bluuebunny/crossref_metadata_2025 huggingface dataset:
Extremity Firearm Trauma: The Impact of Injury Pattern on Clinical Outcomes
Authors: Berg Regan J. , Okoye Obi , Inaba Kenji , Konstantinidis Agathoklis , Branco Bernardino , Meisel Erin , Barmparas Galinos , Demetriades Demetrios
Published: June 2020

As a group, the extremities are the most commonly injured anatomic region in nonfatal firearm trauma and are associated with high rates of vascular and bony injury. This study examines the epidemiology, incidence and distribution of firearm-related extremity trauma and the relationship between injury pattern and local or systemic complications. Review of the National Trauma Databank identified 6987 patients with isolated extremity firearm injury. Epidemiologic data, injury pattern incidence, and local and systemic complications were reviewed. Multivariate analysis identified the impact of extremity injury pattern on complications. Overall fracture incidence was 22 per cent. Fracture was associated with both vascular (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5 to 2.4; P < 0.001) and nerve injury (OR, 2.6; 95% CI, 1.9 to 3.5; P < 0.001). Isolated fracture increased risk of compartment syndrome (OR, 2.4; 95% CI, 1.1 to 5.3; P = 0.035). Vascular injury alone increased the risk of compartment syndrome (OR, 11.5; 95% CI, 5.0 to 26.2; P < 0.001) and deep venous thrombosis (OR, 7.9; 95% CI, 2.5 to 25.2; P < 0.001). Fracture and vascular injury together also increased risk of wound infection (OR, 9.7; 95% CI, 3.9 to 23.4; P < 0.001). In patients with extremity trauma, the injury pattern significantly impacts local but not systemic complication rates. Gunshot-related fracture, occurring in one-fifth of patients, increases the risk of vascular and nerve injury. Vascular injury, with or without fracture, is the biggest predictor of local complications.
Conversion of Laparoscopic to Open Cholecystectomy in the Current Era of Laparoscopic Surgery
Authors: Le Viet H. , Smith Dane E. , Johnson Brent L.
Published: June 2020

Laparoscopic cholecystectomy is the gold standard treatment for benign gallbladder pathologies. In certain circumstances, the procedure must be converted to open to safely complete the operation. This study aims to evaluate the reasons for conversion of this operation in the current era of laparoscopic surgery. A retrospective review of medical records was undertaken to identify all laparoscopic converted to open cholecystectomy performed at a single center over a 2-year period. Reasons for conversion, surgeon's preoperative indications, and specimen pathologic results were documented. A review of published data from the previous two decades was also conducted for comparison of contemporary versus historical reasons for intraoperative conversion. Between May 2008 and April 2010, 3371 laparoscopic cholecystectomies were performed at Greenville Hospital System University Medical Center. Eighty-six patients (2.6%) required conversion to open cholecystectomy during the study period. A diagnosis of acute cholecystitis (58.8%) was more common among converted cases. Inflammation (35%), adhesions (28%), and anatomic difficulty (22%) were the three most common intraoperative findings leading to conversion. In the years since laparoscopic cholecystectomy was introduced, there has been a noted improvement in the quality of laparoscopic equipment affording a near wholesale shift toward the laparoscopic approach in the surgical management of this condition. However, inflammation, adhesions, and anatomic difficulty continue to challenge the use and safety of this approach in a small number of patients. The willingness and ability of surgeons to convert to open cholecystectomy continues to be important to the safety of this operation.
Development of Simulator Guidelines for Resident Assessment in Flexible Endoscopy
Authors: Sutton Erica , Chase Sheree Carter , Klein Rosemary , Zhu Yue , Godinez Carlos , Youssef Yassar , Park Adrian
Published: June 2020

Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE Endoscopy VR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners’ knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.
Clinical Characteristics and Surgical Modality of Plasma Cell Mastitis: Analysis of 91 Cases
Authors: Ming Jia , Meng Gang , Yuan Qiaoying , Zhong Ling , Tang Peng , Zhang Kongyong , Chen Qingqiu , Fan Linjun , Jiang Jun
Published: June 2020

The objective of this study was to investigate the clinical characteristics and surgical modality of plasma cell mastitis (PCM). A total of 93 breasts of 91 female patients with PCM from June 2003 to June 2010 (unilateral in 89 patients and bilateral in two patients) were investigated in this study. All breasts were divided into two groups: the direct excision group (DE group) received focused excision and nipple retraction correction; and the incision drainage group (ID group) received these procedures only in the event of failing at least two incision drainages. Clinical characteristics, extent of excision, and prognosis were compared between two groups. There were 53 breasts in the DE group and 40 breasts in the ID group. No significant differences were noted in the number of retracted nipples and abscesses in the first visit or extent of disease between two groups ( P > 0.05). However, during surgery, 3.85 ± 0.97 abscesses per breast were detectable in the ID group, which was significantly higher than 1.21 ± 0.06 abscesses per breast in the DE group. The ID group had significantly higher inflammation and excised extent compared with the DE group ( P < 0.05). Hospitalization time was 179.60 ± 14.8 days in the ID group, which was significantly higher than 22.49 ± 1.93 days in the DE group ( P < 0.05). Bacterial culture was negative for pus of 39 non-rupturing abscesses. Congenital nipple retraction may be the primary cause of PCM. Early and complete focused excision and nipple retraction correction are effective treatment methods.
Phlebitis, Pulmonary Emboli and Presidential Politics: Richard M. Nixon's Complicated Deep Vein Thrombosis
Authors: Pascarella Luigi , Pappas Theodore N.
Published: June 2020

In September of 1974, Richard Nixon resigned the Presidency of the United States during an impeachment investigation concerning the Watergate Affair. One month after his resignation, the former President had an exacerbation of his chronic deep vein thrombosis. He also received a Presidential pardon from Gerald Ford on the same day that his recurrent deep vein thrombosis was diagnosed. The political, legal, and medical events that unfolded in the fall of 1974 are the substance of this report. Presidents often receive medical care that stretches the ordinary as a result of their position and the importance of their actions. The events surrounding Richard Nixon's care for deep vein thrombosis and its complications were not unusual for Presidential health care but were closely intertwined with the legal proceedings during the prosecution of the Watergate defendants.
Increasing Numbers of Rib Fractures Do Not Worsen Outcome: An Analysis of the National Trauma Data Bank
Authors: Whitson Bryan A. , McGonigal Michael D. , Anderson Christopher P. , Dries David J.
Published: June 2020

Increasing age and number of rib fractures are thought to portend a worse outcome with blunt chest trauma, although this is not clearly substantiated in the literature. We hypothesized that these parameters have a significant and synergistic effect, worsening patient outcome. Using the National Trauma Data Bank, we evaluated patients from 2002 to 2006. Patients with a rib fracture International Classification of Diseases, 9th Revision code were included; those with sternal fractures were excluded. Data on demographics, injury, comorbidity, complications, intensive care unit duration, ventilator duration, length of stay, and death were collected. Significant univariate predictors were included in the multivariate logistic regression analysis to adjust for any potential confounders. We identified 35,467 patients who met the inclusion. The mean age was 45.5 years with a mean Injury Severity Score of 19.3. There were 2.1 per cent open rib fractures. Using univariate analysis, rib fracture number was significant. However, once multivariate analyses were applied, the number of rib fractures was not found to be an independent predictor of outcome. The number of rib fractures is not an independent predictor of outcome. Age and overall trauma burden are more powerful predictors of poor outcomes. Treatment focus should shift from the chest to the broader scope of injuries and comorbidities.
Obesity Does Not Increase Morbidity and Mortality after Laparotomy for Trauma
Authors: Livingston David H. , Lavery Robert F. , N'Kanza Anne , Anjaria Devashish , Sifri Ziad C. , Mohr Alicia M. , Mosenthal Anne C.
Published: June 2020

Obesity has been suggested to be a risk factor for increase morbidity and mortality after trauma and surgery. Trauma laparotomy provides an opportunity to assess the effect of body mass index (BMI) on patients subjected to both trauma and surgery. We hypothesized that obesity would have a deleterious effect on outcomes. A retrospective review was conducted of all patients 18 years of age or older undergoing laparotomy for trauma between July 2001 and June 2011. Patients were stratified according to BMI into the following four groups: underweight (16 to 22 kg/m2), normal (23 to 27 kg/m2), overweight (28 to 34 kg/m2), and obese (35 kg/m2 or higher). Data on the patient's hospital course included length of stay, mortality, respiratory failure, infectious complications, wound dehiscence, and organ failure. A total of 1,297 patients underwent laparotomy. Seven per cent of the study group was obese and 24 per cent was underweight. There was no difference among mean Injury Severity Score, percent of patients arriving in shock, and mean number of units of packed red blood cells administered during their hospital stay. Obese patients had longer intensive care unit and hospital lengths of stay. There were no differences in ventilator days or mortality. Using univariate statistics, obese patients had increased rates of respiratory and renal failure, bacteremia with and without septic shock, and abdominal wound dehiscence. Subjecting the data to logistic regression analysis, BMI was no longer an independent predictor of any complication. Although obese trauma patients do have increased infectious morbidity, wound dehiscence, and a prolonged length of stay, increased BMI is not an independent predictor of increased morbidity or mortality after trauma laparotomy.
Injured Adolescents, Not Just Large Children: Difference in Care and Outcome between Adult and Pediatric Trauma Centers
Authors: Matsushima Kazuhide , Schaefer Eric W. , Won Eugene J. , Nichols Pamela A. , Frankel Heidi L.
Published: June 2020

Adolescent injury victims receive care at adult trauma centers (ATCs) and pediatric trauma centers (PTCs). The purpose of this study was to identify care variations and their impact on the outcome of adolescent trauma patients treated at PTC versus ATC. We queried the Pennsylvania Trauma Systems Foundation database for trauma patients between 13 and 18 years of age from 2005 to 2010. Mortality and hospital complication rates between ATC and PTC were compared in univariable and multivariable analysis. In addition, the differences in the delivery of care were also compared. Of 9033 total patients, 6027 (67%) received care at an ATC. Patients in the ATC group were older (16.7 vs 14.9 years, P < 0.001) and more severely injured (Injury Severity Score: 14.5 vs 12.2, P < 0.001). Admission diagnostic computed tomography (CT), emergent laparotomy and craniotomy, blood transfusion, and drug screening were more frequently performed at an ATC. After adjustment for potential confounders in multivariable regression models, treatment at a PTC was significantly associated with fewer CTs for transferred patients (odds ratio [OR], 0.28; P < 0.001) and with less frequent emergent laparotomy for all patients (OR, 0.65; P = 0.007). The ATC group had a significantly higher hospital mortality rate (2.9 vs 0.9%, P < 0.001) and complication rate (9.7 vs 4.8%, P < 0.001). However, these outcomes were not significantly different between PTC and ATC in multivariable regression models. In the state of Pennsylvania, there were no significant differences in risk-adjusted outcomes between PTC and ATC despite significant difference in use of CT scanning and emergent laparotomy.
Article Commentary: Nonclassical Symptoms of Primary Hyperparathyroidism and Their Response to Parathyroidectomy
Authors: Alex Gillian , Morris Lilah , Pasieka Janice , Perrier Nancy
Published: June 2020

An estimated 100,000 new patients are diagnosed with primary hyperparathyroidism (PHPT) each year in the United States.1 In the past, patients with PHPT typically presented with “stones, bones, abdominal groans, and psychic moans” but today patients often present with more subtle symptoms and physiologic changes associated with earlier stages of disease. Patients without the classic symptoms of PHPT are often referred to as “asymptomatic.” These patients frequently pose a conundrum for clinicians. Uncertainties remain as to which symptoms truly represent PHPT and which are related to comorbidities or the aging process. To address these uncertainties, we review most recent literature regarding the nonclassical manifestations of PHPT and their response to parathyroidectomy.
Outcomes of Laparoscopic Nissen Fundoplication in Patients with Manometric Patterns of Esophageal Motility Disorders
Authors: Dell'Acqua-CassÃO Bruna , Mardiros-Herbella Fernando Augusto , Farah JosÉ F. , Bonadiman Adorisio , Silva Luciana C. , Patti Marco G.
Published: June 2020

The manometric pattern of either diffuse esophageal spasm (DES), nutcracker esophagus (NE), or hypertensive lower esophageal sphincter (HLES) in the presence of gastroesophageal reflux disease (GERD) is considered a secondary finding and treatment should be directed toward GERD. This study aims to evaluate the outcomes of laparoscopic Nissen fundoplication (LNF) in patients with manometric patterns of esophageal motility disorders. Patients with GERD confirmed by pH monitoring and manometric pattern of DES (simultaneous contractions 20 to 90% of wet swallows), NE (increased mean distal amplitude greater than 180 mmHg), or HLES (lower esophageal sphincter pressure greater than 45 mmHg) who underwent LNF were studied. A group of 50 consecutive patients with normal esophageal motility who underwent LNF were used as control subjects. Groups were comparable to control subjects for age, gender, preoperative symptoms, hiatal hernia, and Barrett's esophagus, except for NE that had younger individuals and a lower rate of hiatal hernia. Symptomatic outcome was similar when groups were compared with control subjects. Transient dysphagia was present in the postoperative period in 33, 7, 0, and 20 per cent of the patients with HLES, DES, NE, and control subjects, respectively. LNF is an adequate treatment for patients with GERD and manometric patterns of esophageal motility disorders.
Routine Nasogastric Decompression in Small Bowel Obstruction: Is it Really Necessary?
Authors: Fonseca Annabelle L. , Schuster Kevin M. , Maung Adrian A. , Kaplan Lewis J. , Davis Kimberly A.
Published: June 2020

Bowel rest, nasogastric (NG) decompression, and intravenous hydration are used to treat small bowel obstruction (SBO) conservatively; however, there are no data to support nasogastric tube (NGT) use in patients without active emesis. We aim to evaluate the use of nasogastric decompression in SBO and the safety of managing patients with SBO without the use of a NGT. A retrospective chart review was conducted of adult patients admitted to Yale New Haven Hospital over five years with the diagnosis of SBO. We compared patients who received NG decompression with those who did not. Outcome variables assessed were days to resolution, associated complications, hospital length of stay, and disposition. Of 290 patients who fit the criteria, 190 patients (65.52%) were managed conservatively. Fifty-five patients (18.97%) did not receive NGTs. Sixty-eight patients (23.45%) did not present with emesis; however, nearly 75 per cent of these patients received NGTs. Development of pneumonia and respiratory failure was significantly associated with NGT placement. Time to resolution and hospital length of stay were significantly higher in patients with NGTs. Patients with NG decompression had a significantly increased risk of pneumonia and respiratory failure as well as increased time to resolution and hospital length of stay.
Coronary Stents and Subsequent Surgery: Reported Provider Attitudes and Practice Patterns
Authors: Graham Laura A. , Maddox Thomas M. , Itani Kamal M. F. , Hawn Mary T.
Published: June 2020

Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.
Synchronous Portal-superior Mesenteric Vein or Adjacent Organ Resection for Solid Pseudopapillary Neoplasms of the Pancreas: A Single-institution Experience
Authors: Cheng Kun , Shen Baiyong , Peng Chenghong , Yuan Fei , Yin Qihua
Published: June 2020

Solid pseudopapillary neoplasms of the pancreas (SPN) have been reported increasingly; however, series focusing on portal-superior mesenteric vein (PV/SMV) or adjacent organ resection are limited in the literature. The aim of this study was to present our experience in treating patients with SPN who underwent this extensive resection. Ten eligible patients were retrospectively reviewed and analyzed. Eight females and two males with a median age of 23 years (range, 11 to 58 years) and a median tumor diameter of 12 cm (range, 4 to 20 cm) were observed. All patients had imaging signs of vascular and/or adjacent organ involvement. Resection with curative intent was performed in all patients; eight underwent synchronous PV/SMV resection and two underwent synchronous left nephrectomy. Malignant SPN was confirmed in seven patients. Postoperative mortality was nil and morbidity occurred in five patients. At a median follow-up of 67.5 months (range, 12 to 110 months), nine patients were alive with no evidence of disease and one died of liver metastases. In conclusion, malignant SPN are low-grade tumors with good prognosis. More aggressive attitude should be adopted when PV/SMVor adjacent organ involvement is indicated on preoperative imaging. En bloc synchronous PV/SMV or adjacent organ resection should be applied, when necessary, to achieve complete resection.
The Need for Fundoplication at the Time of Laparoscopic Paraesophageal Hernia Repair
Authors: Van Der Westhuizen Lionel , Dunphy Kaitlyn M. , Knott Brianna , Carbonell Alfredo M. , Smith Dane E. , Cobb William S.
Published: June 2020

Most authors recommend an antireflux operation at the time of laparoscopic paraesophageal hernia (PEH) repair. A fundoplication combats the potential postoperative reflux resulting from disruption of the hiatal anatomy and may minimize recurrence. The purpose of this study is to evaluate the differences in postoperative dysphagia, reflux symptoms, and hiatal hernia recurrence in patients with and without a fundoplication at the time of laparoscopic paraesophageal hernia repair. Patients undergoing laparoscopic PEH repair from July 2006 to June 2012 were identified. Open repairs and reoperative cases were excluded. Patient characteristics, operative details, complications, and postoperative outcomes were recorded. Over the six-year period, 152 laparoscopic PEH repairs were performed. Mean age was 65.8 years (range, 31 to 92) and average body mass index was 29.9 kg/m2 (range, 18 to 52 kg/m2). Concomitant fundoplication was performed in 130 patients (86%), which was determined based on preoperative symptoms and esophageal motility. Mean operative times were similar with fundoplication (188 minutes) and without (184.5 minutes). At a mean follow-up of 13.9 months, there were 19 recurrences: 12.3 per cent (16 of 130) in the fundoplication group and 13.6 per cent (three of 22) in those without. Dysphagia lasting greater than six weeks was present in eight patients in the fundoplication group (6.2%) and in none in those without ( P = 0.603). Eighteen percent of patients without a fundoplication reported postoperative reflux compared with 5.4 per cent of patients with a fundoplication ( P = 0.055). In the laparoscopic repair of PEH, the addition of a fundoplication minimizes postoperative reflux symptoms without additional operative time. Neither dysphagia nor hiatal hernia recurrence is affected by the presence of a fundoplication.
Validity of Agency for Healthcare Research and Quality Patient Safety Indicators at an Academic Medical Center
Authors: Ramanathan Rajesh , Leavell Patricia , Stockslager Gregory , Mays Catherine , Harvey Dale , Duane Therese M.
Published: June 2020

The Agency for Healthcare Research and Quality developed Patient Safety Indicators (PSI) to screen for in-hospital complications and patient safety events through International Classification of Diseases, 9th Revision, Clinical Modification coding. The purpose of this study was to validate 10 common surgically related PSIs at our academic medical center and investigate the causes for inaccuracies. We reviewed patient records between October 2011 and September 2012 at our urban academic medical center for 10 common surgically related PSIs. The records were reviewed for incorrectly identified PSIs and a subset was further reviewed for the contributing factors. There were 93,169 charts analyzed for PSIs and 358 PSIs were identified (3.84 per 1000 cases). The overall positive predictive value (PPV) was 83 per cent (95% confidence interval 79 to -86%). The lowest PPVs were associated with catheter-related bloodstream infections (67%), postoperative respiratory failure (71%), and pressure ulcers (79%). The most common contributing factors for incorrect PSIs were coding errors (30%), documentation errors (19%), and insufficient criteria for PSI in the chart (16%). We conclude that the validity of PSIs is low and could be improved by increased education for clinicians and coders. In their current form, PSIs remain suboptimal for widespread use in public reporting and pay-for-performance evaluation.
Blunt Traumatic Bladder Rupture: A 10-year Perspective
Authors: Matlock Kinzie A. , Tyroch Alan H. , Kronfol Ziad N. , McLean Susan F. , Pirela-Cruz Miguel A.
Published: June 2020

The purpose of this study was to determine the incidence, features, and associated injuries of intraperitoneal (IP) and extraperitoneal (EP) bladder rupture (BR) resulting from blunt trauma. A retrospective study from September 2001 to August 2011 was performed for blunt traumatic BR in adults. Demographics, mean Injury Severity Score (ISS), mean length of stay (LOS), incidence, mortality, operative repair, and associated injuries were evaluated. Of 15,168 adult blunt trauma admissions over 10 years, 54 patients had BR (EP = 22, IP = 27, EP + IP = 5; incidence = 0.36%). Sixty-three per cent were male. The mean age, ISS, and LOS were 40 years, 29, and 15 days, respectively. The mortality rate was 11 per cent. Fifty-two per cent of BR was the result of a motor vehicle crash. Most BRs were diagnosed by computed tomography cystogram. Eighty per cent had pelvic fracture. Hollow viscus injury was present in 34.5 per cent of patients. Colonic injury was seen in 24 per cent and 9.3 per cent had a rectal injury. Although BR is rare in adult blunt trauma, it is associated with high ISS, LOS, and mortality. Pelvic fractures are essentially present in all patients with EP BR. Hollow viscus injuries, especially colonic and rectal injuries, are more prominent in IP BR.
Abdominal Compartment Syndrome is an Early, Lethal Complication of Acute Pancreatitis
Authors: Boone Brian , Zureikat Amer , Hughes Steven J. , Moser A. James , Yadav Dhiraj , Zeh Herbert J. , Lee Kenneth K. W.
Published: June 2020

Data defining the optimal management of abdominal compartment syndrome resulting from acute pancreatitis are lacking. We investigated the outcomes of patients with acute pancreatitis who underwent surgery for treatment of abdominal compartment syndrome at a tertiary referral center. An electronic database was searched to identify patients with acute pancreatitis who underwent laparotomy between January 1, 2000, and December 31, 2009, for treatment of abdominal compartment syndrome. Twelve patients underwent decompressive laparotomy for abdominal compartment syndrome. The median interval between onset of pancreatitis and laparotomy was 4.5 days. Nine patients underwent a laparotomy within seven days of onset of pancreatitis. As a result of cardiopulmonary instability, four decompressive laparotomies were performed in the intensive care unit. In 11 patients, cardiopulmonary improvement was observed. Statistically significant improvements were seen across multiple physiologic parameters. Despite this initial improvement, six patients (50%) died from multisystem organ failure. Two patients survived without need for pancreatic débridement. Abdominal compartment syndrome is an uncommon but likely underrecognized and highly lethal complication of acute pancreatitis that should be considered in patients who become critically ill early in the course of their pancreatitis. Prompt recognition and decompressive laparotomy may rescue some of these patients and does not mandate future débridement.
Fast-track Pathway for Minimally Invasive Colorectal Surgery with and without Alvimopan (Entereg)™: Which is More Cost-effective?
Authors: Kelley Scott R. , Wolff Bruce G. , Lovely Jenna K. , Larson David W.
Published: June 2020

Multimodal fast-track (FT) pathways for both open and laparoscopic colorectal surgery have been shown to improve gastrointestinal recovery, shorten length of stay, and decrease morbidity. The aim of our study was to determine if using alvimopan (Entereg)™ in the setting of a FT minimally invasive colorectal pathway is beneficial and cost-effective. All minimally invasive colorectal surgeries performed by one surgeon using a multimodal FT pathway with and without alvimopan were reviewed. Ninety total patients were identified, 64 patients treated without and 26 with alvimopan. Main outcomes included postoperative day tolerating a soft diet, return of gastrointestinal function, length of stay, 30-day readmission rate, and patient care, anesthesia, pharmacy, and combined cost. Tolerance of a soft diet, return of gastrointestinal function, and length of stay were all shorter and showed significance in the alvimopan group (mean 2.1 vs 2.8 days, mean 1.5 vs 2.4 days, and mean 3.5 vs 4.5 days, respectively) ( P = 0.0197, P = 0.0029, and 0.0158, respectively). Patient care and combined hospital costs were both increased in the nonalvimopan group; however, combined hospital costs was not significant ( P = 0.0216 and P = 0.0875, respectively). The 30-day readmission rate of 6.3 per cent was also not significant in this group ( P = 0.0941). Patients undergoing minimally invasive colorectal surgery treated with a multimodal FT pathway tolerated a soft diet sooner, had earlier return of bowel function, a shorter length of stay, and lower patient care and combined costs when alvimopan was used.
Accuracy of Computed Tomography in Small Bowel Obstruction
Authors: Barnett Rebecca E. , Younga Jason , Harris Brady , Keskey Robert C. , Nisbett Daryl , Perry Jonathan , Cheadle William G.
Published: June 2020

Small bowel obstruction is a common clinical occurrence, primarily caused by adhesions. The diagnosis is usually made on the clinical findings and the presence of dilated bowel loops on plain abdominal radiograph. Computed tomography (CT) is increasingly used to diagnose the cause and location of the obstruction to aid in the timing of surgical intervention. We used a retrospective chart review to identify patients with a diagnosis of small bowel obstruction between 2009 and 2012. We compared the findings on CT with the findings at operative intervention. Sixty patients had abdominal CT and subsequent surgical intervention. Eighty-three per cent of CTs were correct for small intestine involvement and 80 per cent for colon involvement. The presence of adhesions or perforation was correctly identified in 21 and 50 per cent, respectively. Sixty-four per cent correctly identified a transition point. The presence of a mass was correctly identified in 69 per cent. Twenty per cent of the patients who had ischemic small bowel at surgery were identified on CT. CT has a role in the clinical assessment of patients with small bowel obstruction, identifying with reasonable accuracy the extent of bowel involvement and the presence of masses and transition points. It is less reliable at identifying adhesions, perforations, or ischemic bowel.
Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis from Small Bowel Adenocarcinoma
Authors: Sun Yankai , Shen Perry , Stewart John H. , Russell Gregory B. , Levine Edward A.
Published: June 2020

Peritoneal carcinomatosis arising from small bowel adenocarcinoma (PCSBA) carries a dismal prognosis. Presently, limited data have been published on the outcome of PCSBA treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). This series represents the largest series published to date examining our experience with 17 patients. From 1995 to 2011, 17 patients underwent HIPEC with mitomycin for PCSBA. Patients in this study were identified from a prospectively maintained database. Twenty HIPEC procedures were performed on 17 patients with a mean age of 52.2 years. Patients have achieved a mean overall postoperative survival of 18.4 months after progression on chemotherapy with an overall postoperative one- and three-year survival of 52 and 23 per cent, respectively. The mean total length of hospital stay was 10 days. There was no treatment-related mortality. Six patients were readmitted to the hospital within 30 days of discharge (35%). Eight patients (47%) experienced postoperative complications, in which two patients had major postoperative complications in the form of intra-abdominal abscess requiring interventions (12%). HIPEC has encouraging survival results for patients with PCSBA compared with similar patients treated with conventional treatments. However, even with such advancement in management, treatment for small bowel adenocarcinoma still remains a challenge.
Gastrointestinal Stromal Tumors: A Single Institution Experience of 176 Surgical Patients
Authors: Fisher Sarah B. , Kim Steven C. , Kooby David A. , Cardona Kenneth , Russell Maria C. , Delman Keith A. , Staley Charles A. , Maithel Shishir K.
Published: June 2020

Large single-institution series of patients undergoing resection for gastrointestinal stromal tumors (GIST) are lacking. Clinicopathologic characteristics and postoperative outcomes were retrospectively collected and analyzed from patients undergoing resection for GIST from 2002 to 2011. One hundred seventy-six patients were identified; 156 underwent resection of primary nonmetastatic disease. KIT mutations were identified in 131 patients (84.0%). Of the 156 patients with primary disease, the most common site was the stomach (75.6%). Tumors were categorized as very low (24.4%), low (35.9%), intermediate (12.2%), high (24.4%), or unknown (3.2%) risk. Symptomatic patients more often had high risk (35.6 vs 9.8%; P < 0.0001) and larger tumors (7.3 vs 3.0 cm; P < 0.0001). Forty-seven patients (30.1%) underwent laparoscopic resection (LR). Compared with open surgery, LR was performed for smaller tumors (3.8 vs 6.2 cm; P = 0.002). Positive margin rates were similar (4.3% LR vs 10.2% open; P = 0.346). Median follow-up for the 156 patients with primary tumors was 32.9 months; mean overall survival was 120.9 months (median not reached). Of the 20 patients with metastatic GIST (excluded from above analysis), five patients (25.0%) died of disease with a median follow-up of 15.9 months. Most patients with resectable primary GIST have a favorable prognosis. The presence of symptoms directly related to GIST may be associated with a poor prognosis and is likely related to increased tumor size. Laparoscopic resection is well tolerated and does not appear to compromise outcomes in well-selected patients. Highly selected patients with metastatic disease may benefit from resection.
Abdominal versus Perineal Approach for Treatment of Rectal Prolapse: Comparable Safety in a Propensity-matched Cohort
Authors: Mustain W. Conan , Davenport Daniel L. , Parcells Jeremy P. , Vargas H. David , Hourigan Jon S.
Published: June 2020

Abdominal operations for rectal prolapse are associated with lower recurrence rates than perineal procedures but presumed higher morbidity. Therefore, perineal procedures are recommended for patients deemed unfit for abdominal repair. Consequently, bias confounds retrospective comparisons of the two approaches. To clarify the impact of operative approach on outcomes, we analyzed abdominal and perineal procedures in a propensity score-matched analysis. We selected patients undergoing surgery for rectal prolapse from the American College of Surgeons National Surgical Quality Improvement Program data set from 2005 to 2010. We grouped procedures as abdominal or perineal. We identified preoperative variables predictive of complications and regressed against operative approach. The resulting propensity score was used to select a matched cohort with similar clinical risk. We identified 2188 patients (848 abdominal [38.8%]; 1340 perineal [61.2%]). Patients undergoing the perineal approach had higher rates of most risk variables. Propensity matching resulted in 563 matched pairs (1126 patients) with similar clinical risk. In this matched cohort, no significant difference was found in the rate of any complication between the operative approaches; mortality was 0.9 per cent in each group ( P = 1.0). Relative risk for major morbidity after abdominal approach was 1.39 (95% confidence interval, 0.92 to 2.10; P = 0.15). Although many patients with rectal prolapse are high risk for abdominal surgery, our study indicates that many patients treated by perineal repair could be safely treated with a more durable operation.
The Regionalization of Ventral Hernia Repair: Occurrence and Outcomes over a Decade
Authors: Colavita Paul D. , Walters Amanda L. , Tsirline Victor B. , Belyansky Igor , Lincourt Amy E. , Kercher Kent W. , Sing Ronald F. , Heniford B. Todd
Published: June 2020

Ventral hernia repairs (VHRs) have always been considered standard general surgery cases. Recently, there has been a call for “Centers of Excellence.” We sought to investigate outcomes and trends between high- and low-volume centers. The Nationwide Inpatient Sample (NIS) data were analyzed from 1998–1999 (T1) and 2008–2009 (T2) for all VHRs. Hospitals were stratified into high-, medium-, and low-volume centers (HVC/MVC/LVC). Demographics, comorbidities, and outcomes were compared. Surgical cases totaled 22,771 in T1 and 37,044 in T2. In T1, 34.3 per cent were performed in HVC versus 64.2 per cent in T2 ( P < 0.0001). LVC cases decreased between eras: 32.6 versus 16.1 per cent ( P < 0.0001). Comorbidities and emergent admissions increased with time ( P < 0.0001). Mortality was similar in both eras and between volume centers. Length of stay was less in LVC in T2 only (4.2 vs 4.8 days, P < 0.0001). Total charges were higher in HVCs in both eras ( P < 0.0001). These remained significant in T2 in multivariate regression (MVR). Hospital volume was not associated with most complications or death in either era with MVR. Charlson comorbidity score, age, and emergent admission were predictors of complications and death. Regionalization has occurred for VHRs. However, most complication and mortality rates are unrelated to volume and are linked to comorbidities, age, and emergencies.
Using a Relational Database to Improve Mortality and Length of Stay for a Department of Surgery: A Comparative Review of 5200 Patients
Authors: Ang Darwin N. , Behrns Kevin E.
Published: June 2020

The emphasis on high-quality care has spawned the development of quality programs, most of which focus on broad outcome measures across a diverse group of providers. Our aim was to investigate the clinical outcomes for a department of surgery with multiple service lines of patient care using a relational database. Mortality, length of stay (LOS), patient safety indicators (PSIs), and hospital-acquired conditions were examined for each service line. Expected values for mortality and LOS were derived from University HealthSystem Consortium regression models, whereas expected values for PSIs were derived from Agency for Healthcare Research and Quality regression models. Overall, 5200 patients were evaluated from the months of January through May of both 2011 (n = 2550) and 2012 (n = 2650). The overall observed-to-expected (O/E) ratio of mortality improved from 1.03 to 0.92. The overall O/E ratio for LOS improved from 0.92 to 0.89. PSIs that predicted mortality included postoperative sepsis (O/E:1.89), postoperative respiratory failure (O/E:1.83), postoperative metabolic derangement (O/E:1.81), and postoperative deep vein thrombosis or pulmonary embolus (O/E:1.8). Mortality and LOS can be improved by using a relational database with outcomes reported to specific service lines. Service line quality can be influenced by distribution of frequent reports, group meetings, and service line-directed interventions.
SESC Practice Committee Survey: Surgical Practice in the Duty-hour Restriction Era
Authors: Nakayama Don K. , Taylor Spence M.
Published: June 2020

Debate continues as to the relevance of Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions in actual practice and the adequacy of resident training in surgery. A survey of the membership of the Southeastern Surgical Congress using an Internet-based questionnaire was conducted: adherence to duty-hour restrictions, evidence of sleepiness and fatigue, opinions regarding the training, and clinical performance of surgeons who had trained after the institution of duty-hour restrictions in 2003 (termed “recently trained surgeons”). One hundred seventy-seven members respondents out of 1008 (18%). Most (101 of 170 [59%]) worked more than 80 hours in a week and half (86 of 174 [49%]) more than 24 hours consecutively once or more a month. Falling asleep inappropriately was reported by 6 to 12 per cent. Forty per cent (71 of 176) thought that graduates of residencies today are prepared for clinical practice. Those who had hired a recently trained surgeon believed the latter was sufficiently trained (61 of 123 [50%]) more often than those who had not hired one (10 of 51 [20%]; P = 0.006). Those with a new colleague gave first assistant help in 75 per cent (91 of 121) during the first year. Surgeons in practice regularly violate ACGME duty-hour restrictions. Many surgeons have doubts whether new graduates of residency training programs have adequate training to practice surgery. Those who have hired a new surgeon trained under duty-hour restrictions are more likely to be satisfied with the latter's training. Most new trainees receive direct assistance from their practice partners, continuing their training beyond residency.
Evaluation of Alpha-fetoprotein Staging System for Hepatocellular Carcinoma in Noncirrhotic Patients
Authors: Burnett Nicolas P. , Dunki-Jacobs Erik M. , Callender Glenda G. , Anderson Ryan J. , Scoggins Charles R. , McMasters Kelly M. , Martin Robert C.G.
Published: June 2020

The Barcelona Clinic Liver Cancer (BCLC) staging classification is commonly used for staging hepatocellular carcinoma (HCC). This system assumes the coexistence of cirrhosis; however, a significant proportion of patients with HCC present without cirrhosis. Recently, an alternative system was proposed that stratifies patients according to alpha-fetoprotein (AFP) level. The aim of this study was to apply the AFP staging system to noncirrhotic patients with HCC and evaluate its ability to predict overall survival (OS). A prospective hepatopancreatobiliary database was reviewed for all patients with a diagnosis of HCC. Patients were staged based on BCLC classification as well as by AFP stage according to four levels: less than 10 ng/mL, 10 to 150 ng/mL, 150 to 500 ng/mL, and greater than 500 ng/mL. Cirrhotic patients were compared with noncirrhotic patients in terms of patient demographics and HCC stage. Kaplan-Meier (KM) analysis of OS was performed for noncirrhotic patients according to BCLC and AFP staging systems. Cirrhotic and noncirrhotic patients differed significantly in terms of median age at presentation (64 vs 70 years, P < 0.001) and gender (76 vs 65% male, P = 0.006). BCLS staging classification did not distinguish between cirrhotics and noncirrhotics ( P = 0.733), whereas AFP staging demonstrated a significant difference between the two groups ( P < 0.0001). KM analysis of OS for noncirrhotic patients with HCC was significant for both the BCLC and the AFP staging systems ( P = 0.003 vs P < 0.0001, respectively). Patients presenting with HCC in the absence of cirrhosis appear to have different characteristics than patients with cirrhosis. Staging according to AFP level is an appropriate predictor of prognosis in noncirrhotic patients with HCC.
Use of Damage Control and the Open Abdomen in Combat
Authors: Bograd Benjamin , Rodriguez Carlos , Amdur Richard , Gage Fred , Elster Eric , Dunne James
Published: June 2020

Despite the well-documented use of damage control laparotomy (DCL) in civilian trauma, its use has not been well described in the combat setting. Therefore, we sought to document the use of DCL and to investigate its effect on patient outcome. Prospective data were collected on 1603 combat casualties injured between April 2003 and January 2009. One hundred seventy patients (11%) underwent an exploratory laparotomy (ex lap) in theater and comprised the study cohort. DCL was defined as an abbreviated ex lap resulting in an open abdomen. Patients were stratified by age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), mechanism of injury, and blood product administration. Multivariate regression analyses were used to determine risks factors for intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and the need for DCL. Mean age of the cohort was 24 ± 5 years, ISS was 21 ± 11, and 94 per cent sustained penetrating injury. Patients with DCL comprised 50.6 per cent (n = 86) of the study cohort and had significant increases in ICU admission ( P < 0.001), ICU LOS ( P < 0.001), HLOS ( P < 0.05), ventilator days ( P < 0.001), abdominal complications ( P < 0.05), but not mortality ( P = 0.65) compared with patients without DCL. When compared with the non-DCL group, patients undergoing DCL required significantly more blood products (packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate; P < 0.001). Multivariate regression analyses revealed blood transfusion and GCS as significant risk factors for DCL ( P < 0.05). Patients undergoing DCL had increased complications and resource use but not mortality compared with patients not undergoing DCL. The need for combat DCL may be different compared with civilian use. Prospective studies to evaluate outcomes of DCL are warranted.
Patterns of Early Mortality after Trauma in a Neighborhood Urban Trauma Center: Can We Improve Outcomes?
Authors: Berbiglia Lindsay , Lopez Peter P. , Bair Leah , Ammon Adelaide , Navas Gwyneth , Keller Melissa , Diebel Lawrence N.
Published: June 2020

Even with specialized trauma systems, a significant number of deaths occur within the early postinjury period. Our goal was to examine deaths within this period for cause and determine if care could improve outcomes. A retrospective chart review was performed on all patients who were dead on arrival or died within 4 hours of arrival between January 1, 2005, and December 31, 2011. Survival probabilities and Injury Severity Score (ISS) were calculated. Chart review and trauma review processes were used to determine cases with opportunities for care improvement. Two hundred eighty-nine patients were dead on arrival (DOA), and 176 patients died within 4 hours of arrival. The most common mechanism of injury was gunshot wounds (68.4%). The most common causes of death were uncontrolled hemorrhage (68.2%) and neurologic trauma (23.4%). Average ISS was 32. Twenty-nine patients had survival probability percentages over 50. Ten of 176 (5.7%) deaths were found to have opportunities for care improvement. In three cases (1.7%), errors contributed to death. The majority of trauma patients DOA or dying within 4 hours of hospital arrival have nonsurvivable injuries. Regular trauma review processes are invaluable in determining opportunities for care improvement. Autopsy information increases the reliability of the review process.