bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscopic Self-Expanding Metal Stents for Acute Colonic Obstruction
Authors: Tirosh Dan , Perry Zvi , Walfisch Shlomo , Rozental Alex , Fich Alex , Krugliak Pavel , Mizrahi Solly , Kirshtein Boris
Published: June 2020

The current study presents our experience with the introduction of self-expanding metal stents (SEMS) and assesses success rate, clinical outcomes, and complications. We conducted a historical cohort study reviewing endoscopic SEMS insertions between 2000 and 2010. Overall, 51 patients underwent stent insertion: 38 with an emergent procedure and 13 with a semielective procedure. SEMS was inserted in 27 men and 24 women with a mean age of 68.9 years. Colonic malignancy was the cause of obstruction in all patients. The tumors were localized in the rectosigmoid in 33 (64.7%), in the left colon in 16 (31.4%), and in the right colon in two cases (3.9%). Endoscopic SEMS insertion was technically successful in 68.4 per cent of patients in an emergency and in 84.6 per cent of patients in a semielective setting. Successful stent insertion allowed a “bridge to surgery” in 23 and palliative care in 14 patients. Stent migration occurred in three, obstruction in two, and bowel perforation in three cases. Nineteen patients in the emergent group underwent a subsequent successful semielective colonic resection within 8.1 days (range, 2 to 30 days) of stent insertion. There were two cases (11.1%) of major and four cases (22.2%) of minor postoperative complications in this series. No anastomotic leaks were observed. Mean postoperative hospitalization was 10.1 days (range, 5 to 45 days). Endoscopic stent insertion is a relatively simple procedure providing an effective first-line treatment for relief of symptoms of acute malignant colorectal obstruction, preventing acute perforation, and serving either as a preoperative procedure (allowing lower morbidity semielective surgery) or as palliative care.
Impact of Age and Comorbidity on the Short-Term Surgical Outcome after Laparoscopy-Assisted Distal Gastrectomy for Adenocarcinoma
Authors: Park Han-A , Park Seong-Heum , Cho Sung-Il , Jang You-Jin , Kim Jong-Han , Park Sung-Soo , Mok Young-Jae , Kim Chong-Suk
Published: June 2020

The aim of this study was to determine whether age and comorbidity are valuable risk factors of the short-term surgical outcome after laparoscopy-assisted distal gastrectomy (LADG) in patients with adenocarcinoma. A series of 387 patients who underwent LADG at three university hospitals between March 2006 and December 2010 were retrospectively studied. To compare the short-term surgical outcomes of LADG of elderly patients with those of younger patients, patients were categorized into an elderly group (older than 70 years of age) and a younger group (70 years of age or younger). For another comparative analysis to identify risk factors of postoperative complications after LADG, patients were categorized into two groups: those with complications and those without complications. With the exception of sex ratio and comorbidity rate, two age groups were nonsignificantly different in terms of demographic, operative, pathologic, and short-term surgical outcome data. Our data support the safety and feasibility of LADG in elderly patients. However, our data show that comorbidity is an important predictor of postoperative systemic complications after LADG. Patients with an age-adjusted Charlson comorbidity index (CCI) of 3 or greater were found to be at a greater risk of developing systemic complications, which suggests that age-adjusted CCI is a useful predictor of systemic complications after LADG and that it could be used routinely for the perioperative care of aged patients with comorbidity. We recommend age-adjusted CCI be used in comparative clinical research studies on the surgical outcomes across surgeons and hospitals.
Novel Prognostic Scoring System after Surgery for Klatskin Tumor
Authors: Kaiser Gernot M. , Paul Andreas , Sgourakis George , Molmenti Ernesto P. , DechÊNe Alexander , Trarbach Tanja , Stuschke Martin , Baba Hideo A. , Gerken Guido , Sotiropoulos Georgios C.
Published: June 2020

Klatskin tumor is a rare hepatobiliary malignancy whose outcome and prognostic factors are not clearly documented. Between April 1998 and January 2007, 96 patients with hilar cholangiocarcinoma underwent resection. Data were collected prospectively. Thirty-one variables were evaluated for prognostic significance. There were 40 trisectionectomies, 40 hemihepatectomies, five central hepatectomies, and 11 biliary hilar resections. Thirty-seven (n = 37) patients required vascular reconstruction. There were 68 R0, 26 R1, and two R2 resections. Age ( P = 0.048), pT status ( P = 0.046), R class ( P = 0.034), and adjuvant chemoradiation ( P = 0.045) showed predictive significance by multivariate Cox proportional hazard regression analysis. A point scoring system was determined as follows: age younger than 62 years:age 62 years or older = 1:2 points; pT1:pT2 to 4 = 1:2 points; R0:R1/2 = 1:2 points; and chemoradiation yes:no = 1:2 points. The only model that reached statistical significance ( P = 0.0332) described the following three groups: score 6 or less; score = 7; and score = 8. Median survival for score 6 or less, score = 7, and score = 8 was 26.5, 12, and 2.2 months, respectively ( P = 0.032). The corresponding 1- and 3-year survival rates were 73 to 56 per cent, 52 to 38 per cent, and 17 to 0 per cent, respectively. We propose a scoring system predictive of long-term surgical outcome that could potentially improve patient selection for further postoperative oncologic treatment for Klatskin tumors.
Variations of Urinary Bladder and the Urogenital Fatty Fascial Compartment with Different Filling of the Bladder are Notable Factors Relevant to Hernia Repair-Related Bladder Injury
Authors: Jiang Zhi-Peng , Wang Dong-Ye , Lai Dong-Ming , Zhou Quan-Bo , Zhang Yu-Chao , Yang Bin , Chen Shuang
Published: June 2020

The present study investigated bladder and urogenital fatty fascial compartment (UFFC) variations during bladder filling in an attempt to identify other possible causes of hernia repair-related bladder injury besides mesh migration. The study included 30 patients scheduled for abdominal computed tomography (CT) scan for nonhernia diseases. Sixty-four-slice CT scan was performed immediately after urination and no more than 30 minutes later. Three-dimensional images were constructed by two independent experienced readers. The empty bladder was triangular in shape, narrow in the front and broad in the rear. Its vertex deviated from midline of the abdominal wall in 11 cases (36.7%). With normal filling, it appeared as an irregular oval shape. Only two cases (6.7%) of empty bladder extended inside Hesselbach's triangle. However, this area was occupied to some extent in all cases during bladder filling ( P = 0.003). The UFFC formed a molar-like structure in cross-section. In three dimensions, it appeared as an inverted V-shaped structure from the front. In the lateral view it appeared as a spoon that contained the bladder. UFFC volume increased from 61.85 ± 6.23 to 139.23 ± 5.29 cm3 with bladder filling ( P < 0.0001). The UFFC can be clearly identified by CT scanning or three-dimensional reconstruction. The considerable spatial variation of the UFFC and movement and deformation of the mesh within this area may be related to bladder injury.
‘Let's Just Wait One More Day': Impact of Timing on Surgical Outcome in the Treatment of Adhesion-Related Small Bowel Obstruction
Authors: Joseph Sigi P. , Simonson Mike , Edwards Christopher
Published: June 2020

Controversy exists but most surgeons agree that surgical treatment for failed conservative management of adhesion-related small bowel obstruction (SBO) should be within 48 hours. However, many find themselves delaying definitive treatment in the hopes of resolution. Our aim was to determine what impact timing has on surgical outcomes of SBO. A retrospective review of all consecutive patients surgically treated for adhesion-related SBO was performed from January 2001 to August 2006. Study groups included patients treated emergently (less than 6 hours), ex-peditiously (6 to 48 hours), and delayed (greater than 48 hours). Laparoscopic, open, and converted treatment types were controlled for as confounding variables using analysis of variance. Outcome measures were return of bowel function after surgery (RBF), length of stay after surgery (LOS), and morbidity. There were 27 emergencies, 30 treated expeditiously, and 34 delayed. Groups were matched in age and gender. RBF after surgery was significantly longer for those delayed in treatment compared with those treated expeditiously (greater than 48 hours = 7.4 days vs less than 6 hours = 7.6 and 6 to 48 hours = 5.4; P < .05) as well as LOS after surgery (greater than 48 hours = 12.3 days vs less than 6 hours = 10.1 and 6 to 48 hours = 7.6; P < 0.05). Patients treated with laparoscopy within 6 to 48 hours had a significantly shorter RBF and LOS than any other combination of timing and treatment. Postoperative morbidity was higher in the delayed group (79%) than the other groups (44% emergent and 40% expeditious) ( P < 0.05). There was one death in the delayed group. Delaying surgical treatment beyond 48 hours for SBO is common and results in worse outcomes and longer LOS. Laparoscopic treatment within 48 hours is superior to open treatment.
History of the Department of Surgery at Albany Medical Center
Authors: Conti David J. , Lempert Neil , Stain Steven C.
Published: June 2020

Surgeons have always played an integral role in the history of the Albany Medical Center and Albany Medical College. In addition to supporting vital patient care and teaching programs, the Department of Surgery has played an important administrative role providing the college with five deans. The origins of the Department of Surgery reach back to 1910 when the American Medical Association-sponsored Flexner report proposed dramatic changes in the structure and format of medical education in the United States. In response to the recommendations of the report, the medical center restructured its faculty and curriculum to meet the demands of a rapidly advancing profession. One result of this reorganization was the formation of the Department of Surgery in 1912. Dr. Arthur Elting was named the first Chair of the Department in 1915. This report will review the history of the Department, focusing on the eight surgeons who have served as Chair.
The Differential Effects of Intermediate Complications with Postoperative Mortality
Authors: Borgi Jamil , Rubinfeld Ilan , Ritz Jennifer , Jordan Jack , Velanovich Vic
Published: June 2020

Most attempts at understanding perioperative mortality have been based on assessing individual patient risk factors, types of operations, and hospital characteristics. The hypothesis of this study is that there is a relationship between postoperative mortality and postoperative complications; therefore, understanding this relationship may provide a basis for prevention and rescue. Using the 2007 SemiAnnual National Surgical Quality Improvement Program Report, we obtained data for each reporting hospital's rates of observed mortality, overall observed morbidity, observed cardiac, respiratory, renal complications, venothromboemoblic events (VTEs), surgical site infections (SSIs), and urinary tract infections (UTIs). Simple and multiple linear regression analyses were done comparing absolute rate of observed mortality with absolute rate of observed morbidity and each morbidity group. One hundred ninety-seven hospitals were included in the study. There were statistically significant associations between observed mortality rates and observed morbidity rates, cardiac complications, respiratory complications, and VTE rates. Renal complications, SSIs, and UTIs showed no statistically significant association with observed morbidity. This study demonstrates that rates of observed morbidity, especially cardiac, respiratory, and VTE complications, are associated with observed mortality. These findings suggest that care providers should focus efforts at prevention and rescue of cardiac, respiratory, and VTE complications.
Transverse Incisions for Resection of Ileocolic Crohn's Disease
Authors: Campbell Michael J. , Paull Nathaniel B. , Thirlby Richard C.
Published: June 2020

Laparoscopic ileocecectomy is advocated as the ideal surgical approach for ileocecal Crohn's disease. Our experience suggests that equivalent outcomes are accomplished through a small right lower quadrant (RLQ) transverse incision in this patient population. We conducted a retrospective chart review of 39 patients undergoing ileocectomy for Crohn's disease using a RLQ transverse incision between 1991 and 2009. The mean operative time was 99 minutes with a mean length of hospital stay of 4.2 days and mean duration until return of bowel function of 2.9 days. There were no deaths or major complications. Long-term follow-up revealed four patients (13%) who required hospitalization for small bowel obstructions, one patient (3%) developed an incisional hernia, and no patients required an ileostomy. Ileocecectomy performed for Crohn's disease using a RLQ transverse incision yielded similar hospital lengths of stay and time to return of bowel function as those published for laparoscopic resection. This approach may result in shorter operative times when compared with the inexperienced surgeon performing a laparoscopic resection. Long-term follow-up revealed the risk for future RLQ ileostomy is low and the development of hernias or bowel obstruction is unlikely.
Safety and Effectiveness of Vessel Sealing for Dissection during Pancreaticoduodenectomy
Authors: Pointer David T. , Slakey Lauren M. , Slakey Douglas P.
Published: June 2020

Traditional pancreaticoduodenectomy dissection techniques are tedious and time-consuming. The LigaSure® Vessel Sealing System is an alternative to standard dissection methods. LigaSure® can be used in replace of ligatures, clips, and sutures in most of the pancreaticoduodenectomy procedure. The objective of this study was to examine our experience with LigaSure® in pancreaticoduodenectomies and to show the safety and time-effectiveness. Forty-three pancreaticoduodenectomies were performed by a single surgeon using the LigaSure® device in place of traditional dissection techniques. A retrospective chart review was conducted to evaluate patient management and outcome. Demographics, preoperative, intraoperative, and postoperative data were analyzed. The average patient age was 61 years. Primary pathologic diagnoses were: periampullary carcinoma (56%), chronic pancreatitis (5%), cystic lesion (26%), neuroendocrine tumor (7%), and other (5%). Our patient population demonstrated American Society of Anesthesiologists Class I (2%), Class II (14%), III (75%), and IV (9%). Average operative time was 4:11 hours. The study group required an average of 0.49 ± 1.35 units of blood. Eight patients (19%) received blood transfusion, receiving an average of 2.63 ± 2.13 units. Patients had a median hospital stay of 10 days (range, 5 to 41 days). An oral diet was ordered for most patients by Day 4. Fourteen patients (32.5%) had a complication, including two patients requiring additional surgery for drainage of abscess. There were no postoperative deaths. The use of LigaSure® is a practical and safe alternative to standard dissection techniques. Operative time, blood loss, and complication rate are favorable compared with published series.
Trauma Transfers and Definitive Imaging: Patient Benefit but at What Cost?
Authors: Quick Jacob A. , Bartels Ashley N. , Coughenour Jeffrey P. , Barnes Stephen L.
Published: June 2020

Many patients undergo computed tomography (CT) scan before transfer to definitive care. Despite this, studies are often repeated on arrival to the trauma center. We evaluated a policy to provide formal in-house interpretation of images performed at outside hospitals. A 3-month retrospective analysis was performed. Two groups were compared. Patients in the in-house interpretation (IHI) group underwent in-house interpretation of outside images. Those images not meeting criteria were placed in the comparison group without in-house radiologic interpretation. Demographics, CT scan data, billing and productivity loss, and extrapolated cancer risk reduction were analyzed. There were no significant differences in demographic or injury data. Fewer total CT scans were performed in the IHI group (223 vs 320, P = 0.04). The IHI group underwent fewer repeated CT scans (25 vs 62, P = 0.02; odds ratio [OR], 0.53). Fewer patients were exposed to repeat CT scans (17 vs 32; OR, 0.48). Total hospital billings decreased by $188,285 ($4,592/patient) in the IHI group. Uncaptured work relative value units totaled 152.19 (3.71/patient) in the IHI group. Radiation exposure decreased by 8 per cent. Use of outside hospital imaging as the definitive evaluation of injured patients is safe and results in an overall decrease in radiation exposure and healthcare cost.
Clinical Outcome Using the Fluency Stent Graft for Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension
Authors: Wu Xingjiang , Ding Weiwei , Cao Jianmin , Fan Xinxin , Li Jieshou
Published: June 2020

The objective of this study was to evaluate the clinical outcomes using the Fluency stent graft for transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension. From January 2008 to December 2011, 150 patients (110 male and 40 female with a mean age of 51 years) with portal hypertension underwent TIPS creation with the Fluency stent graft. Indications for TIPS treatment were variceal bleeding in 134 cases and refractory ascites in 16 cases. The clinical results pre- and postprocedure were evaluated. All 150 patients underwent a successful TIPS procedure without any technical complications. The portal pressure decreased from 24.3 ± 3.2 mmHg preoperatively to 15.1 ± 2.7 mmHg postoperatively ( P < 0.001), and the portal flow velocity increased from 18.3 ± 4.6 cm/s to 55.6 ± 15.8 cm/s ( P < 0.001). Emergency TIPS was performed in 18 patients with uncontrolled variceal bleeding. During hospitalization, the rates of shunt occlusion, hepatic encephalopathy, variceal rebleeding, and death were 1.3, 0.0, 1.3, and 2.0 per cent, respectively. At a mean follow-up of 24.1 ± 8.8 months, the rates of shunt occlusion, hepatic encephalopathy, variceal rebleeding, and death were 10.0, 15.3, 11.3, and 10.0 per cent, respectively. The main causes of death were hepatic failure, hepatic carcinoma, and recurrent variceal bleeding. The Fluency stent graft is effective in TIPS creation with high patency rates and improves the results of TIPS for portal hypertension.
Scalenus Minimus Muscle: Overestimated or Not? An Anatomical Study
Authors: Natsis Konstantinos , Totlis Trifon , Didagelos Matthaios , Tsakotos George , Vlassis Konstantinos , Skandalakis Panagiotis
Published: June 2020

The wide range of scalenus minimus muscle incidence reported in the literature along with the plethora of fibromuscular structures that may appear in the interscalene triangle, having various terminologies, were the reasons to conduct the present study questioning the reported high incidence of this supernumerary scalene muscle. Seventy-three Greek cadavers were dissected and examined for the presence of a scalenus minimus muscle. It was found unilaterally in three of 73 (4.11%) cadavers studied. The literature review, concerning its incidence, revealed a wide range between 7.8 and 71.7 per cent, which cannot be attributed only to racial variation. Thus, there is a matter whether other variations of the scalene muscles are considered as a true scalenus minimus muscle. Recognition of this muscle is important not only for anatomists, but also has clinical significance for the diagnosis of the thoracic outlet syndrome. Surgeons performing scalenectomy and anesthesiologists during interscalene brachial plexus block should keep in mind the anatomical variations of this region.
Sentinel Lymph Node Biopsy for Melanoma: Comparison of Lymphocele Rates by Surgical Technique
Authors: White Ian , Mills Jane K. , Diggs Brian , Fortino Jeanine , Ellis Michelle C. , Vetto John T.
Published: June 2020

Lymphocele is a common wound complication of sentinel lymph node biopsy (SLNB). The surgical technique may play a key role in lymphocele formation. This study compared rates of postoperative lymphocele formation by different surgical techniques (Harmonic Scalpel [HS], LigaSure [LS], and traditional electrocautery with clips) after SLNB in the groin or axilla for the staging of clinically node-negative cutaneous melanoma. Patients were selected by convenience sample from a single-institution, single-surgeon, prospectively collected melanoma database over a 27-month period. One hundred fifty consecutive patients underwent SLNB, 70 with clips, 37 with HS, and 43 with LS. The median number of nodes removed was two and did not vary significantly between groups. Twenty-three lymphoceles occurred for an overall rate of 15 per cent; rates were 9.9 and 26.5 per cent for the axilla and groin, respectively. Sixteen (70%) were aspirated for size or symptoms; lymphoceles after groin SLNB were significantly (P = 0.03) more likely to require aspiration. Lymphocele rates for the clip, HS, and LS groups were 20.0, 18.9, and 4.7 per cent, respectively. The differences between the LS and other groups were statistically significant. Use of the LS may lead to lower lymphocele rates after groin and axillary SLNB compared with electrocautery and clips.
Change in Hematocrit during Trauma Assessment Predicts Bleeding Even with Ongoing Fluid Resuscitation
Authors: Thorson Chad M. , Ryan Mark L. , Van Haren Robert M. , Pereira Reginald , Olloqui Jeremy , Otero Christian A. , Schulman Carl I. , Livingstone Alan S. , Proctor Kenneth G.
Published: June 2020

This study tests the hypothesis that a change in hematocrit (ΔHct) during initial trauma work-up is as reliable as conventional vital signs for detecting bleeding, even with ongoing fluid resuscitation. Consecutive trauma patients admitted to a Level I trauma center receiving two Hct measurements during initial resuscitation between January 2010 and January 2011 were stratified based on estimated blood loss greater than 250 mL (bleeding) or nonbleeding. Sensitivity, specificity, and receiver operating characteristic curves were calculated for systolic blood pressure (SBP), heart rate, base deficit, and ΔHct. In 168 (72%) nonbleeding versus 64 (28%) bleeding patients, age and gender were similar. Arrival SBP was highly specific (90 to 99%) but poorly sensitive (13 to 31%) for detecting bleeding. Combinations of vital signs increased specificity, albeit at the expense of sensitivity. For bleeding versus nonbleeding patients (all receiving resuscitation fluid), ΔHct was 9.0 versus 1.8, ΔHct/liter was 4.8 versus 1.5, and ΔHct/liter/hour was 2.8 vs 0.6 (all P < 0.001). Only SBP (area under the curve [AUC] 0.608 to 0.695) and ΔHct (AUC 0.731 to 0.921) were significant for identifying bleeding with ΔHct 6 or greater being the best predictor (sensitivity 89%, specificity 95%, AUC 0.921). During ongoing fluid resuscitation of a trauma victim, ΔHct is the single most reliable indicator of continuing blood loss. A ΔHct 6 or greater during initial resuscitation is highly suspicious for ongoing blood loss, but even lesser changes have predictive value. Altogether, these results support the idea that fluid shifts are rapid after hemorrhage and Hct can be valuable during initial trauma assessment.
Video-assisted Laparoscopic Débridement for Retroperitoneal Pancreatic Collections: A Reliable Step-up Approach
Authors: García-Ureña Miguel Ángel , López-Monclús Javier , Melero-Montes Daniel , Blázquez-Hernando Luis Alberto , Castellón-Pavón Camilo , Calvo-DurÁN Enrique , Gordo-Vidal Federico , Aguilera-Del Hoyo Luis Felipe
Published: June 2020

Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.
Retropancreatic Retroperitoneal Tumors: A 30-year Experience with 38 Cases
Authors: Zhang Tao-Tao , Guo Ke-Jian , Ma Gang , Song Shao-Wei
Published: June 2020

Retropancreatic retroperitoneal tumors (RRTs) are seldom encountered in clinical practice. The lack of characteristics on clinical presentation and imaging make preoperative diagnosis difficult and surgical management remains a challenge. This retrospective report surveys the presenting diagnosis and surgical management of 38 patients with RRTs presenting at our center between August 1981 and May 2012. Six patients were misdiagnosed on the basis of computerized tomography and one each by magnetic resonance imaging and magnetic resonance cholangiopancreatography. Tumors were localized posterior to the pancreatic head and uncinate process (n = 18); posterior to the neck and body of the pancreas (n = 9); or posterior to the body and tail of the pancreas (n = 11). Thirty-three patients underwent surgical resections. Operative approaches were chosen on the basis of tumor size and localization. The tumors were mostly commonly originating from neurogenic tissue (n = 16). There were 25 benign neoplasms (65.8%), 10 malignant tumors (26.3%), and three undefined tumors. The morbidity of postsurgical complications was 21 per cent (eight of 38). The number of patients who underwent follow-up was 21, and the mean follow-up time was 35 months (range, 2 to 90 months). Three patients died during follow-up. The morbility of local recurrence was 10.5 per cent (four of 38). Definitive diagnosis of RRTs is made at laparotomy. Complete resection remains the fundamental objective of disease management. Different operative approaches should be used according to tumor localization and size.
Risk Factors Associated with Venous Thromboembolism in Isolated Blunt Chest Trauma
Authors: Kahn Steven A. , Schubmehl Heidi , Stassen Nicole A. , Sangosanya Ayodele , Cheng Julius D. , Gestring Mark L. , Bankey Paul E.
Published: June 2020

Isolated chest trauma is not historically considered to be a major risk factor for venous thromboembolism (VTE). After blunt chest trauma, VTE may be underappreciated because pain, immobility, and inadequate prophylaxis as a result of hemorrhage risk may all increase the risk of VTE. This investigation determines the predictors and rate of VTE after isolated blunt chest trauma. A review of patients admitted to a Level I trauma center with chest trauma between 2007 and 2009 was performed. Demographics, injuries, VTE occurrence, prophylaxis, comorbidities, Injury Severity Score, intensive care unit/hospital length of stay, chest tube, and mechanical ventilation use were recorded. VTE rate was compared between those with isolated chest injury and those with chest injury plus extrathoracic injury. Predictors of VTE were determined with regression analysis. Three hundred seventy patients had isolated chest trauma. The incidence of VTE was 5.4 per cent (n = 20). The VTE rate in those with chest injury plus extrathoracic injury was not significantly different, 4.8 per cent (n = 56 of 1140, P = 0.58). Independent risk factors for VTE after isolated chest trauma were aortic injury ( P < 0.01, odds ratio [OR], 47.7), mechanical ventilation ( P < 0.01; OR, 6.8), more than seven rib fractures ( P < 0.01; OR, 6.1), hemothorax ( P < 0.05; OR, 3.9), hypercoagulable state ( P < 0.05; OR, 6.3), and age older than 65 years ( P < 0.05; OR, 1.03). Patients with the risk factors mentioned are at risk for VTE despite only having thoracic injury and might benefit from more aggressive surveillance and prophylaxis.
Length of Nonoperative Treatment and Risk of Pleural Empyema in the Management of Pancreatitis-induced Pancreaticopleural Fistula
Authors: Schweigert Michael , Solymosi Norbert , Dubecz Attila , Ofner Dietmar , Stein Hubert J.
Published: June 2020

Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Initial conservative treatment fails in a significant number of cases. Ascending infection through the fistulous tract results in pleural empyema. The aim of this study is to investigate the relation between lengths of nonoperative management and risk of pleural empyema. The retrospective study includes our own experience as well as all case reports identified by a systematic review of the English literature from 1954 to 2012. Inclusion criteria were acute or chronic pancreatitis, whereas tumorous fistulization or complications of pancreatic surgery were kept out. A total of 113 patients were identified. There were 86 men and 27 women. The mean age was 46.5 years and 78 patients had a history of alcoholism. The mortality rate was 1.8 per cent (two of 113). Non-operative management including interventional therapy and endoscopic stenting was successful in only 40 cases (36%), whereas 73 patients (64%) finally underwent surgery. The most common procedure was distal pancreatectomy (32 of 73). Pleural empyema occurred in 17 cases. Successful nonoperative management had a mean length of 5.5 weeks, whereas surgery was performed after an average of 10.9 weeks of failed conservative efforts. Initial nonoperative therapy was significantly longer in patients eventually sustaining empyema (17 weeks, P < 0.001) and all needed surgical intervention. Prolonged nonoperative treatment is associated with a noteworthy risk of septic complications such as pleural empyema. Further improvement seems achievable by reducing the time gap between fruitless conservative efforts and surgical intervention.
Postoperative Quality of Life after Open Transinguinal Preperitoneal Inguinal Hernia Repair Using Memory Ring or Three-dimensional Devices
Authors: Williams Kristopher B. , Bradley Joel F. , Wormer Blair A. , Zemlyak Allay , Walters Amanda L. , Colavita Paul D. , Lincourt Amy E. , Tsirline Victor B. , Belyansky Igor , Heniford B. Todd
Published: June 2020

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m2. MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different ( P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD ( P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation ( P = 0.02); 28.7 versus 14.8 per cent had movement limitations ( P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.
Times and Trends in the Treatment of Spontaneous Perforation of the Esophagus: From Herman Boerhaave to the Present Age
Authors: Schweigert Michael , Dubecz Attila , Solymosi Norbert , Ofner Dietmar , Stein Hubert J
Published: June 2020

Spontaneous rupture of the esophagus is a rare devastating condition, which was first described by Herman Boerhaave in 1724. Only a handful of cases were recorded during the 18th and 19th centuries. Diagnosis was usually obtained on autopsy. Only in 1914 Irving Walker achieved the first antemortem diagnosis of spontaneous rupture of the esophagus. The dawn of thoracic surgery during the first decades of the 20th century opened up the way for operative cure. More than 200 years after Boerhaave's initial report, Barrett as well as Clagett and Olsen independently accomplished the first successful surgical treatment by primary repair of the esophageal lesion in 1947. Since those pioneer days, various suggestions for proper treatment have been made ranging from conservative, nonoperative means to extended procedures such as esophagectomy. Invention of minimally invasive surgery and endoscopic measures has further broadened the spectrum of available therapeutic options. The aim of this history article is to outline the development of diagnosis and management of spontaneous rupture of the esophagus from the age of Herman Boerhaave to the present times.
Multi-institutional Comparison of Helicopter Transfers Directly to the Operating Room versus the Pit Stop in the Emergency Department
Authors: Van Der Wilden Gwendolyn M. , Janjua Sumbal , Wedel Suzanne K. , Agarwal Suresh , Shapiro Mark L. , Andersen Nicholas D. , Odom Stephen R. , Gates Jonathan D. , Frakes Michael A. , Chang Yuchiao , Velmahos George C. , Alam Hasan B. , King David R. , Moya Marc A. De
Published: June 2020

Presented September 24, 2011, at the 92nd annual meeting of the New England Surgical Society, September 23–25, 2011, Mt. Washington, New Hampshire.
Postmastectomy Reconstruction is Associated with Improved Survival in Patients with Invasive Breast Cancer: A Single-institution Study
Authors: Baker Jennifer L. , Mailey Brian , Tokin Christopher A. , Blair Sarah L. , Wallace Anne M.
Published: June 2020

Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.
Exploring Potential Use of Internet, E-mail, and Instant Text Messaging to Promote Breast Health and Mammogram Use among Immigrant Hispanic Women in Los Angeles County
Authors: Dang Catherine M. , Estrada Sylvia , Bresee Catherine , Phillips Edward H.
Published: June 2020

Breast cancer is now the leading cause of death in Hispanic women (HW). Internet, e-mail, and instant text messaging may be cost-effective in educating HW about breast health and in reducing breast cancer mortality. We surveyed 905 HW women attending a free health fair about their technology use, acculturation, insurance status, mammography use, and breast cancer knowledge. Data were analyzed by t test or χ2 tests. Mean age was 51.9 ± 14.2 years (range, 18 to 88 years). Ninety-two per cent were foreign-born. Most had completed some high school (39%) or elementary (38%) education. Most (62%) were uninsured. The majority spoke (67%) and read (66%) only Spanish. Only 60 per cent of HW older than 40 years had a recent mammogram. HW older than 40 years who had not had a recent mammogram were younger (mean 54.9 ± 10.8 vs 58 ± 10.4 years) and less likely to have health insurance (25 vs 44%; P < 0.001). Most HW never use the Internet (58%) or e-mail (64%). However, 70 per cent have mobile phones (66% older than 40 years), and 65 per cent use text messaging daily (58% older than 40 years, P = 0.001). In fact, 45 per cent wish to receive a mammogram reminder by text. Text messaging may be an inexpensive way to promote breast health and screening mammography use among uninsured HW.
Seatbelt Sign as an Indication for Four-vessel Computed Tomography Angiogram of the Neck to Diagnose Blunt Carotid Artery and Other Cervical Vascular Injuries
Authors: Dhillon Ramandeep Singh , Barrios Cristobal , Lau Cecilia , Pham Jacqueline , Bernal Nicole , Kong Allen , Lekawa Michael , Dolich Matthew
Published: June 2020

Computed tomography angiography (CTA) of the neck has become the most common modality for diagnosing blunt carotid artery injury (BCAI). The protocol at our institution includes CTA on trauma patients with a seatbelt sign. The purpose of this study is to evaluate whether a solitary seatbelt sign is an indication for CTA of the neck to diagnose BCAI. We conducted a retrospective review of patients from 2000 to 2010 who received CTAs as a result of a seatbelt sign performed at our Level I trauma center. Four hundred eighteen patients received CTAs based on the presence of a seatbelt sign. Two hundred twenty-six had skeletal injuries, obvious soft tissue injuries, and/or positive findings on imaging, including 11 positive vascular findings with two BCAIs found. Patients with noncarotid vascular injuries on CTA had a higher Injury Severity Score than patients with solitary seatbelt signs (11.4 ± 7.6 vs 3.4 ± 4.2, P < 0.01). The correlation between seatbelt sign and positive finding on CTA was weak ( r = 0.007). Patients with vascular findings on CTA also had obvious hard/soft tissue injuries and/or positive findings on standard trauma imaging. This suggests that a protocol for CTA of the neck for patients with a seatbelt sign can be reserved for those with associated injuries on physical examination and/or findings on standard trauma imaging.
Can the Need for Colectomy after Computed Tomography-guided Percutaneous Drainage for Diverticular Abscess be Predicted?
Authors: Felder Seth I. , Barmparas Galinos , Lynn Juliane , Murrell Zuri , Margulies Daniel R. , Fleshner Phillip
Published: June 2020

The primary aim of this study was to define predictors of computed tomography (CT)-guided percutaneous abscess drainage treatment failure in complicated diverticulitis. A 10-year retrospective analysis of inpatients seen in surgical consultation for diverticular abscess management subsequently referred for CT-guided percutaneous drainage (PD) was conducted. The clinical courses of patients undergoing a technically successful PD were categorized into three groups: 1) no colectomy; 2) elective colectomy; and 3) nonelective colectomy. Forty study patients were identified. Thirteen (33%) of the 40 patients required a nonelective colectomy, 20 patients (50%) underwent elective resection, and seven patients (18%) have been managed nonoperatively with no recurrent diverticulitis for a median of 46.8 months (range, 3.2 to 84.3 months). Forward logistic regression identified the presence of immunosuppression or renal insufficiency (creatinine 1.5 mg/dL or greater) as factors independently associated with failure of PD and need for non-elective colectomy. No clinical, laboratory, or radiologic variables were predictive of long-term nonoperative success. Although PD allows for the resolution of intra-abdominal sepsis for most cases of diverticulitis complicated by an abscess, a substantial proportion progress to nonelective colectomy, emphasizing the need for clinical vigilance in follow-up.
Introspection into Institutional Database Allows for Focused Quality Improvement Plan in Cardiac Surgery: Example for a New Global Healthcare System
Authors: Lancaster Elizabeth , Postel Mackenzie , Satou Nancy , Shemin Richard , Benharash Peyman
Published: June 2020

Reducing readmission rates is vital to improving quality of care and reducing healthcare costs. In accordance with the Patient Protection and Affordable Care Act, Medicare will cut payments to hospitals with high 30-day readmission rates. We retrospectively reviewed an institutional database to identify risk factors predisposing adult cardiac surgery patients to rehospitalization within 30 days of discharge. Of 2302 adult cardiac surgery patients within the study period from 2008 to 2011, a total of 218 patients (9.5%) were readmitted within 30 days. Factors found to be significant predictors of readmission were nonwhite race ( P = 0.003), government health insurance ( P = 0.02), ejection fraction less than 40 per cent ( P = 0.001), chronic lung disease ( P < 0.001), and hospital length of stay greater than 7 days ( P = 0.02). Patients undergoing aortic and mitral valve operations had an increased risk of readmission compared with other cardiac operations ( P < 0.001). The most common reasons for rehospitalization were pneumonia and other respiratory complications (n = 27 [12.4%]). Recognition of risk factors is crucial to reducing readmissions and improving patient care. Our data suggest that optimizing cardiopulmonary status in patients with comorbidities such as heart failure and chronic obstructive pulmonary disease, increasing directed pneumonia prophylaxis, patient education tailored to specific patient social needs, earlier patient follow-up, and better communication between inpatient and outpatient physicians may reduce readmission rates.
Choledochoduodenostomy as the Biliary–Enteric Bypass of Choice for Benign and Malignant Distal Common Bile Duct Strictures
Authors: Luu Carrie , Lee Byrne , Stabile Bruce E.
Published: June 2020

Choledochoduodenostomy (including hepaticoduodenostomy) for common bile duct (CBD) strictures has been underused because of concerns regarding postoperative duodenal fistula and cholangitis attending the so-called “sump syndrome.” An institutional retrospective review of 55 consecutive choledochoduodenostomy procedures for CBD strictures from 1995 to 2011 was performed to examine its suitability as the biliary–enteric bypass procedure of choice. There were 30 male (55%) and 25 female (45%) patients with a mean age of 49 years (range, 13 to 73 years). Thirty-seven (67%) patients had benign CBD strictures and 18 (33%) had unresectable periampullary adenocarcinomas. Forty-nine (89%) underwent choledochoduodenostomy and six (11%) underwent hepaticoduodenostomy. There were no 30-day postoperative deaths, anastomotic leaks, or intra-abdominal abscesses. Five patients (9%) sustained Clavien Grade III or IV complications. Over a mean long-term follow-up of 29 months (range, 1 to 162 months), there was one anastomotic stricture successfully managed by endoscopic dilation and temporary stenting. Liver function tests in all other patients returned to and remained within normal limits. We conclude that choledochoduodenostomy is the preferred biliary–enteric bypass for both benign and malignant distal CBD strictures because of its ease, safety, and durability. Persistent fears of duodenal fistula and the “sump syndrome” are not warranted by the empiric data and should be abandoned.
A Unique Use of Intraoperative Digital Specimen Radiography in the Treatment of Primary Hyperparathyroidism
Authors: Saguan Nicholas , Recabaren James
Published: June 2020

Intraoperative evaluation of primary parathyroid specimens historically has been difficult. Frozen section diagnosis is not reliable and time-consuming. A visible rim of compressed normal parathyroid tissue is seen histologically surrounding a parathyroid adenoma and absent in parathyroid hyperplasia. Adjuncts such as radionuclide scanning and intraoperative parathyroid hormone levels help but are indirect methods of evaluation. Intraoperative digital specimen radiography (IDSR) of specimens is a novel technique that was compared with frozen section analysis. The study spanned a 12-month period. Thirty-six patients with primary hyperparathyroidism met eligibility criteria. Resected parathyroid specimens were evaluated with the Bioptics PiXarray100 digital radiograph system and pathologic evaluation. Thirty-nine specimens were evaluated with IDSR, reflecting three patients with multiple glands excised. Thirty patients were pathologically found to have adenomas (83%) and six were hyperplasia (17%). Twenty-seven of 30 adenoma specimens had an IDSR visible rim of compressed tissue (sensitivity 90%) and no hyperplasia specimens had an IDSR visible rim (specificity 100%). Fisher's exact test was significant ( P = 0.000). Frozen section correctly diagnosed adenoma in only 16 of 30 specimens (sensitivity 53%). IDSR of parathyroid specimens is a powerful modality in the real-time differentiation of parathyroid adenomas from hyperplasia (sensitivity 90%). This technique is noninferior to the current “gold standard,” frozen section (sensitivity 53%). We propose IDSR evaluation of all parathyroid surgical specimens for the immediate diagnosis of adenoma versus hyperplasia.
Total Thyroidectomy as Primary Definitive Treatment for Graves’ Hyperthyroidism
Authors: Snyder Samuel , Govednik Cara , Lairmore Terry , Jiang Da-Shu , Song Juhee
Published: June 2020

The objective of this study was to compare the results of total thyroidectomy (TT) for hyperthy-roidism secondary to Graves’ disease (GD) with TT for other benign thyroid diseases to determine if TT should be considered more often as first-line therapy for GD. Seven hundred eighty patients underwent TT for benign disease: 203 for GD, 56 for other hyperthyroidisms, and 521 for other benign diseases from March 1, 2003, to December 31, 2009. The perioperative results of these three groups were compared for demographics, blood loss, operative time, complications, and hospitalization. There were no significant differences among the three groups except the patients with GD were more likely to be younger (42 vs 56 vs 57 years; P < 0.001), have more blood loss (154 vs 99 vs 110 mL; P = 0.05), and were more likely to develop permanent hypoparathyroidism (1.0 vs 1.8 vs 0%; P = 0.03) when compared with other causes of hyperthyroidism and other benign thyroid diseases. Permanent recurrent laryngeal nerve injury did not occur in the GD group (0 vs 0 vs 0.4% nerves at risk; P = 0.69) with transient recurrent laryngeal nerve injury occurring in 1.7 versus 2.7 versus 3.1 per cent nerves at risk ( P = 0.35). The lack of a euthyroid state preoperatively had no influence on surgical outcomes or complications. Eighty percent of the TTs for GD were done as same-day outpatient procedures. TT offers a safe, low-risk, and rapid cure for GD to justifiably be considered as a reasonable first-line therapy in selected patients with Graves’ hyperthyroidism.