bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergency Room Thoracotomy: A Single Surgeon's Thirteen-Year Experience
Authors: Kennedy Frank , Sharif Sharareh
Published: November 2022

Our objectives were to elucidate the postoperative complications in patients who have had emergency room thoracotomy (ERT), to define anatomic and physiologic parameters that are compatible with survival and to document the evolution of management of these patients. A single surgeon's experience over a 13-year period was reviewed. All patients where he was the primary or supervising surgeon for the ERT were included. Data were analyzed for mechanism (penetrating/blunt), hospital where performed, survival to intensive care unit, survival to discharge, and postoperative complications. Among survivors, data were analyzed for the anatomic injuries and the patients' physiologic condition in the field and on arrival. There were a total of 102 patients; penetrating injury 94 (92 percent); blunt, 8 (8 percent). Ten patients (10 percent) reached the intensive care unit alive. Three of the ten (30 percent) died at 2 hours, 12 hours, and 7 days postoperatively. Seven patients survived to hospital discharge. All seven had penetrating chest injuries and were not in cardiac arrest when first examined by paramedics. Four of the seven survivors (57 percent) had major complications. Survival for the early period was 1.6 percent (1/62) and for the later period 15 percent (6/40); P < 0.05. During the study period, changes in patient management included 1) for penetrating torso injury, withholding ERT when survival was extremely unlikely; 2) increased use of blood- and fluid-warming measures; 3) elimination of aortic cross-clamping, instead judiciously using manual compression; 4) making the main purpose of ERT the relief of cardiac tamponade; and 5) immediately controlling any cardiac injury with a simple running suture on a large needle. We conclude the following: 1) The postoperative course after ERT carried significant mortality and morbidity. 2) Compatibility with survival required both the absence of cardiac arrest when initially evaluated in the field and the presence of penetrating chest injury. 3) Significant changes occurred in patient management during this 13-year period. Survival was higher in the latter part of this period.
Pelvic Actinomycosis Presenting as Malignant Large Bowel Obstruction: A Case Report and a Review of the Literature
Authors: Yegüez José F. , Martinez Sergio A. , Sands Laurence R. , Hellinger Michael D.
Published: November 2022

Actinomycosis is an infrequent chronic infectious disease. In most cases the diagnosis is made postoperatively because of its unusual clinical presentation. Moreover, abdominal actinomycosis may mimic cancer, inflammatory bowel disease, or diverticulitis. Delay in diagnosis leading to inadequate management and unnecessary procedures has been reported. We report the case of a 49-year-old woman with large bowel obstruction secondary to extensive pelvic actinomycosis involving the rectosigmoid and cecum. She required emergency surgery, which involved both resection and colostomy. A review of the literature on abdominal actinomycosis during the last 50 years is also reported. Rarely has emergency surgery been described in this condition. Although the incidence of actinomycosis has decreased, the abdominal-pelvic form has been increasing over the past 10 years secondary to increased prolonged use of the intrauterine device. As the clinical spectrum of actinomycosis has dramatically changed, so have the therapeutic considerations. Aggressive surgical management in advanced cases with multiorganic involvement seems to have reemerged in recent years. Consideration of actinomycosis in a woman with prolonged use of an intrauterine device and symptoms of bowel obstruction could help to improve the preoperative diagnosis and management of this rare disease.
Diagnosis and Treatment of Opportunistic Infections in Immunocompromised Surgical Patients
Authors: Dunn David L.
Published: November 2022

The advent of successful therapy for patients who suffer many types of organ dysfunction and failure, malignancies, and acquired immunodeficiency syndrome has led to the concurrent threat of infection due to a wide array of pathogens, particularly opportunistic microbes that rarely cause disease under routine circumstances. Among patients who are subjected to extreme degrees of immunosuppression, almost any type of bacterial, fungal, viral, protozoal, or parasitic organism can exhibit pathogenic potential and lead to devastating consequences for the host. Immunosuppressive drug therapy for the purpose of organ allograft maintenance, cancer chemotherapy, or the human immunodeficiency virus exerts potent effects upon cellular immunity. Therefore, although these groups of patients are more susceptible to all types of infectious disease processes, infections due to those pathogens that require a component of cellular immunity for their eradication, such as fungi and viruses, occur at a higher frequency than that observed among normal individuals. Of critical importance, all types of infections are associated with higher rates of morbidity and mortality in immunosuppressed patients. Currently, improved diagnostic techniques and new treatment modalities have rendered many serious infections, for which suitable therapy previously did not exist, amenable to treatment. Because of the large number of immunosuppressed patients who now lead highly productive lives, it is important for the surgical practitioner to become familiar with the modalities currently available to precisely diagnose and effectively treat opportunistic infections in immunocompromised surgical patients.
Soft Tissue Infections
Authors: Stone H. Harlan
Published: November 2022

Soft tissue infections are almost routinely the product of direct microbe inoculation through a bridged protective skin. Day of onset and clinical presentation reflect the causative pathogen(s) and course that should be taken in treatment. Exclusive of chronic states, only in the most fulminating cases are culture and antimicrobial drugs of any real value.
Symmetrical Peripheral Gangrene: A New Presentation of an Old Disease
Authors: Knight T. T. , Gordon Stephen V. , Canady Jerome , Rush Daniel S. , Browder William
Published: November 2022

This report concerns two cases and a review of the literature on the subject of symmetrical peripheral gangrene. Symmetrical peripheral gangrene is defined as symmetrical distal ischemic damage in two or more sites in the absence of major vascular occlusive disease. It occurs in patients who are septic and have disseminated intravascular coagulation and in nonseptic patients who have cardiogenic or hypovolemic shock. The syndrome is devastating and rare, and controlled studies of its etiology and management are lacking. Recommendations are presented for its prevention and treatment. Cooperative multicenter studies may be necessary to obtain valid data about its prevention and management.
Laparoscopic Colon Resections: A Five-Year Retrospective Review
Authors: Gibson M. , Byrd C. , Pierce C. , Wright F. , Norwood W. , Gibson T. , Zibari G.B.
Published: November 2022

In recent years, laparoscopic surgery has become a matter of growing interest. It has been shown that laparoscopic colectomy is well tolerated and safe for benign disease. However, there is some uncertainty about using this method for malignant disease when curative resection is the aim. These uncertainties mainly consist of spread of cancer to port site, long-term survival, and adequacy of resection. The majority of laparoscopic colectomies are technically assisted procedures in which anastomosis is performed outside the abdomen. However, some surgeons are now performing this surgery totally laparoscopically with the anastomosis performed inside the abdomen. Laparoscopic colectomy is currently practiced with great frequency by general surgeons. Its performance requires a steep learning curve and a large number of cases to obtain proficiency. The indications for laparoscopic colectomy are different from one institution to another. In some institutions all patients with colorectal disease are candidates for laparoscopic colectomy and in others it may be limited to benign disease only. The purpose of this review is to analyze all laparoscopic colectomies performed at our medical center since 1992. We conducted a retrospective chart review of both hospital and clinic charts of patients who underwent colectomies at our hospital. A total of 338 patient charts were reviewed. In a comparison of both laparoscopic (n = 285) and converted (n = 53) methods, the age and operative time were about the same. Age average and operating room time average were similar for both groups. With laparoscopy, there was a 3-day drop in length of hospital stay as well as a 1-day-earlier regaining of bowel function. Hospital cost dropped $5000 average for the laparoscopic colectomy. The conversion rate at our center was 15 per cent. Complication rates were lower in the laparoscopic group. Recurrence of cancer at the port site (0.7%) was no higher than in the converted group (incisional recurrence, 1.8%). We conclude that laparoscopic colectomy does show an improvement in return of bowel function, hospital cost, and shorter hospital stay. Long-term follow-up will be necessary to determine the effectiveness of laparoscopic colon resection for colorectal cancer.
Heterotopic Pregnancy Presenting as an Acute Abdomen: A Diagnostic Masquerader
Authors: Mistry Bhargav M. , Balasubramaniam Sanjeeve , Silverman Ralph , Sakabu Stanley A. , Troop Bryan R.
Published: November 2022

Simultaneous intrauterine and extrauterine pregnancy is called heterotopic pregnancy. It is a rare complication of pregnancy, especially in the absence of predisposing factors. It is known to present with a variety of symptoms and signs often leading to a delay in establishing the correct diagnosis. We report the case of a 29-year-old woman, known to be 14 weeks pregnant, presenting with acute abdominal pain. The confirmation of a viable intrauterine pregnancy led to a general surgery consultation. A heterotopic ruptured right ectopic tubal pregnancy was found. Right salpingectomy was performed. The patient recovered uneventfully. The intrauterine pregnancy was not affected. This case illustrates the variable presentation of heterotopic pregnancy and the need for general surgeons to be suspicious of pregnancy related complications, even in the presence of a viable intrauterine pregnancy.
Phyllodes Tumors of the Breast: A Review of 32 Cases
Authors: Geisler D.P. , Boyle M.J. , Malnar K.F. , Mcgee J.M. , Nolen M.C. , Fortner S.M. , Broughan T.A.
Published: November 2022

Most general surgeons involved in breast cancer care have limited experience with phyllodes tumors. We analyzed a comprehensive database incorporating 8567 breast cancer cases treated surgically in the Tulsa, Oklahoma, region between 1969 and 1993. This yielded 32 cases of phyllodes tumors (0.37%) in 31 patients. The median age was 57 years (range, 18–91). There were 9 low-grade (28%), 2 intermediate-grade (6%), and 21 high-grade (66%) lesions. Size distribution consisted of 23 (72%) lesions 5 cm or less and 9 (28%) greater than 5 cm (mean, 3; range, 1.2–17.5 cm). Of 137 resected nodes in 13 patients, none were positive for metastatic disease. Surgical management consisted of wide excision or mastectomy. No patients received adjuvant chemoradiation therapy. The disease-free, locoregional disease-free, and overall mean survival rates were 80, 81, and 97 months, respectively. Ten-year disease-free survival (DFS), locoregional disease-free survival (LRDFS), and overall survival (OS) rates were 66, 72, and 55 per cent, respectively. Although there was a tendency toward a higher rate of locoregional recurrences and metastases with high-grade lesions, this was not statistically significant and did not affect DFS, LRDFS, or OS rates. Similarly, size of lesion did not affect DFS, LRDFS, or OS rates. Three patients (9.6%) had metastatic disease at presentation, and a further two (6.4%) developed metastases during follow-up. Overall, nine (28.1%) recurrences developed in eight patients, seven locoregional and two distant. Four patients (12.9%) died with evidence of disease. These findings indicate prolonged survival in this patient population with cystosarcoma phyllodes. Wide local excision of primary and recurrent lesions remains the mainstay of therapy. Neither regional lymph node dissection nor adjuvant chemoradiation adds significant benefit.
The Role of Positron Emission Tomography in Selecting Patients with Metastatic Cancer for Adrenalectomy
Authors: Harrison Jacqueline , Ali Amjad , Bonomi Philip , Prinz Richard
Published: November 2022

Metastases to the adrenal glands usually signal disseminated disease. However, isolated metastases do occur that may be curable with adrenalectomy. Functional imaging with positron emission tomography (PET) can differentiate benign from malignant pathology and isolated from disseminated metastases. The purpose of this study was to determine whether PET scanning can influence the outcome of adrenalectomy for metastatic disease. We conducted a retrospective review of eight patients undergoing adrenalectomy for presumed isolated metastatic disease from 1985 through 1997. The patients included six women and two men with an average age of 58 (range, 36–74). Their primary tumors were six lung carcinomas, one renal cell carcinoma, and one colon carcinoma. The adrenal masses were located on the right in six patients, on the left in one, and bilaterally in one. Before operation, all patients were evaluated by chest and abdominal CT. Four patients were also evaluated by PET scan. Six right, one left, and one bilateral adrenalectomies were performed. Associated organ resections included two right partial nephrectomies and one right total nephrectomy, one left partial nephrectomy, two distal pancreatectomies, one splenectomy, and two partial hepatic resections. All eight patients survived operation. There were no major perioperative complications, but one patient required readmission for congestive heart failure. Three of the four patients who did not have PET scanning died from 4 to 48 months after operation with disseminated disease from lung, colon, and renal carcinoma respectively. The remaining patient who did not have PET scanning is alive and well 11 years later. Two of the four patients who had PET scans showing isolated disease are alive at 28 and 43 months after operation, whereas the other two died of disseminated disease at 29 and 36 months after operation. We conclude that 1) adrenalectomy can provide survival benefit in patients with isolated metastases, and 2) PET scanning is useful in confirming isolated metastatic disease and selecting patients for adrenalectomy.
Five-Year Experience with the “Four-Before” Laparoscopic Ventral Hernia Repair
Authors: Reitter David R. , Paulsen J. Kevin , Debord James R. , Estes Norman C.
Published: November 2022

Between 1993 and 1998, we performed a linear study of laparoscopic ventral hernia repair performed in a standard fashion using expanded polytetrafluoroethylene on 49 patients. Eighteen patients had recurrent hernias and 30 patients were morbidly obese with a body mass index >30. Conversion to open procedure was required in two patients. Patients were observed a mean of 27 months. Three patients died of unrelated causes during the observation period. Three patients developed recurrent hernias. By a follow-up survey, we found that 90 per cent of patients were “satisfied” with their operation and results. Because of decreased complications, postoperative pain, hospital stay, and hernia recurrence, the “four-before” laparoscopic repair is our preference for ventral hernias. It has been particularly useful for obese patients and patients with recurrent ventral hernias.
Cytoreductive Surgery with Intraperitoneal Hyperthermic Chemotherapy for Disseminated Peritoneal Cancer of Gastrointestinal Origin
Authors: Loggie Brian W. , Fleming Ronald A. , Mcquellon Richard P. , Russell Gregory B. , Geisinger Kim R.
Published: November 2022

No standard effective treatment exists for peritoneal carcinomatosis of gastrointestinal origin. The pharmacokinetic advantage of intraperitoneal chemotherapy and the synergy of heat and certain anticancer agents have prompted researchers to investigate intraperitoneal hyperthermic chemotherapy in treating disseminated peritoneal cancers. We have conducted a large Phase II trial to determine the safety and efficacy of aggressive cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC) in treating peritoneal carcinomatosis of gastrointestinal origin. Patients with disseminated peritoneal carcinomatosis of gastrointestinal origin with or without malignant ascites were eligible. After aggressive surgical debulking, patients were administered a 2-hour heated (40.5° C) intraperitoneal perfusion with mitomycin C. The major response variable monitored was overall survival. Patients were assessed for toxicity after IPHC administration using the National Cancer Institute Common Toxicity Criteria. Eighty-four patients with peritoneal carcinomatosis of gastrointestinal origin were evaluated for survival and toxicity (colon, n = 38; appendix, n = 22; stomach, n = 19; other gastrointestinal, n = 5). Thirty-nine (46%) patients had malignant ascites at the time of therapy. The operative mortality (30-day) was 6 per cent. Hematologic toxicity was the most common toxicity but was of mild to moderate severity (7 and 4% of patients had grade 3/4 white blood cell or platelet toxicity, respectively). The overall median survival was 14.3 months. The median survival of patients with peritoneal carcinomatosis of appendiceal, colorectal, and gastric origins were 31.1+, 14.6, and 10.1 months, respectively. Significant differences in median survival were seen in patients without and with malignant ascites (27.7 vs 7.6 months; P = 0.0004) and R0/R1 (complete gross tumor resection) versus R2 (gross residual tumor) surgical resection status (28.5+ vs 10.8 months, P = 0.0002). These data suggest that aggressive cytoreductive surgery with IPHC using mitomycin C is safe and effective in treating peritoneal carcinomatosis of gastrointestinal origin. Additional studies and broader applications of this treatment are encouraged.
A Trauma Systems Assessment of Boating Safety: A Comparison of Commercial and Recreational Boating Practices
Authors: Ciraulo David L. , Smith Philip , Ciraulo Sandra C.
Published: November 2022

OBJECTIVE: With contemporary interest of Trauma Systems and injury prevention strategists focusing upon boating safety, a prospective study was designed to survey practices of commercial and recreational boaters' compliance with United States Coast Guard (USCG) regulations. Data were collected by interview survey. Information was obtained from 24 commercial and 57 recreational boaters. Prevalence rates were calculated for compliance with USCG regulations. An analysis for statistical difference was conducted using the Wilcoxon rank sum test. Data analysis revealed that commercial boaters statistically spend more days on the water per year and have more years of boating experience than do recreational boaters ( P < 0.05). No statistical difference was demonstrated between commercial and recreational boaters for life jacket-to-crew member ratio, swimming competency, or compliance with USCG safety equipment, with exception to flotation suits. The prevalence of alcohol use by the operators of commercial and recreational boats was found to be 8 and 12 per cent ( P < 0.60) respectively, and for crew members 8 and 35 per cent ( P < 0.01), respectively. Boating practices in these sample populations conform to USCG regulations. Swimming competency exhibited by these boaters is complementary to safe boating behaviors. The consumption of alcohol while boating, although comparable to reported statistics, is still of concern to injury prevention strategists.
Changes in Liver Function Tests after Laparoscopic Cholecystectomy: Not So Rare, Not Always Ominous
Authors: Saber Alan A. , Laraja Raymond D. , Nalbandian Harout I. , Pablos-Mendez Ariel , Hanna Kayan
Published: November 2022

The incidental findings of increased alanine aminotransferase (ALT) and aspartate amino transferase (AST) after uneventful laparoscopic cholecystectomy (LC) prompted us to investigate the incidence and the clinical significance of this phenomenon. Changes in liver function test after LC (n = 55) were compared with those after OC (n = 16). Liver function tests were obtained preoperatively and postoperatively on days 1, 2, and 7. All of the patients fulfilled the selection criteria: normal preoperative liver function test and no endoscopic retrograde cholangiopancreatography, common bile duct exploration, or postoperative biliary complications (injury, infection, or obstruction). Converted cholecystectomies were also excluded. During LC, the intra-abdominal pressure was maintained within the conventional range of 14 to 15 mm Hg. ALT had doubled in the first 48 hours from the preoperative mean in 58.2 per cent in LC patients versus only 6.3 per cent in the OC group. AST doubled from the preoperative mean value in 38.2 per cent in the LC group versus only 6.3 per cent in the OC group. By the 7th postoperative day, the enzymes returned to the preoperative values in both the LC and the OC group. In many instances, a significant increase in ALT and AST blood levels occurred after uneventful LC. The phenomenon is transient as these enzymes returned to normal value within 7 days. These changes are clinically silent in patients with a normal liver function.
Transanal Excision for Low Rectal Cancers is Curative in Early-Stage Disease with Favorable Histology
Authors: Blair Sarah , Ellenhorn Joshua D.I.
Published: November 2022

Controversy still exists as to the optimal treatment of early-stage low rectal cancers. Standard resections such as abdominal perineal resections or low anterior resection with coloanal anastomosis can be associated with significant morbidity. Local excision has been considered as a potentially far less morbid option for these patients. We identified 20 patients from our prospective tumor registry database that underwent transanal resection of early rectal cancers between 1988 and 1998. Five patients had carcinoma in situ, and 15 patients had T1 lesions. All T1 lesions were well or moderately well differentiated, and none had lymphovascular invasion. The mean tumor size was 2.65 cm, and the average distance from the anal verge was 4.55 cm. One patient required temporary colostomy because of postoperative complications. Four patients had postoperative adjuvant therapy (radiation alone, two; radiation and chemotherapy, two) for close margins after they refused an abdominal perineal resection. With a median follow-up of 60 months there were no recurrences and no cancer-related deaths. This series suggests that transanal excision is a safe and effective treatment for selected early low rectal cancers with favorable histology.
A Case-Control Study of Laparoscopic versus Open Sigmoid Colectomy for Diverticulitis
Authors: Faynsod Moshe , Stamos Michael J. , Arnell Tracey , Borden Cristina , Udani Sejal , Vargas Hernan
Published: November 2022

Laparoscopic sigmoid colectomy (LSC) for diverticular disease accounts for a limited number of laparoscopic colon cases performed nationally because of the technical challenge it presents. Our objective was to determine the feasibility and impact of the laparoscopic approach in elective sigmoid colectomy for diverticular disease and to compare these results with those of the open approach. Twenty elective laparoscopic sigmoid colectomies (LSCs) were performed for diverticulitis between April 1992 and July 1999 at a university-affiliated urban hospital. A case-control study was performed comparing LCS with a matched control group of conventional open sigmoidectomies. Fourteen of 20 sigmoidectomies were successfully completed laparoscopically. The mean operative time for LSC was similar to that for open sigmoid colectomy (251 vs 243 minutes). There was earlier return to oral intake in the LSC group (1 vs 5 days; P < 0.001). The mean length of stay was significantly shorter ( P = 0.029) in LSC (4.8 days) versus open sigmoid colectomy (7.8 days). Conversion to open sigmoidectomy extended hospital stay to 8.16 days. The overall complication rate was 10 per cent in both groups. We conclude that LSC can be performed effectively and with a low complication rate for diverticular disease. LSC provides the benefit of quicker return of bowel function and shorter hospitalization.
Laparoscopic Inguinal Hernia Repair: Optimal Technical Variations and Results in 1700 Cases
Authors: Quilici Philippe J. , Greaney Edward M. , Quilici Jean , Anderson Susan
Published: November 2022

A follow-up series of 1700 laparoscopic inguinofemoral herniorrhaphies by a single surgical team is presented (1381 patients). Two standard techniques were used: transabdominal preperitoneal (1452 cases) and totally extraperitoneal (248 cases). Mean follow-up was 5.3 years. There were 348 patients with bilateral hernias, 121 with recurrent hernias, and 27 with incarcerated hernias. Numerous technical variations were used as the study progressed. A SurgiPro mesh (USSC, Norwalk, CT) with staple/tack fixation was used in all patients. Average operating time was 41 minutes for unilateral repairs, and 97.3 per cent of the procedures were outpatient procedures. Five recurrences were reported. The postoperative permanent neuropathy rate was found to be negligible, but a 5.1 per cent rate of uncomplicated ipsilateral postoperative seromas is reported. All patients were instructed to return to unrestricted physical activities on postoperative day one. Ninety per cent of the patients were able to do so within 5 days versus 93 per cent in 7 days. Ninety-six per cent of all patients felt minimal pain and discomfort after 72 hours. There was no significant difference in recovery or morbidity between the transabdominal preperitoneal and totally extraperitoneal repairs. To date laparoscopic inguinal herniorrhaphy continues to be a difficult procedure with a significant learning curve. The reported surgical performance data and the described optimal technical variations make this procedure a viable and competitive repair in the surgical management of inguinofemoral hernia.
Intensive Care Unit Outcomes of Surgical Centenarians: The “Oldest Old” of the New Millennium
Authors: Wilson Matthew T. , Crawford Kenneth L. , Shabot M. Michael
Published: November 2022

This study compared the severity of illness and outcomes of surgical intensive care unit (SICU) patients age 100 years or older with those of younger SICU patients. Severity of illness was measured with the Simplified Acute Physiology Score (SAPS) and the Quantified Therapeutic Intervention Scoring System (QTISS). Outcomes were evaluated with SICU length of stay (LOS), hospital LOS, SICU mortality, and hospital mortality. All patients admitted to an urban, tertiary-care SICU from August 1, 1986 to July 31, 1998 (12 years) were included. A total of 24,395 consecutive patients were evaluated of whom nine (0.037%) were age 100 or more. Complete outcome data were available for 13,773 patients who were divided into five groups on the basis of age: <70, 70 to 79, 80 to 89, 90 to 99, and 100 years and above. Nine centenarians were admitted to the SICU of whom one died in the SICU and another died in the hospital after SICU discharge (22.2% overall mortality). Centenarian patients had higher SAPS and QTISS on admission than patients in all other groups, although this difference was not significant because of the small number of centenarians. SICU and hospital LOS were not significantly longer for centenarians. Mortality in the SICU and hospital was significantly different across the age groups and rose with age. However, the modest 11.1 per cent SICU mortality rate in centenarians along with their LOS statistics indicate that these patients fare relatively well in surgical intensive care.
Splenectomy for Idiopathic Thrombocytopenic Purpura: A Five-Year Retrospective Review
Authors: Michael Gibson , Sehon J. Kenneth , Stephen White , Gazi B. Zibari , Lester W. Johnson
Published: November 2022

Idiopathic thrombocytopenic purpura is a condition that is characterized by persistently low platelet counts. Idiopathic thrombocytopenic purpura results from splenic sequestration and accelerated platelet destruction mediated by antiplatelet antibody. Most cases arise in previously healthy patients, mostly women ages 20 to 40. Clinical symptoms consist of bruising, petechiae, mucosal bleeding, menorrhagia, and intracranial bleeding. Platelet-associated immunoglobulin G can be detected in 90 per cent of patients. Therapy for adults and children is somewhat different. Splenectomy in adults should be considered in patients who fail to respond to steroids, develop thrombocytopenia after taper, or develop steroid toxicity. Ninety per cent of children will maintain normal platelet counts in 9 to 12 months. Some will recover spontaneously without medical therapy. Splenectomy in children is recommended if idiopathic thrombocytopenic purpura persists for more than one year or fails to respond to steroids. Our purpose was to determine whether management of idiopathic thrombocytopenic purpura in patients who undergo splenectomy at our institutions is appropriate and effective. We undertook a 5-year retrospective review of 27 patients with idiopathic thrombocytopenic purpura which have undergone splenectomy. All of the 27 patients were referred to surgeons after initial medical management. The patients were divided into two groups on the basis of length of therapy: longer than 6 months and less than 6 months. The longer than 6 months group contained 15 patients. This group had a postoperative complication rate of 40 per cent. Those in the group with <6 months therapy had a complication rate of 7 per cent. Average follow-up for all patients was 20 months. Eighty-eight per cent of the patients had complete response. Three per cent had a partial response with platelet counts >50,000. The partial response group did not respond well to preoperative steroid boluses with a great rise in platelet counts. Eighteen per cent of patients received platelet transfusions. Sixty per cent of the transfusions were given for inappropriate reasons. A large percentage of our patients had prolonged medical therapy before splenectomy. The inappropriate use of platelets was a common error in management. Patients treated for more than 6 months had more postoperative complications. An initial increase in platelets after steroid bolus is a good indicator for favorable response to splenectomy. We conclude that splenectomy is a safe and effective method of treatment for idiopathic thrombocytopenic purpura with no deaths or postsplenectomy sepsis to date.
Age-Adjusted Outcomes in Traumatic Flail Chest Injuries in the Elderly
Authors: Albaugh Gregory , Brian Kann , Matthew M. Puc , Pratibha Vemulapalli , Steven Marra , Steven Ross
Published: November 2022

Severe chest trauma does not independently predict poor outcome in elderly patients. We chose a specific injury, flail chest, to determine whether age factored into outcome of these patients. A retrospective chart review of all trauma admissions to our Level I trauma center between January 1994 and January 1998 sustaining flail chest was undertaken. Sixty-eight patients were identified, but ten patients were excluded because of death on arrival. Fifty-eight patients were included in the study and separated into groups. The first group comprised those under the age of 55 (n = 32) and the second comprised those over age 55 (n = 26). Parameters evaluated were age, Injury Severity Score (ISS), neurologic injury, the need for mechanical ventilation, need for tracheostomy, length of stay, and death. Statistical analysis was performed with Wilcoxon t test, χ2, and logistic regression where appropriate. A 95 per cent confidence interval was sought as determinant of significance. Of the 58 surviving patients analyzed there was no significant difference between the groups regarding ISS, length of stay, days on the ventilator, head injury, tracheostomy, or development of pneumonia or adult respiratory distress syndrome. The likelihood of death was shown to increase by 132 per cent for every 10 years starting at the second decade and continuing to the eighth decade of life. The likelihood of death also increased by 30 per cent for each unit increase in ISS. The likelihood of death decreased by 23 per cent for every day survived in the hospital. Blunt chest trauma directly impacts respiratory mechanics. Elderly patients are more likely to have comorbid conditions and less likely to tolerate traumatic respiratory compromise. Age (and its effects on the body) is the strongest predictor of outcome with flail chest and is associated with an increased mortality ( P ≤ 0.05).
Zinc, Copper, and Metallothionein Metabolism after Jejunoileal Bypass Surgery or Small Bowel Resection in Rats
Authors: Rodriguez Jaime A. , Sandoval Manuel , Udall J.N. , O'Leary J. Patrick , Hempe James M.
Published: November 2022

Liver dysfunction is a frequent complication of jejunoileal bypass (JIB) surgery, a procedure commonly used until recently to treat morbid obesity. It has been suggested that liver failure in JIB patients is due to bacterial overgrowth and translocation from the bypassed intestine. Because invading microorganisms cause hepatic inflammation these experiments evaluated zinc, copper, and metallothionein (MT) in two experimental rat models of intestinal surgery to determine whether their distribution in plasma and tissues was similar to the highly characteristic pattern observed during an inflammatory response. In the JIB rat model 90 per cent of the small intestine was isolated from the flow of digesta but remained viable in the abdominal cavity. In the small bowel resection (SBR) model 90 per cent of the small intestine was removed and the remaining intestine was resected. Data collected 21 days after surgery showed decreased growth rate and plasma zinc in the SBR and JIB rats that was significantly improved by supplemental zinc. All other measures of zinc, copper, and MT metabolism in the SBR rats were similar to those of controls. In JIB rats, however, liver copper, MT protein, and MT mRNA were significantly elevated, and a high proportion of the intracellular zinc and copper was associated with MT. The pattern of zinc, copper, and MT distribution in systemic circulation and liver of JIB rats suggests hepatic inflammation superimposed on low zinc and copper status. Lack of a similar response in the SBR rats confirms the involvement of the bypassed intestinal segment and supports the hypothesis that bacterial overgrowth and translocation are responsible for liver inflammation and dysfunction in JIB patients.
Laparoscopic Donor Nephrectomy: Impact on an Established Renal Transplant Program
Authors: Shafizadeh Stephen , McEvoy John R. , Murray Craig , Baillie G. Mark , Ashcraft Elizabeth , Sill Tamela , Rogers Jeffrey , Baliga Prabhakar , Rajagopolan P.R. , Chavin Kenneth
Published: November 2022

The current disparity of viable organs and patients in need of a transplant has been an impetus for innovative measures. Live donor renal transplantation offers significant advantages compared with cadaveric donor transplantation: increased graft and patient survival, diminution in incidence of delayed graft function, acute tubular necrosis (ATN), and reduction in waiting time. Notwithstanding these gains live donors continue to be underutilized and account for only approximately one quarter of all renal transplants performed in the United States. It has been felt that inherent disincentives to live donation have slowed its growth. These include degree and duration of postoperative pain and convalescence, child care concerns, cosmetic concerns, and time until return to full activities and employment. In an attempt to curtail the disincentives to live donation, laparoscopic live donation (laparoscopic donor nephrectomy; LDN) was developed. The purpose of this study was to compare the results of our first 25 laparoscopic nephrectomies (performed over a 10-month period from September 1998 through July 1999) with the previous 25 standard open donor nephrectomies (ODNs) completed over the past 3 years. We conducted a retrospective review of all donor nephrectomies and recipient pairs performed over the past 3 years. End points included sex, operative time, length of stay, immediate and long-term renal function, and willingness to donate. There were no differences in demographics of the ODN versus the LDN group. The average length of stay was 2.48 ± 0.72 days for the LDN versus 4.08 ± 0.28 days for the ODN. ODN and LDN have comparable short- and long-term function with no delayed graft function and no complications. Growth of living donor transplant has increased from 16 per cent of all kidney transplants performed in 1995 to 23 per cent in 1999. We conclude that LDN is a viable alternative to the standard donor operation. LDN has had a positive impact on the donor pool by minimizing disincentives to live donation. With the initiation of our laparoscopic program the number of LDNs has increased. Presently the live donor pool is the most viable alternative to significantly increase the number of kidneys for transplantation.
Hepatic Angiosarcoma: Long-Term Survival after Complete Surgical Removal
Authors: Timaran Carlos H. , Grandas Oscar H. , Bell John L.
Published: November 2022

Angiosarcoma of the liver constitutes 2 per cent of all primary tumors of the liver. This lesion has demonstrated an intimate relationship between the environment and potential malignant transformation. The CT appearance of hepatic angiosarcoma is nonspecific, whereas arteriography provides the best imaging tool for diagnosis. Hepatic resection is rarely feasible but should be considered if the disease is limited and the remainder of the liver is relatively normal. The prognosis of patients with this malignancy is poor with a median survival of 6 months. A patient with a hepatic angiosarcoma is described. Complete surgical resection was possible and was associated with a prolonged (10-year) postoperative survival.
Laparoscopic Splenectomy in Children with Hematological Disorders: Preliminary Experience at the Children's Hospital of New Orleans
Authors: Liu Donald C. , Meyers Michael O. , Hill Charles B. , Loe William A.
Published: November 2022

Minimally invasive surgery has recently gained acceptance as the surgical approach of choice for a variety of surgical disorders in children. Although traditional open surgery is still regarded as the standard approach for a splenectomy in children when necessary for hematologic disorders a few cases of successful laparoscopic splenectomy (LS) have been reported. We present our initial 11 cases of LS in children assessing surgical outcome. Eleven patients ages 2 through 15 years underwent LS between June of 1996 and July of 1999 at the Children's Hospital of New Orleans. Indications for surgery included idiopathic thrombocytopenic purpura, congenital spherocytosis, and hemolytic anemia. In all patients the diameter of the spleen was less than 15 cm. Surgical outcome was assessed according to the following parameters: operative time, postoperative length of stay, postoperative morbidity, and cosmetic results. Data were accumulated on the basis of retrospective chart review. LS was completed in all 11 patients. Postoperative morbidity was minimal and the median postoperative stay was 2.4 days (range 1–5). Mean operative time was 3 hours and 10 minutes (range 1.5–7 hours) with the last six procedures completed in an average of just over 2 hours. Intravenous analgesia was discontinued in <48 hours in all patients. Cosmetic results were judged excellent in all cases. We conclude that LS was safe in children with certain hematologic disorders. Adequate selection of patients, appropriate preoperative preparation of patients, meticulous surgical technique, and careful postoperative care were key factors in obtaining the same long-term results as with open surgery.
The Role of the Rural Surgeon as Endoscopist
Authors: Sariego Jack
Published: November 2022

As the number of physicians and surgeons practicing in rural communities decreases the roles of those physicians must necessarily expand to meet the needs of the community. Nowhere is this more apparent than in the field of endoscopy. This analysis was undertaken to examine the role of the rural general surgeon in the performance of endoscopy and the outcomes of endoscopic procedures in the hands of the general surgeon. This is a retrospective analysis of all endoscopic procedures performed at a single institution between July 1, 1996 and December 31, 1998. Data were stratified on the basis of type of procedure, indication, and findings. The patient group was a consecutive sample of all patients during the study period referred to the single general surgeon at a small acute-care hospital in rural east-central Mississippi for endoscopic procedures. All patients met accepted criteria for the proposed procedure. Patients underwent either esophagogastroduodenoscopy, colonoscopy, or diagnostic laparoscopy. Endoscopy comprised 24 per cent of all cases performed by the surgeon. Upper endoscopy accounted for 65 per cent of the total, colonoscopy for 29 per cent, and diagnostic laparoscopy for 6 per cent. Positive findings of significance were found in 75 per cent of endoscopic cases overall. Endoscopy comprises a significant proportion of the general surgeon's practice in the rural setting. With good patient selection in this setting the positive-finding rate is very high.
Porcelain Gallbladder is Not Associated with Gallbladder Carcinoma
Authors: Towfigh Shirin , Mcfadden David W. , Cortina Galen R. , Thompson Jesse E. , Tompkins Ronald K. , Chandler Charles , Hines Oscar J.
Published: November 2022

The surgical management of porcelain gallbladder is based on studies performed in 1931 and 1962, which indicated a correlation between porcelain gallbladder and carcinoma. We sought to evaluate the characteristics of patients with porcelain gallbladder and the risk for gallbladder carcinoma. The medical records of 10,741 cholecystectomies performed between 1955 and 1998 were reviewed and recorded. The pathology slides were evaluated for evidence of calcification and gallbladder carcinoma. Fifteen (0.14%) of 10,741 specimens were porcelain gallbladders. Ten patients (67%) had symptoms suggestive of biliary colic or cholecystitis. Five (33%) were asymptomatic and diagnosed incidentally. All specimens demonstrated chronic cholecystitis and partial calcification of the gallbladder wall. Nine (60%) had cholelithiasis. None had gallbladder carcinoma by recent review of pathologic material. During this same period 88 (0.82%) patients had gallbladder carcinoma, none of which showed calcification of the wall. This report represents the largest modern review of porcelain gallbladders. No carcinoma was identified among patients with porcelain gallbladder. In addition no patient with gallbladder carcinoma had calcified gallbladder. With a better understanding of the natural history of the porcelain gallbladder the current management of these patients may change.
The Role of Follow-up Radiographic Studies in Nonoperative Management of Spleen Trauma
Authors: Uecker John , Pickett Creighton , Dunn Ernest
Published: November 2022

The management of splenic injuries has evolved significantly in recent years from an operative to a nonoperative approach in stable patients with blunt abdominal trauma. The management of these patients with serial radiographic studies before hospital discharge remains controversial. We reviewed the management of 90 patients retrospectively who were admitted to our Level II trauma center with splenic injuries secondary to blunt trauma to determine the value of serial radiographic studies. Forty-seven (52%) patients underwent immediate laparotomy. Forty-three (48%) patients were managed conservatively without surgery. All nonoperative patients had an initial CT of the abdomen to evaluate their abdominal injuries. Among the 43 patients managed without surgery 31 had no follow-up radiographic studies. Twelve patients had follow-up studies before discharge. Two of these 12 patients subsequently underwent splenectomy. Both had developed hypotension, tachycardia, and a decreasing hematocrit, which prompted their repeat radiographic studies. Ten patients had no change in their clinical status and showed no significant change in the radiographic injury pattern to the spleen. One patient who was initially managed nonoperatively became hemodynamically unstable with increasing abdominal pain and subsequently underwent splenectomy without follow-up radiographic studies. The remaining 30 patients who had no follow-up studies had no significant change in their clinical abdominal examinations and had no further complications from their splenic injuries. Routine follow-up radiographic evaluations are not necessary in the nonoperative management of stable patients with splenic injuries.
The Impact of Liver Dysfunction on Outcome in Patients with Multiple Injuries
Authors: Harbrecht Brian G. , Doyle Howard R. , Clancy Keith D. , Townsend Ricard N. , Billiar Timothy R. , Peitzman Andrew B.
Published: November 2022

Multiple organ dysfunction syndrome (MODS) is the leading cause of late deaths after traumatic injury. The relative importance of dysfunction of individual organ systems in determining outcome from MODS has not been clearly defined. Some studies have suggested that hepatic dysfunction associated with MODS increases mortality, whereas others have suggested that it contributes little to outcome in trauma patients. To clarify the role of the hepatic dysfunction after traumatic injury we retrospectively reviewed all trauma patients with an Injury Severity Score ≥14 admitted from January 1, 1994 through June 30, 1997 for the presence of hepatic dysfunction defined as a serum bilirubin ≥2.0 mg/dL. Of the 1962 patients who met the entry criteria 154 developed hepatic dysfunction during their hospital stay. Patients with hepatic dysfunction were older (46 ± 2 versus 41 ± 1 years), were more severely injured (Injury Severity Score 31.5 ± 0.9 versus 23.3 + 0.2), and had a lower prehospital blood pressure (102 ± 3 versus 117 ± 1 mm Hg) compared with patients who did not develop hepatic dysfunction. Patients with hepatic dysfunction were more likely to present with shock as reflected in a lower initial emergency room blood pressure (109 ± 3 versus 128 ± 1 mm Hg) and base deficit (-6.9 ± 0.6 versus -3.5 ± 0.1 mEq/L). Patients who developed hyperbilirubinemia had longer lengths of stay in the intensive care unit (15.8 ± 1.2 versus 3.4 ± 0.2 days) and the hospital (27.4 ± 1.7 versus 11.1 ± 0.2 days) and a higher in-hospital mortality (16.2% versus 2.5%). These data demonstrate that the development of hepatic dysfunction reflects the severity of injury and is associated with a significantly worse outcome after traumatic injury.