved (P < 0.0001 for all, Wilcoxon matched-pairs test). Likewise, postoperative symptoms were noted to be greatly improved or resolved in 67 per cent to 82 per cent of patients for each symptom. Furthermore, after fundoplication, patients were less likely to modify their dietary (82% vs 49%) or sleeping habits (70% vs 28%) to avoid initiating/exacerbating symptoms. Although extraesophageal symptoms are conventionally thought to be inadequately palliated by surgery, this study documents excellent relief of extraesophageal symptoms after laparoscopic Nissen fundoplication, denotes high patient satisfaction, and encourages application of laparoscopic Nissen fundoplication.
Appendiceal Diverticulitis
Authors: Kabiri Hamed , Clarke Leon E. , Tzarnas Chris D.
Published: June 2020

The incidence of appendiceal diverticulitis in pathologic specimens is 0.004 to 2.1 per cent and is unusual in younger patients. Despite being first described in 1893, this condition is commonly dismissed by surgeons and pathologists as a variant of true appendicitis. However, appendiceal diverticulitis is a discrete clinical process that must be considered in the appropriate setting because of the much higher risk of perforation. The average age is older, the pain is often intermittent, and although it can be localized in the right lower abdominal quadrant, it is of longer duration. Although no further treatment in addition to appendectomy is needed, it is important that surgeons be aware of this condition, as the clinical presentation can be different from the classical acute appendicitis picture. Patients often seek medical treatment much later than those with classic appendicitis, and if there is a delay in establishing the correct diagnosis, perforation within the mesentery is found at the time of operation. Also, it is often mistakenly identified as carcinoma and it has higher rate of perforation and a longer convaslescence. We describe a case of a 42-year-old man and review the literature.
Adrenalectomy for Bilateral and Recurrent Pheochromocytoma: Increased Intraoperative Risk?
Authors: Gockel Ines , Heintz Achim , Roth Walter , Junginger Theodor
Published: June 2020

Adrenalectomy for pheochromocytoma is per se associated with a specific intraoperative cardiovascular risk caused by catecholamine secretion during manipulation of the tumor. Bilateral or multiple, and recurrent chromaffine tumors are special subentities with a potentially more intensified and longer surgical preparation. The aim of our study was to examine these effects on hemodynamic changes compared with those observed for primary, solitary tumors. Of the 82 studied interventions between February 1992 and May 2005, 58 were seen to involve primary, unilateral tumors, 17 involved bilateral (1 trilateral) findings, and there were 7 cases of recurrency. The hemodynamic changes related to primary, solitary pheochromocytomas revealed a higher frequency of intraoperative blood pressure crises (37%) compared with the comparative groups (11.8% in bilateral and 0% in recurrent tumors), as well as higher maximum pCO2 values noted. The intraoperative blood loss was more pronounced in interventions involving recurrencies. Aside from an appropriate preliminary therapy using an α-blocker and the careful surgical preparation of the adrenal gland, the different hemodynamic changes possibly may be related to the presence of smaller tumors in bilateral pheochromocytoma, as well as being based upon the already existent ligature of the draining vein in the event of recurrent procedures. The extent to which the adrenergic effect of the increased maximum pCO2 value plays a role on the development of higher maximum blood pressure values and more frequent intraoperative blood pressure crises continues to remain unclear.
Assessment of Early Tracheostomy in Trauma Patients: A Systematic Review and Meta-Analysis
Authors: Dunham C. Michael , Ransom Kenneth J.
Published: June 2020

The objective of this review was to assess outcomes in trauma patients undergoing early tracheostomy (ET). Abstract databases for the Eastern and American Associations for the Surgery of Trauma and Medline were searched to find trauma patient studies comparing ET and late tracheostomy (LT) or ET and no ET. Fixed-effects meta-analyses were performed on the randomized controlled trial (RCT) studies. Of five retrospective and four RCT studies, none demonstrated survival benefit or harm with ET (P > 0.05). In five RCT studies of ET and no ET, ET pneumonia rates were similar to the no ET group (relative risk 1.00 [95% confidence intervals 0.88–1.15], P = 0.97). In five RCT studies of ET and no ET, ET ventilator/intensive care unit (ICU) days were similar to the no ET group (P = 0.27). In the two severe brain injury studies, ET ventilator/ICU days were lower than the no ET group (P = 0.06). In the three nonbrain injury studies, ET ventilator/ICU days were similar to the no ET group (P = 0.79). Five studies described similar laryngotracheal pathology rates with ET and no ET or LT (P > 0.05). In conclusion, ET has no influence on mortality, pneumonia, or laryngotracheal pathology rates in trauma patients. Patients with severe brain injury may be more rapidly liberated from mechanical ventilation with ET. However, additional research is needed.
Correlation of Clinical Findings and Autopsy Results after Fatal Injury from Motor Vehicular-Related Crashes
Authors: Shen Luke Y. , Marcotte Kendra N. , Helmer Stephen D. , Dudley Mary H. , Smith R. Stephen
Published: June 2020

In the past, autopsy served as the gold standard to document diagnostic accuracy. Although a valuable contributor to medical education, information collected from autopsies is frequently delayed and poorly used. The purpose of this study was to determine the degree of concordance between clinical findings and autopsy results of trauma patients involved in fatal vehicular-related crashes. A 10-year retrospective review of trauma patients involved in fatal vehicular-related crashes who subsequently had an autopsy performed was conducted at an American College of Surgeons-verified Level I trauma center. The clinical record, trauma registry data, and autopsy results were reviewed. Degree of concordance was evaluated using the Goldman Type Errors Criteria. A total of 207 decedents were included (mean age, 41; 63% male; median Glascow Coma Scale score, 3; median Injury Severity Score, 37). The majority (69.6%) of decedents were injured in motor vehicle crashes. Total treatment time was <15 minutes in 29.0 per cent of cases, <6 hours in 59.4 per cent of cases, and <24 hours in 73.9 per cent of cases. Location of death was the emergency department (43.0%), the intensive care unit (49.8%), the operating room (5.4%), and the nursing floor (1.0%). There were no Goldman Class I or IV type errors, (i.e., no major or minor discrepancies, respectively, that may have altered therapy or survival of the patient). Following ATLS-based protocols results in appropriate identification of clinically significant injuries in patients involved in motor vehicular-related crashes. The routine use of autopsy results offers little additional information to a mature American College of Surgeons-verified Level I trauma program.