bluuebunny/crossref_metadata_2025 huggingface dataset:
Primary Site Predicts Grade for Gastroenteropancreatic Neuroendocrine Tumors
Authors: Fitzgerald Timothy L. , Mosquera Catalina , Lea C. Suzanne , Mcmullen Matthew
Published: June 2020

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare and abstruse neoplasms with increasing incidence and clinical relevance. The National Cancer Data Base was examined to identify GEP-NETcases from 2004 to 2013. In total, 39,454 patients diagnosed with GEP-NET were identified. Median age was 61 years. Majority was female (50.13%), white (79.49%), and had low-grade neoplasms (84.39%). On univariate analysis, age, sex, race, primary site, tumor size, and regional lymph node involvement were associated with tumor grade (P < 0.0001). On multivariate analysis, older age [odds ratio (OR) = 9.57], gender (male, OR = 1.29), and race continued to be associated with high-grade neoplasms. The primary site also remained a significant predictor of tumor grade. High-grade neoplasms were more likely to arise from the esophagus (OR = 317.75), hepatobiliary system (OR = 23.15), colorectum (OR = 14.37), ampulla of Vater (OR = 11.61), and stomach (OR = 7.84) compared with the appendix (OR = 5.41), pancreas (OR = 5.31), and small bowel (referent). The tumor grade for GEP-NETs is highly dependent on the primary site, suggesting different sites may be biologically distinct diseases. A personalized approach to GEP-NET treatment, tailored to the site of origin, is imperative.
The Clinical Utility and Cost of Postoperative Mammography Completed within One Year of Breast Conserving Therapy: Is it Worth It?
Authors: Allen Ahkeel , Cauthen Allison , Vaughan Justin , Dale Paul
Published: June 2020

Breast conserving therapy (BCT), lumpectomy followed by radiotherapy, is an effective treatment for a majority of breast cancers. According to the National Comprehensive Cancer Network, mammographic imaging should be completed at least six months after completion of radiation. This study evaluates the clinical significance and financial cost of postoperative breast imaging within one year of BCT. Patients treated with BCT between 2014 and 2016 at an academic center were identified retrospectively. The medical records were reviewed to identify the timing and type of the first imaging study after BCT. This study evaluated the clinical significance and the cost of postoperative imaging. A total of 128 patients were included into the study. Seventy-six patients received mammograms 3 to 12 months after BCT. Six of the 76 postoperative mammograms required additional imaging/intervention for a total of seven additional imaging studies and three procedures, all of which revealed benign findings. None of these patients had physical examination findings that were of clinical concern. The total cost of postoperative imaging and procedures performed less than a year after BCT was estimated to be $32,506. Postoperative imaging performed on breast cancer patients less than a year after BCT proved to be of no medical benefit and revealed no additional significant pathology. The mammographic surveillance in this study did not lead to the diagnosis of recurrent malignancy or second primary lesions and placed additional financial burden on the patient population. This study demonstrates that breast imaging within a year after BCT had no clinical impact and resulted in increased cost of care.
Variability in Perioperative Fasting Practices Negatively Impacts Nutritional Support of Critically Ill Intubated Patients
Authors: Douglas Molly J. , Ciraulo David
Published: June 2020

The aim of the study was to quantify nutritional losses related to pre- and postoperative fasts in critically ill intubated patients and to explore whether shorter fasts are safe and appropriate in this population. A retrospective review of mechanically ventilated adults undergoing surgery more than 24 hours after admission to a Level I trauma center over 15 months was done, which yielded 132 procedures and 81 unique patients. Ninety per cent of preoperative periods and 43 per cent of postoperative periods were affected by nonmedical barriers to feeding. Eighty-two per cent of gastrically fed nonemergent cases were fasted for longer than the 6-hour American Society of Anesthesiologists guideline, whereas 91 per cent of emergent cases had shorter fasts. There were no anesthetic complications, placing an upper limit of 6 per cent on the rate of aspiration for fasts shorter than six hours (95% confidence). Forty-three per cent of cases did not resume tube feeds within 90 minutes postoperatively, and only 37 per cent had a documented justification for delay. Intubated patients were frequently fasted preoperatively for longer than recommended and postoperatively for longer than medically indicated. No complications were observed with shorter-than-guideline fasts. This strengthens the evidence that “standard” preoperative fasting is unnecessary and deleterious in many critically ill intubated patients. New protocols and national guidelines are needed to ensure adequate nutrition.
Open Retromuscular Repair of Parastomal Hernias with Synthetic Mesh
Authors: Beffa Lucas R. , Warren Jeremy A. , Cobb William S. , Knoedler Bryan , Ewing Joseph A. , Carbonell Alfredo M.
Published: June 2020

Parastomal hernias (PHs) cause significant morbidity in patients with permanent ostomies, and several laparoscopic and open repair techniques have been described. We report our experience with open retromuscular repair of PHs using permanent synthetic mesh. A prospectively maintained database was retrospectively reviewed to identify patients undergoing PH repair. Primary outcomes are surgical site occurrence, surgical site infection (SSI), and hernia recurrence. Variables were analyzed using Pearson's χ2 test or Fisher's exact test. Values of P < 0.05 were considered significant. Forty-six patients underwent retromuscular PH repair with permanent synthetic mesh. There were 26 patients with colostomies and 20 with ileostomies. All the patients were repaired using a keyhole retromuscular technique and direct passage of stoma through mesh. Transversus abdominis release was performed in 65.2 per cent of cases. Permanent synthetic polypropylene mesh was used in all cases. Surgical site occurrence occurred in 47.8 per cent of patients, SSI in 17.4 per cent, and hernia recurrence in 21.7 per cent. Resiting the stoma yielded the highest rate of SSI (40%) compared with leaving the stoma in situ (11.8%) or rematuring the stoma (0%; P = 0.011). Open keyhole retromuscular PH repair of PH with permanent synthetic mesh is safe, effective, and durable.
Esophageal Perforation: A Common Clinical Problem with Many Different Management Options
Authors: Felmly Lloyd M. , Kwon Hyejin , Denlinger Chadrick E. , Klapper Jacob A.
Published: June 2020

Esophageal perforation is a complex clinical entity that has multiple etiologies and variability in presentation, making it challenging to diagnose and treat. The mortality of esophageal perforation has improved because therapies have evolved. Whereas primary repair is the standard of care, multiple treatments may be employed successfully. We retrospectively reviewed all cases of suspected or confirmed esophageal perforation that were admitted to the thoracic surgery service at our institution between January 2011 and June 2016. We reviewed the charts of 61 patients. Twenty-three underwent primary repair, 13 underwent stent placement, 12 underwent drainage, 12 underwent medical management, and one underwent exclusion and diversion. All patients were included in the final analysis except the singular patient who underwent diversion. Overall mortality was 4.9 per cent. None of the studied variables were found to be associated with mortality (P > 0.05). Factors associated with choice of treatment were age (P < 0.0005), Charlson Index (P = 0.032), etiology (P < 0.0005), and location (P = 0.005). The application of different management options is based on a thorough understanding time course, patient anatomy, severity of presentation, and underlying disease process.
Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database
Authors: Buonpane Christie , Efiong Enobong , Hunsinger Marie , Fluck Marcus , Shabahang Mohsen , Wild Jeffrey , Halm Kristen , Long Kevin , Buzas Christopher , Blansfield Joseph
Published: June 2020

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.
Inpatient Peripherally Inserted Central Venous Catheter Complications: Should Peripherally Inserted Central Catheter Lines be Placed in the Intensive Care Unit Setting?
Authors: Martyak Michael , Kabir Ishraq , Britt Rebecca
Published: June 2020

Peripherally inserted central venous catheters (PICCs) are now commonly used for central access in the intensive care unit (ICU) setting; however, there is a paucity of data evaluating the complication rates associated with these lines. We performed a retrospective review of all PICCs placed in the inpatient setting at our institution during a 1-year period from January 2013 to December 2013. These were divided into two groups: those placed at the bedside in the ICU and those placed by interventional radiology in non-ICU patients. Data regarding infectious and thrombotic complications were collected and evaluated. During the study period, 1209 PICC line placements met inclusion criteria and were evaluated; 1038 were placed by interventional radiology in non-ICU patients, and 171 were placed at the bedside in ICU patients. The combined thrombotic and central line associated blood stream infection rate was 6.17 per cent in the non-ICU group and 10.53 per cent in the ICU group (P = 0.035). The thrombotic complication rate was 5.88 per cent in the non-ICU group and 7.60 per cent in the ICU group (P = 0.38), whereas the central line associated blood stream infection rate was 0.29 per cent in the non-ICU group and 2.92 per cent in the ICU group (P = 0.002). This study seems to suggest that PICC lines placed at the bedside in the ICU setting are associated with higher complication rates, in particular infectious complications, than those placed by interventional radiology in non-ICU patients. The routine placement of PICC lines in the ICU settings needs to be reevaluated given these findings.
An Expanded Preoperative Component within an Enhanced Recovery Protocol Improves Outcomes in Colorectal Surgery
Authors: Johnson Nathan M. , Fogel Sandy L.
Published: June 2020

Enhanced Recovery Protocols (ERPs) have been shown to lead to quicker recovery in colorectal surgery, with reduced postoperative length of stay (LOS). ERPs could potentially be improved with an expanded preoperative component reflecting current evidence. We hypothesize that an ERP with an expanded preoperative component will reduce LOS consistent with or exceeding that seen with traditional ERPs. Our ERP was implemented in June of 2014. Data was collected for two full years from July 2014 through June 2016. The protocol was employed in colorectal cases, both elective and emergent. Data from ERP cases were compared with contemporaneous controls that did not go through the ERP. Patients who underwent colorectal procedures and participated in the ERP with the expanded preoperative component had an average LOS of 5.33 days, whereas controls stayed for an average of 7.93 days (P value, <0.01). ERP cases also experienced fewer read-missions and complications, although statistical significance could not be established. The results demonstrate that an ERP with an enhanced preoperative component significantly reduces LOS and potentially decreases the rate of readmissions and total complications.
Age and Achalasia: How Does Age Affect Patient Presentation, Hospital Course, and Surgical Outcomes?
Authors: Downs Darrell J. , Jadick Giavanna , Swaid Forat , Ross Sharona B. , Rosemurgy Alexander S.
Published: June 2020

Heller myotomy is the “gold-standard” therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. Observation has suggested many differences between young and old patients with achalasia, raising the question: is achalasia in younger patients a different disorder than it is in older patients? This study was undertaken to answer this question. With Institutional Review Board approval, 648 patients undergoing laparoscopic Heller myotomy from 1992–2016 were prospectively followed up. Patients self-assessed symptom frequency/severity preoperatively and postoperatively using a Likert scale; 0 (never/not bothersome) to 10 (always/very bothersome). Before myotomy, frequency/severity of many symptoms (e.g., “dysphagia,” “chest pain,” and “regurgitation”) inversely correlated with age (P < 0.01 each). Symptom duration and the number of previous abdominal operations correlated with age, as did intraoperative complications (e.g., gastrotomy), postoperative complications (e.g., atrial fibrillation), and length of stay (P < 0.01 for each). Patients experienced amelioration of all symptoms queried, regardless of age (P < 0.01 each). Age did affect outcome because older patients had less frequent and severe symptoms. Age did not affect improvement of symptoms (e.g., dysphagia) (i.e., differences between preoperative and postoperative scores) (P = 0.88). Age did not influence symptom resolution or patient satisfaction (P = 0.98 and P = 0.15, respectively). The presentation with achalasia, hospital course, and outcome after myotomy are significantly impacted by age, whereas patient improvement after myotomy is constant independent of age. Younger and older patients have different presentations, experiences, and outcomes; these patients seem to have “different disorders”, but Heller myotomy provides similar significant amelioration of symptoms independent of age.
Tumor Mitotic Rate and Association with Recurrence in Sentinel Lymph Node Negative Stage II Melanoma Patients
Authors: Laks Shachar , Meyers Michael O. , Deal Allison M. , Frank Jill S. , Stitzenberg Karyn B. , Yeh Jen Jen , Thomas Nancy E. , Ollila David W.
Published: June 2020

Tumor mitotic rate (TMR) is a known prognostic variable in thin melanoma patients. Its significance in stage II melanoma patients is yet to be demonstrated. Retrospective analysis of a prospective melanoma database from 9/1997 to 7/2015 was performed. All stage II melanoma, with documented TMR, and six months of follow-up were included. We evaluated the association of clinicopathologic variables, TMR, as a continuous and categorical variable with recurrence-free survival (RFS) and overall survival (OS) using Cox proportional hazards modeling. We used a statistical model, X-tile, to develop optimal categorizations of TMR. A total of 265 patient characteristics are included in this study. Recurrences occurred in 82 (30.9%) patients, including 5 local, 41 regional, and 36 distant patients. In multivariate model, ulceration, Breslow, and continuous TMR were associated with worse RFS\OS. Continuous TMR demonstrated worse RFS (hazards ratio [HR] 1.02 (1.00–1.05)) and OS (HR 1.02 (1.00–1.04)), whereas dichotomized TMR (≥1 vs <1) was not significant. TMR >10.4 mitoses/mm2 has a 5-year RFS\OS of 27.2 and 44.3 per cent, respectively, compared with 57.4 and 71.4 per cent, respectively, for TMR <3.2 mitoses/mm2. Continuous TMR predicts incidence of recurrence in stage II melanoma. We propose a new categorization method developed by statistical modeling for optimal stratification that may guide surveillance for this disparate patient population.
What are the Costs of Trauma Center Readiness? Defining and Standardizing Readiness Costs for Trauma Centers Statewide
Authors:   Members of the Georgia Research Institute for Trauma (GRIT), Ashley Dennis W. , Mullins Robert F. , Dente Christopher J. , Garlow Laura , Medeiros Regina S. , Atkins Elizabeth V. , Solomon Gina , Abston Dena , Ferdinand Colville H.
Published: June 2020

Trauma center readiness costs are incurred to maintain essential infrastructure and capacity to provide emergent services on a 24/7 basis. These costs are not captured by traditional hospital cost accounting, and no national consensus exists on appropriate definitions for each cost. Therefore, in 2010, stakeholders from all Level I and II trauma centers developed a survey tool standardizing and defining trauma center readiness costs. The survey tool underwent minor revisions to provide further clarity, and the survey was repeated in 2013. The purpose of this study was to provide a follow-up analysis of readiness costs for Georgia's Level I and Level II trauma centers. Using the American College of Surgeons Resources for Optimal Care of the Injured Patient guidelines, four readiness cost categories were identified: Administrative, Clinical Medical Staff, Operating Room, and Education/Outreach. Through conference calls, webinars and face-to-face meetings with financial officers, trauma medical directors, and program managers from all trauma centers, standardized definitions for reporting readiness costs within each category were developed. This resulted in a survey tool for centers to report their individual readiness costs for one year. The total readiness cost for all Level I trauma centers was $34,105,318 (avg $6,821,064) and all Level II trauma centers was $20,998,019 (avg $2,333,113). Methodology to standardize and define readiness costs for all trauma centers within the state was developed. Average costs for Level I and Level II trauma centers were identified. This model may be used to help other states define and standardize their trauma readiness costs.
Guideline-Driven Care Improves Outcomes in Patients with Traumatic Rib Fractures
Authors: Flarity Kathleen , Rhodes Whitney C. , Berson Andrew J. , Leininger Brian E. , Reckard Paul E. , Riley Keyan D. , Shahan Charles P. , Schroeppel Thomas J.
Published: June 2020

There is no established national standard for rib fracture management. A clinical practice guideline (CPG) for rib fractures, including monitoring of pulmonary function, early initiation of aggressive loco-regional analgesia, and early identification of deteriorating respiratory function, was implemented in 2013. The objective of the study was to evaluate the effect of the CPG on hospital length of stay. Hospital length of stay (LOS) was compared for adult patients admitted to the hospital with rib fracture(s) two years before and two years after CPG implementation. A separate analysis was done for the patients admitted to the intensive care unit (ICU). Over the 48-month study period, 571 patients met inclusion criteria for the study. Pre-CPG and CPG study groups were well matched with few differences. Multivariable regression did not demonstrate a difference in LOS (B = -0.838; P = 0.095) in the total study cohort. In the ICU cohort (n = 274), patients in the CPG group were older (57 vs 52 years; P = 0.023) and had more rib fractures (4 vs 3; P = 0.003). Multivariable regression identified a significant decrease in LOS for those patients admitted in the CPG period (B = -2.29; P = 0.019). Despite being significantly older with more rib fractures in the ICU cohort, patients admitted after implementation of the CPG had a significantly reduced LOS on multivariable analysis, reducing LOS by over two days. This structured intervention can limit narcotic usage, improve pulmonary function, and decrease LOS in the most injured patients with chest trauma.
Lobular Carcinoma in Situ: A 15-Year Single Institution Review
Authors: Vora Halley , Kim Sungjin , Amersi Farin , Giuliano Armando , Chung Alice
Published: June 2020

The optimal management of lobular carcinoma in situ (LCIS) has largely been debated. This study evaluated practice patterns and outcomes in women diagnosed with LCIS at a single institution from 2000 to 2014. Patient characteristics, histology, method of diagnosis, and management were examined in relation to disease-free survival, and overall survival (OS). A total of 209 patients were identified. Surgical management in the majority of patients was excisional biopsy or local excision. Patients diagnosed with LCIS by core biopsy were less likely to have mastectomy as compared with other methods of initial diagnosis (P = 0.01). A total of 108 (90.8%) patients received chemoprevention (CP) counseling, and 47 (43.5%) used chemoprevention. Estimated five-year disease-free survival rate was 96.3 per cent (95% confidence interval (CI): 92.0–98.3%) and OS rate was 98.6 per cent (95% CI: 94.6–99.7%). Older age was associated with a higher risk of subsequent breast cancer (hazard ratio (HR): 1.04; 95% CI: 1.01–1.07; P = 0.01). Older age (HR: 1.06; 95% CI: 1.02–1.11; P = 0.004) and diagnosis in the earlier years of the study period (HR: 0.65; 95% CI: 0.48–0.89; P = 0.007) were significantly associated with worse OS in multivariate analysis. LCIS has a favorable prognosis and is most commonly managed conservatively.
Ultrasound Accuracy in Diagnosing Appendicitis in Obese Pediatric Patients
Authors: Love Bryan E. , Camelo Monica , Nouri Sarvenaz , Kriger Diego , Ludi Daniel , Nguyen Henry
Published: June 2020

The use of ultrasound to diagnose appendicitis in pediatric patients has been growing with the improvement of ultrasound technology and operator skills, but its utility in the increasingly obese pediatric population has not been thoroughly investigated. A retrospective review of all pediatric (≤18 years old) patients with appendicitis who were admitted at a single hospital from 2014 to 2016 was conducted. Patients were stratified into body mass index (BMI) percentile categories based on the centers for disease control guidelines. Comparisons were then made. There were 231 patients with an average BMI percentile of 72.6; 99 (42.9%) who had an ultrasound, of which 54 (54.5%) were positive for acute appendicitis, whereas 43 (43.4%) were nondiagnostic. In patients who had a nondiagnostic ultrasound, 37 had a CT demonstrating acute appendicitis. These were compared with 123 patients who had CT alone demonstrating acute appendicitis. The CT-only group was older (12 vs 9, P < 0.005), tended to be male (78 (63%) vs 15 (41%), P = 0.019), had fewer operations performed (81 (66%) vs 30 (81%), P = 0.048) but had no significant difference in BMI percentile (75.8 vs 71.7, P = 0.465). Ultrasound had a 100 per cent positive predictive value in obese and overweight children. Ultrasound is a reliable study in obese and overweight pediatric patients with acute appendicitis.
Application of a Geriatric Injury Protocol Demonstrates High Survival Rates for Geriatric Trauma Patients with High Injury Acuity
Authors: Karamanukyan Tigran , Pakula Andrea , Martin Maureen , Francis Ashwitha , Skinner Ruby
Published: June 2020

Geriatric trauma has historically been associated with poor outcomes, particularly in the setting of severe polytrauma. Although geriatric trauma protocols are common, there are limited data on their impact in patients with high injury severity. In this study, we sought to investigate the impact of a geriatric injury protocol on outcomes in patients with severe trauma acuity. Ninety-eight geriatric patients (age ≥65) admitted to our trauma center with injury severity scores (ISS) ≥15 comprised the study cohort. The mean age was 75 ± 7.7 yrs. The mean ISS was 25 ± 9.2, and the mean geriatric trauma outcome score was 150 ± 3. Mortality was 17 per cent and 70 per cent were due to central nervous system injury. When patients with nonsurvivable injuries or advanced directives resulting in early care withdrawal were excluded, the mortality was 6 per cent. Extremes of age did not impact mortality [(>80 years, 21%) vs (65–79, 16%, P = 0.5)]. Most patients (53%) were discharged home. The application of our geriatric trauma protocol led to favorable results despite high injury acuity. These data suggest that even at the extremes of age, a large percentage of patients can be expected to survive. A prospective validation of these findings is warranted.
Efficacy of Negative Pressure Wound Treatment in Preventing Surgical Site Infections after Whipple Procedures
Authors: Gupta Ryan , Darby Geoffrey C. , Imagawa David K.
Published: June 2020

Surgical site infections (SSIs) occur at an average rate of 21.1 per cent after Whipple procedures per NSQIP data. In the setting of adherence to standard National Surgery Quality Improvement Program (NSQIP) Hepatopancreatobiliary recommendations including wound protector use and glove change before closing, this study seeks to evaluate the efficacy of using negative pressure wound treatment (NPWT) over closed incision sites after a Whipple procedure to prevent SSI formation. We retrospectively examined consecutive patients from January 2014 to July 2016 who met criteria of completing Whipple procedures with full primary incision closure performed by a single surgeon at a single institution. Sixty-one patients were included in the study between two cohorts: traditional dressing (TD) (n = 36) and NPWT dressing (n = 25). There was a statistically significant difference (P = 0.01) in SSI formation between the TD cohort (n = 15, SSI rate = 0.41) and the NPWT cohort (n = 3, SSI rate = 0.12). The adjusted odds ratio (OR) of SSI formation was significant for NPWT use [OR = 0.15, P = 0.036] and for hospital length of stay [OR = 1.21, P = 0.024]. Operative length, operative blood loss, units of perioperative blood transfusion, intraoperative gastrojejunal tube placement, preoperative stent placement, and postoperative antibiotic duration did not significantly impact SSI formation (P > 0.05).
Efficiency and Safety of One-Step Procedure Combined Laparoscopic Cholecystectomy and Eretrograde Cholangiopancreatography for Treatment of Cholecysto-Choledocholithiasis: A Randomized Controlled Trial
Authors: Liu Zhiyi , Zhang Luyao , Liu Yanling , Gu Yang , Sun Tieliang
Published: June 2020

We aimed to evaluate the efficiency and safety of one-step procedure combined endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) for treatment of patients with cholecysto-choledocholithiasis. A prospective randomized study was performed on 63 consecutive cholecysto-choledocholithiasis patients during 2008 and 2011. The efficiency and safety of one-step procedure was assessed by comparing the two-step LC with ERCP + endoscopic sphincterotomy (EST). Outcomes including intraoperative features, postoperative features (length of stay and postoperative complications) were evaluated. One- or two-step procedure of LC with ERCP + EST was successfully performed in all patients, and common bile duct stones were completely removed. Statistical analyses showed that length of stay and pulmonary infection rate were significantly lower in the test group compared with that in the control group (P < 0.05), whereas no statistical difference in other outcomes was found between the two groups (all P > 0.05). The one-step procedure of LC with ERCP + ESTis superior to the two-step procedure for treatment of patients with cholecysto-choledocholithiasis regarding to the reduced hospital stay and inhibited occurrence of pulmonary infections. Compared with two-step procedure, one-step procedure of LC with ERCP + EST may be a superior option for cholecysto-choledocholithiasis patients treatment regarding to hospital stay and pulmonary infections.
Predictive Factors for Treatment Failure after Peritoneovenous Shunt for Hepatic Ascites
Authors: Iida Hiroya , Aihara Tsukasa , Ikuta Shinichi , Yamanaka Naoki
Published: June 2020

Peritoneovenous shunt (PVS) is used to treat refractory ascites. Here, we identify predictive factors for inhospital death after PVS placement. Thirty-five patients with refractory ascites related to liver cirrhosis and/or hepatocellular carcinoma (HCC) who underwent PVS placement between February 2005 and February 2013 were included in the study. Group A comprised 13 patients for whom the PVS placement outcome was inhospital death. Group B comprised 22 patients who were discharged after PVS placement without complications. Patient background and laboratory data were analyzed to identify risk factors for inhospital death. HCC prevalence in Groups A and B was 92 and 55 per cent, respectively (P = 0.02) and that of portal venous tumor thrombus (PVTT) was 54 and 9 per cent, respectively (P = 0.003). The mean des-γ-carboxy prothrombin (DCP) level in both groups was 15,553 ± 49,330 and 787 ± 2600 mAU/mL, respectively (P = 0.009). Multivariate analysis revealed that the presence of PVTT was the only independent predictor of inhospital death (P = 0.007). The presence of PVTT, HCC, and elevated des-γ-carboxy prothrombin levels are predictors of inhospital death after PVS placement. Therefore, PVS should not be used to treat refractory ascites in patients with these predictors, particularly with PVTT.
Major General Malcolm C. Grow, M.D. (1887–1960) Soldier, Surgeon, Airman
Authors: Walker Tyler R. , Cowan Scott W. , Yeo Charles J. , Beekley Alec C.
Published: June 2020

World War I (WWI) and World War II (WWII) both presented physicians with challenges unseen before in history. New inventions such as the machine gun and poisonous gas in WWI and the massive aircraft battles in WWII required physicians and surgeons to adapt and innovate to provide the best care and preventative measures for service members. One physician, Malcolm Cummings Grow, distinguished himself as an innovator, a researcher, and a leader. His contributions to the field of military medicine, flight surgery, and medical administration led to countless lives being saved during the two World Wars and laid the groundwork for many different combat protective equipment still in use today.
Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children
Authors: Sola Richard , Wormer Blair A. , Anderson William E. , Schmelzer Thomas M. , Cosper Graham H.
Published: June 2020

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AAwith ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm–7 am weekdays and on weekends, 70.7%) than during business hours (7 am–7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of non-diagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 x 103/μL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.
Incorporation of Anterior Lumbosacral Spine Exposure into a General Surgical Practice
Authors: Champney Michael S. , Abuhakmeh Yousef H. , Chung Andrew S.
Published: June 2020

Many spine surgeons enlist the aid of an “access surgeon” to provide anterior exposure of the lumbosacral spine. We proposed that a single, community hospital general surgery practice can successfully develop an anterior spine exposure program with acceptable clinical outcomes. One hundred and forty-three consecutive anterior exposures were performed between 2008 and 2014. Morbidity and 30-day mortality were recorded. The effects of American Society of Anesthesiologists Physical Status classification (ASA class) and number of levels exposed on length of stay (LOS) and estimated blood loss (EBL) was reported. The growth of the program during this period was also evaluated. During the six-year period, there were nine (6.3%) major complications and 17 (11.9%) minor complications with no 30-day mortality. The mean LOS was similar for one-level and two-level exposures (3.8 days). Mean LOS was higher in ASA III patients (4.4 days) than ASA I (2.9 days) or ASA II (3.2 days). Mean EBL for one-level exposures (336.3 mL) was not significantly different than EBL for two-level exposures (425.9 mL). EBLs in ASA class III patients were greater than in class I and class II patients. The program began in July of 2008 with a single spine surgeon and one operation that year. A high of 54 procedures, with seven different spine surgeons, was recorded in 2013. A single, community hospital general surgery practice can successfully develop an anterior approach to spine exposure program with acceptable clinical outcomes and with sustained growth of the program.
Risk Factors for Elevated Preoperative Alkaline Phosphatase in Patients with Refractory Secondary Hyperparathyroidism
Authors: Yang Meng , Zhang Ling , Huang Linping , Sun Xiaoliang , Ji Haoyang , Lu Yao
Published: June 2020

Elevated preoperative levels of alkaline phosphatase (ALP) in patients with refractory secondary hyperparathyroidism are correlated with postoperative hypocalcemia and mortality. The aim of this study was to identify the predictors of preoperative ALP in patients with secondary hyperparathyroidism. From April 2012 to December 2015, 220 patients with refractory secondary hyperparathyroidism undergoing total parathyroidectomy without autotransplantation were reviewed. A total of 164 patients presented with elevated preoperative ALP. Univariate analysis showed that patients with elevated ALP were significantly younger. The elevated ALP group had significantly higher levels of preoperative parathyroid hormone (PTH), lower preoperative serum calcium, higher preoperative phosphorus, lower postoperative hypocalcemia, and a longer hospital stay. Logistic regression analysis showed that elevated preoperative PTH was a significant independent risk factor for elevated preoperative ALP (P = 0.000), and its value of 1624 pg/mL was the optimal cutoff point. Factors predictive of elevated preoperative ALP in patients with secondary hyperparathyroidism include preoperative PTH. Earlier surgery, aggressive calcium supplementation, and more careful or aggressive postoperative care for high-risk patients are needed.
Methicillin-Resistant Staphylococcus aureus in a Trauma Population: Does Decolonization Prevent Infection?
Authors: Maxwell Robert A. , Croft Chasen A. , Creech C. Buddy , Thomsen Isaac , Soper Nicole , Brown Laura E. , Mejia Vicente A. , Dart Benjamin W. , Barker Donald E.
Published: June 2020

The purpose of this study was to determine if a decolonization regimen reduces the frequency of methicillin-resistant Staphylococcus aureus (MRSA) infections and if colonization isolates are genetically related to subsequent infectious strains. Trauma patients admitted to the intensive care unit with positive MRSA nasal swabs were randomized to either daily chlorhexidine gluconate (CHG) baths and mupirocin (MUP) ointment to the nares or soap and water baths and placebo ointment for five days. Nasal swabs performed at the end of treatment and invasive MRSA infections during the remaining hospitalization were compared with the original nasal isolate via polymerase chain reaction for genetic relatedness as well as CHG and MUP resistance genes. Six hundred and seventy-eight intensive care unit admissions were screened, and 92 (13.6%) had positive (+) MRSA nasal swabs over a 22-month period ending in 3/2014. After the five day treatment period, there were 13 (59.1%) +MRSA second nasal swabs for CHG + MUP and 9 (90%) for soap and water baths and placebo, P = 0.114. No isolates tested positive for the MUP or CHG resistance genes mupA and qacA/B but 7 of 20 (35%) contained smr. There were seven (31.8%) MRSA infections in the CHG group and six (60%) for soap, P = 0.244. All 13 patients with MRSA infections had the same MRSA isolate present in the original nasal swab. There was no difference in all-cause Gram-negative or positive infections for CHG versus soap, 12 (54.5%) versus 7 (70%), P = 0.467. CHG + MUP are ineffective in eradicating MRSA from the anterior nares but may reduce the incidence of infection. Subsequent invasive MRSA infections are typically caused by the endogenous colonization strain.
Robotic Inguinal Hernia Repair
Authors: Edelman David S.
Published: June 2020

Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Concurrent robotic inguinal hernia repair at the time of prostatectomy has been shown to have a lower recurrence rate than open repair. Robotic surgery adds high definition visualization and articulating instruments which enhances dexterity that makes laparoscopic hernia repair more refined. A series of robotic, laparoscopic, inguinal hernia repairs by a single surgeon with an extensive laparoscopic hernia experience at a single institution was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery. Five hundred forty-two laparoscopic inguinal hernia operations were performed from April 2012 through December 2015. There were 154 cases of robotic transabdominal pre-peritoneal procedures done during that time. Hospital records and follow-up care were pro-spectively reviewed and data collected for age, sex, American Society of Anesthesia class, and operative time. Follow-up was done at 2, 8, and 16 weeks after surgery. All patients consented for the study. Ninety percent of the patients were male. Age averaged 57.04 years with a range of 21 to 85 years. American Society of Anesthesia averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and gastroesophageal reflux disease being the most common. Body mass index was between 19 and 31.6, averaging 24.34. Twenty-five patients (16%) had an umbilical hernia repair done concomitantly. Operating room time ranged from 25 to 140 minutes with an average of 63.6 minutes decreased as experience increased. One patient with a large, left scrotal hernia was converted to open; one patient developed perforated sigmoid diverticulitis seven days postop and case #5 recurred indirectly after a direct hernia repair. Four patients required prolonged postoperative Foley catheterization. Robotic inguinal hernia repair is safe and effective. Operating room time was longer than standard laparoscopic herniorrhaphy but decreased with experience. A single-port platform may have use in patients with umbilical hernias, 16 per cent, and will need to be studied.
Comparison of Risk-Adjusted Outcomes in Medicare Open versus Laparoscopic Cholecystectomy
Authors: Fry Donald E. , Pine Michael , Nedza Susan M. , Reband Agnes M. , Huang Chun-Jung , Pine Gregory
Published: June 2020

More than 90 per cent of cholecystectomies are performed laparoscopically and this has resulted in concern that surgeons will not have sufficient experience to perform open procedures when clinical circumstances require it. We reviewed the open cholecystectomies (OCs) of Medicare patients from 2010 to 2012 in hospitals with 20 or more cases, created risk-adjusted models for adverse outcomes which were evaluated for 90-days after discharge, and compared the hospital-level outcomes with laparoscopic cholecystectomy performed in the same hospitals for the same period of time. Results demonstrated that inpatient deaths, inpatient prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day readmissions were statistically the same with an overall adverse outcome rate of 21.6 per cent in OC versus 20.9 per cent in laparoscopic cholecystectomy. Conversion of laparoscopic to open procedures was not associated with increased adverse outcomes. Laparoscopic cholecystectomy provides patients with many advantages, but when clinical circumstances are necessary, OC continues to be performed with the same overall adverse outcome rates, and the conversion process is not associated with poorer results in this high-risk population of patients.
Results after Definitive Surgical Treatment in Patients with Enteroatmospheric Fistula
Authors: Martinez Jose L. , Luque-De-LeÓN Enrique , Souza-Gallardo Luis Manuel , JimÉNez-LÓPez Maricela , Ferat-Osorio Eduardo
Published: June 2020

As enteroatmospheric fistulas (EAF) lack healthy overlying tissue, spontaneous healing is very unlikely. Our aim was to identify risk factors for recurrence and mortality after definitive surgical treatment for EAF. Sixty-two consecutive patients with a diagnosis of EAF were submitted to definitive surgical repair (fistula resection and primary anastomosis) during a 6-year period. Several patient, disease, and operative variables were assessed as risk factors associated to our endpoints: recurrence and mortality. All patients were followed-up until hospital discharge or death. Univariate and multivariate analysis were performed. There were 24 females and 38 males with a median age of 53 years (interquartile ranges 43–63). EAF recurred in 23 patients. Univariate analysis identified several risk factors for recurrence which included performing more than one anastomosis (20 vs 52%, P = 0.013), failure of achieving total abdominal closure (16 vs 47%, P = 0.025), intraoperative hemorrhage >400 cc (28 vs 65%, P = 0.007), presence of multiple fistulas (25 vs 61%, P = 0.008), and preoperative C-reactive protein >0.5 mg/dL (54 vs 82%, P = 0.029). The latter two remained significant after multivariate analysis. Final EAF closure was attained in 47 patients (76%) and 8 more (13%) had a low-output (<50 mL/day) enterocutaneous fistula. Timing of surgery was not related to fistula recurrence. Eight patients died (13%), and fistula recurrence was the only risk factor found related to mortality both through univariate (26 vs 5%, P = 0.043) and after multivariate analysis. EAF management represents a rather challenging problem. Timing for surgical treatment is controversial and is based mostly on patient status and surgeon's criteria. Recurrence is associated to EAF characteristics and an inflammatory state; it was also the only factor associated to mortality.
Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury?
Authors: Allen Casey J. , Subhawong Ty K. , Hanna Mena M. , Chelala Lydia , Bullock M. Ross , Schulman Carl I. , Proctor Kenneth G.
Published: June 2020

Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
Impact of Trauma-Certified Registered Nurse Anesthetists Team on Intra-Operative Resuscitation and Postoperative Outcomes of Trauma Patients
Authors: Duchesne Juan , Majoue Chad , Duke Marquinn , Robledo Rosemarie , Achord Chad , Mchale Leslie , Davis Brandy , Nahapetyan Lusine
Published: June 2020

A Trauma Certified Registered Nurse Anesthetists Team (TCT) was created and trained to provide trauma-focused anesthesia and resuscitation. The purpose of this study was to examine patient outcomes after implementation of TCT. We conducted retrospective analyses of trauma patients managed with surgical intervention from March to December 2015. During the first five months, patients managed before the development of TCT were grouped No-TCT, patients managed after were grouped TCT. To assess outcomes, we used hospital and intensive care unit length of stay, ventilator days, and a validated 10-point intraoperative Apgar score (IOAS). IOAS is calculated using the estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery. Higher IOAS are associated with significantly decreased complications and mortality after surgery. We used t test and nonparametric tests for analyses. Fifty two patients were included (mean age 39 years, 75% male; 46.2% managed with TCT). Patients in the No-TCT group had significantly lower use of vasopressors (0.019), lower mean IOAS ( P = 0.02), and spent more days on ventilator ( P = 0.005) than patients in the TCT. These results suggest that trauma centers should take into consideration implementation of TCT to improve intraoperative and overall outcomes.
Span-1 and CA19-9 as Predictors of Early Recurrence and Lymph Node Metastasis for Patients with Invasive Pancreatic Cancer after Pancreatectomy
Authors: Shimizu Tetsunosuke , Asakuma Mitsuhiro , Tomioka Atsushi , Inoue Yoshihiro , Hirokawa Fumitoshi , Hayashi Michihiro , Uchiyama Kazuhisa
Published: June 2020

Because pancreatic cancer is a disease with a dismal prognosis due to the high rate of early recurrence even after curative surgery, selecting the most effective treatment in an individual requires pre-operative assessment of the tumor characteristics, including the potential for early recurrence. The study cohort included 84 patients undergoing surgical resection of pancreatic cancer. Univariate and multivariate analyses were conducted to identify the risk factors for early recurrence within six months after curative resection. Early recurrence was associated with a platelet-lymphocyte ratio ≥0.23 ( P = 0.04), carbohydrate antigen 19-9 (CA19-9) ≥200 ( P = 0.01), and S-pancreas-1 antigen (Span-1) ≥37 ( P = 0.0004) by univariate analysis. Multivariate analysis identified CA19-9 ≥200 and Span-1 ≥37 as independent risk factors for early recurrence. Patients with both risk factors had a significantly higher rate of lymph node metastasis than those with no or one risk factor. Span-1 ≥ 37 and CA19-9 ≥ 200 are independent risk factors for early recurrence in patients who underwent surgical resection, and the combination of Span-1 ≥37 and CA19-9 ≥200 is a useful indicator of lymph node metastasis.