bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiac Herniation after Intrapericardial Pneumonectomy and Subsequent Cardiac Tamponade
Authors: Kiev Jon , Parker Mark , Zhao Xian , Kasirajan Vigneshwar
Published: June 2020

The first case of postpneumonectomy cardiac herniation was described in 1948. Despite advances in surgical technique and patient care, this very rare, potential surgical catastrophe may still be seen today. We present a similar case to that of the original description, but furthermore accentuated by an additional unsuspected surgical complication. This case involves a 59-year-old African-American man initially treated with radical pneumonectomy to resect an invasive T3 squamous cell lung cancer. After surgical resection, the patient developed both clinical and radiographic manifestations of cardiac herniation. Primary suture repair of the pericardial sac led to subsequent cardiac tamponade necessitating correction with Prolene mesh.
Cholangitis: Analysis of Admission Prognostic Indicators and Outcomes
Authors: Rosing David K. , De Virgilio Christian , Nguyen Alex T. , Masry Monica El , Kaji Amy H. , Stabile Bruce E.
Published: June 2020

Acute cholangitis is a life-threatening complication of biliary obstruction that is exacerbated by delays in diagnosis and treatment. Since the introduction of endoscopic retrograde cholangiography and endoscopic therapeutic modalities, few investigations have addressed admission prognostic indicators of adverse outcomes. A retrospective review of all patients with a diagnosis of acute cholangitis from 1995 to 2005 was performed. Primary endpoints were organ failure and death. One-hundred and seventeen patients met criteria for acute cholangitis. Only 49 (42%) had Charcot's triad and 3 (3%) had Reynolds’ pentad. One-hundred and four (89%) patients underwent biliary decompression, of which 79 (76%) were treated by endoscopic methods. There were 29 (25%) cases of organ failure and 9 (8%) deaths. The admission white blood cell (WBC) count ( P = 0.0003) and total bilirubin (TBili) ( P = 0.04) were statistically significant predictors of organ failure or death. With an admission of WBC ≥ 20,000 cells/mm3, the sensitivity, specificity, positive predictive value, and negative predictive value for organ failure and death were 50 per cent, 92 per cent, 63 per cent, and 88 per cent, respectively. A TBili of ≥10 mg/dL had sensitivity, specificity, positive predictive value, and negative predictive value of 56 per cent, 85 per cent, 21 per cent, and 96 per cent, respectively for predicting death. Admission WBC ≥ 20,000 cells/mm3 and TBili ≥ 10 mg/dL are selective predictors of adverse outcomes in acute cholangitis.
Improved Outcomes Using a Systematic and Evidence-Based Approach to the Laparoscopic Roux-En-Y Gastric Bypass in a Single Academic Institution
Authors: Hwa Han Soo , Gracia Carlos , Mehran Amir , Basa Nicole , Hines Joe , Suleman Lubna , Vira Darshni , Dutson Erik
Published: June 2020

No standardized approach exists for laparoscopic Roux-en-Y gastric bypass (LRYGB). At a newly instituted bariatric surgery program, four experienced laparoscopic surgeons used the systematic and evidence-based approach consisting of multidisciplinary preoperative evaluation, screening, and education; standardized operative technique; inpatient clinical pathway; and close postoperative follow-up. The outcomes were subsequently analyzed to determine if this approach improved the morbidity and mortality. From January 2003 to June 2006, 835 consecutive LRYGBs were performed. The patient population was 85 per cent women with a mean body mass index (BMI) of 50.4 kg/m2 (range 33–96 kg/m2). The mean age was 44 (range 15–67). Sixty-two per cent of the patients had previous abdominal or pelvic operations. The conversion rate to open surgery was 0.2 per cent. The average length of hospital stay was 2.6 days (range 2–13 days). There were no anastomotic leaks or deaths. The 30-day readmission and re-operation rates were 3.2 per cent and 1.8 per cent, respectively. The incidence of anastomotic stricture, marginal ulcer, bleeding, pulmonary embolism, and internal hernia was 0.8 per cent, 3.5 per cent, 4.2 per cent, 0.1 per cent, and 0.4 per cent, respectively. A systematic and evidence-based approach to the LRYGB by experienced laparoscopic surgeons resulted in a lower incidence of complications when compared with the published results from other comparable institutions.
Is High BMI Associated with Specific Complications after Laparoscopic Roux-en-Y Gastric Bypass?
Authors: Parikh Janak , Yermilov Irina , Mcgory Marcia , Jain Sushma , Ko Clifford Y. , Maggard Melinda
Published: June 2020

Controversy remains whether patients with body mass index (BMI) ≥ 50 kg/m2 experience more complications after laparoscopic Roux-en-y gastric bypass (LRYGB) than those with a lower BMI. Whether BMI ≥ 50 kg/m2 is associated with specific complications remains unknown. Charts of 152 patients who underwent LRYGB were reviewed. Logistic regression was used to determine whether high BMI is associated with minor or major complications. Overall, there was a trend that major complications occurred more frequently in patients with BMI ≥ 50 compared with BMI < 50, (30.4% vs 19.8%, P = 0.138). Major bleeding complications occurred in 16.1 per cent of high BMI patients as compared with 5.2 per cent with lower BMI ( P = 0.025). Multivariate regression found that BMI ≥ 50 was associated with higher odds of a major technical complication (OR = 2.73, P = 0.04), particularly for bleeding complications (odds ratio [OR] = 5.59, P = 0.01). Male gender was also associated with higher odds of a major technical complication (OR = 3.43, P = 0.04). These results suggest that high BMI patients may be better candidates for other types of weight loss surgery, such as staged procedures, and that surgeons early in their career should operate on patients with lower BMI.
Lymphatic Mapping in Patients with Breast Cancer and Previous Augmentation Mammoplasty
Authors: Kaminski Anna , Amr Dena , Kimbrell Melinda Lacerna , Difronzo L. Andrew
Published: June 2020

Sentinel lymph node biopsy (SLNB) is now an established method of axillary staging in patients with breast cancer. However, the augmented breast poses an interesting challenge to this procedure. We hypothesized that SLNB is feasible in patients with augmented breasts who subsequently develop breast cancer. A retrospective study was performed from 1995 to 2006. Ten patients with augmented breasts underwent breast conservation therapy with SLNB. Sentinel lymph nodes were identified in all 10 patients. Three patients had positive sentinel nodes. Two patients proceeded to axillary lymph node dissection (ALND), and one declined. The subsequent ALND were negative for metastatic cancer. Seven patients had negative sentinel nodes. One patient with a negative sentinel node underwent ALND with all nodes negative for metastasis. Two patients were lost to follow-up. Of the remaining eight patients, the mean duration of follow-up was 71 months. None of these patients had evidence of axillary recurrence or distant metastasis at time of last follow-up. SLNB is a feasible method of axillary node staging in patients who have undergone augmentation mammoplasty who subsequently develop breast cancer. Further studies are needed to better determine the accuracy of lymphatic mapping in this patient population.
Reanalysis of Prehospital Intravenous Fluid Administration in Patients with Penetrating Truncal Injury and Field Hypotension
Authors: Yaghoubian Arezou , Lewis Roger J. , Putnam Brant , De Virgilio Christian
Published: June 2020

In 1994, Bickell et al. published a prospective study recommending restricting prehospital intravenous fluids (IVF) to less than 100 cc in patients with penetrating truncal injuries and field hypotension, reporting a 30 per cent mortality with IVF restriction and a 38 per cent mortality with liberal IVF use. However, since this study, few papers have investigated whether emergency medical systems (EMS) adhere to these IVF guidelines. The purpose of this study was to determine whether a policy of IVF restriction is being followed and whether the volume of prehospital and emergency department (ED) IVF affects outcome in patients with penetrating truncal injury and field hypotension at a Level I trauma center in Los Angeles County. A retrospective analysis of a trauma database from 1998 to 2005 of all patients with penetrating truncal injury and field hypotension (systolic blood pressure less than 90 mm Hg) was performed. Multiple variables, including originating EMS agency, mechanism of injury, transport time, Injury Severity Score, field and ED vital signs, and IVF volume infused, complications, and mortality were compared. One hundred ninety-four patients with a median age of 26 years with penetrating truncal injury and field hypotension were analyzed. The most common mechanisms of injury were gunshot (73%) and stab (22%) wounds. The median field systolic blood pressure was 80 mm Hg. The median transport time was 11 minutes. The median prehospital IVF was 500 cc with only 25 per cent receiving less than 100 cc of IVF. There were no differences in the amount of IVF administered by the degree of field hypotension or by originating EMS agency. Median ED IVF was 1000 cc. The overall mortality rate was 25 per cent. When a comparison was made of those receiving less than 100 cc prehospital IVF in comparison to those receiving greater than 100 cc, there were no differences detected with respect to median age, systolic blood pressure, Injury Severity Score, transport time, or morbidity rate. The mortality rate was 21 per cent in the group that received greater than 100 cc of IVF in comparison to a 37 per cent mortality rate in the group that received less than 100 cc IVF ( P = 0.04). On multivariate analysis, after adjusting for Trauma Injury Severity Score, there were no differences in survival by the amount of prehospital or ED IVF administered. It appears that the recommendations of IVF restriction for patients with penetrating truncal injuries and field hypotension are not being followed by Los Angeles County EMS. There were no differences in survival with respect to the amount of prehospital or ED IVF. Given the retrospective nature of this study, further investigation is needed to define the role of prehospital IVF resuscitation in these patients.
The Role of Positron Emission Tomography Scanning in Patients with Radioactive Iodine Scan-Negative, Recurrent Differentiated Thyroid Cancer
Authors: Roberts Micah , Maghami Ellie , Kandeel Fouad , Yamauchi David , Ellenhorn Hannah-Leeba , Ellenhorn Joshua D.I.
Published: June 2020

An elevated thyroglobulin (Tg) level after total thyroidectomy for differentiated thyroid cancer is often associated with disease recurrence. 131I-whole body scans (131I-WBS) and cross-sectional imaging are commonly used to localize occult metastases in these patients. Localizing disease when 131I-WBS are negative and cross-section imaging is equivocal remains a challenge. The medical records of 12 patients with thyroid cancer undergoing positive positron emission tomography (PET) scans for 131I-WBS-negativeTg elevations or the presence of anti-Tg antibodies were identified and charts were reviewed in a retrospective fashion. All had been treated with total thyroidectomy and 131I ablation in the past. Computed tomography, magnetic resonance imaging, or ultrasound studies revealed suspicious lesions in eight patients. All 12 patients underwent resection of the PET-positive lesions. All resections were positive for thyroid cancer in the regions predicted by the positive PET scan. All nine (100%) patients with elevated preoperative Tg levels experienced a reduction in Tg level after resection. PET scans accurately predict the presence of recurrent thyroid cancer when 131I-WBS are negative. PET scans should be considered in the follow up of 131I-WBS-negative patients with thyroid cancer who are suspected of having recurrent disease.
Duodenal Lymphoma: A Rare and Morbid Tumor
Authors: Chestovich Paul J. , Schiller Gary , Sasu Sebastian , Hiatt Jonathan R.
Published: June 2020

We conducted a retrospective tumor registry review of a 36-year experience in a university center and identified 10 patients with duodenal lymphoma (five localized, five disseminated). Histologic types included diffuse large B-cell in four patients, mucosa-associated lymphoid tumor in three, and Hodgkin, follicular, and unclassified (one each). Treatments included chemotherapy in four patients, radiation therapy (RT) in two patients, Helicobacter pylori treatment in two, and observation in one. Five patients underwent operations (emergent in two, elective in three) for indications including massive bleeding in two patients, obstruction in two, or both in one. Survival for surgical group was 25 per cent at 1 year. One-year survival for nonsurgical group was 100 per cent, and all nonoperated patients lived at least 5 years, except for one who is alive 2 years after diagnosis. Surgical patients were younger and had more advanced lesions and less favorable cell types. When operation is required for bleeding or obstruction from secondary tumors in younger patients with disseminated disease, surgical challenges are formidable and survival is very limited. Tumors of less aggressive histology have far better prognosis.
Light-Assisted Stab Phlebectomy: Early Postoperative Experience
Authors: Vardanian Andrew J. , Cao Huynh L. , Lawrence Peter F.
Published: June 2020

Light-assisted stab phlebectomy (LASP) is a technique that we have developed for treatment of lower extremity varicose veins. It combines powered and stab phlebectomy with minimally invasive surgical instruments to optimize intraoperative visualization of varicose veins and to remove branch veins with minimal bruising, hematoma, or pain. The early experience with this technique has not been reported. We conducted a retrospective review of all patients who underwent LASP to characterize the associated perioperative experience and to identify postoperative factors that indicated a successful outcome. From 2004 to 2006, LASP was performed on 268 limbs to remove lower extremity branch veins. The majority of patients were women (75%), and the mean age was 52 years. A group of 184 patients underwent LASP in combination with another procedure, and 49 patients underwent LASP alone. Nearly all patients had conscious sedation for anesthesia (99%); operating room time averaged 44 minutes, and blood loss averaged 88 cc. Immediate postoperative complications were infrequent, occurring in 10 per cent of patients, and included unresected or missed veins, hematoma, and cellulitis. LASP provides improved visualization of branch veins and allows varicose veins to be removed with a short operating room time and minor postoperative complications.
Is Wide Local Excision for Pilonidal Disease Still Justified?
Authors: Tejirian Talar , Lee Jenny J. , Abbas Maher A.
Published: June 2020

There is an ongoing debate regarding the optimal operation for chronic pilonidal disease. The current study analyzes the outcome of wide local excision (WLE) compared with unroofing and marsupialization (UM) as primary intervention for chronic pilonidal disease. A retrospective review of a single institution experience over a 5-year period was performed. Sixty-eight patients were treated for pilonidal disease. Their mean age was 25 years. There were 42 males (62%) and 26 females (38%). Twenty-six patients underwent WLE and 42 had UM. The type of operation was based on surgeon preference, but individual surgeons were consistent with their choice. Mean time for final healing was significantly higher for WLE compared with UM (21 vs 6 weeks, P < 0.01). Postoperative complications and reoperative rate were significantly higher in the WLE group ( P < 0.01). Nine patients in the WLE group (35%) required one or more reoperations compared with only one (2%) in the UM group ( P < 0.01). This study demonstrates that WLE carries a high complication and reoperative rate. UM should be considered as the initial operation for most patients with pilonidal disease.
The Abdominal Cocoon: A Rare Cause of Intestinal Obstruction in Two Patients
Authors: Cai Jun , Wang Yong , Xuan Zhengrong , Hering Justin , Helton Scott , Espat N. Joseph
Published: June 2020

The abdominal cocoon is a rare disease that is characterized by total or partial encasement of the small bowel by a thick and fibrotic membrane. After an increased number of case reports, the characteristic age group and sex distribution of abdominal cocoon have changed. Although the etiology is unknown, congenital malformation is implicated as the causative factor in the two patients in this report. Although preoperative diagnosis is a matter of challenge and usually made at laparotomy, our experience suggests that computed tomographic evidence of clustered small bowel loops encased by a thin membrane-like sac is a characteristic preoperative finding in patients with abdominal cocoon. Surgical removal of the membrane and adhesions is the most appropriate choice of therapy.
Ballistic Arterial Trauma to the Lower Extremity: Recent South African Experience
Authors: Degiannis Elias , Bowley Douglas M. , Bode Frank , Lynn William R. , Glapa Miriam , Baxter Shaun , Shapey James , Smith Martin D. , Doll Dietrich
Published: June 2020

The aim of this study was to determine the current outcome of gunshots to the arteries of the lower extremity. The authors conducted a retrospective analysis of 104 patients with gunshots to the femoral (n = 71) and popliteal (n = 33) artery. One hundred four patients presented over the 60-month period. Ninety-six (92%) were male and eight of 104 female. Ninety-nine were gunshot injuries, five from shotguns. Nine patients had injury to the common femoral artery, 62 patients had injury to the superficial femoral artery, and 33 had popliteal artery injury. One patient died in the emergency room and another died in the postoperative period, giving an overall in-hospital mortality of two of 104 (1.9%). Forty-three of 70 femoral reconstructions had completion angiograms compared with 20 of 32 popliteal artery reconstructions ( P = 1). Nineteen of 63 (30%) of the completion angiograms prompted revision of the reconstruction. Of the 63 patients who had completion angiograms, two of 63 (3%) required amputation. Seven of 39 (18%) patients who did not have completion angiograms required amputation ( P = 0.025). Including the primary amputation, there were 10 amputations in the 103 patients (9.7%) who survived to undergo operation. Ballistic arterial trauma of the lower limb leads to significant disability. Completion arteriography leads to revision of the reconstruction in nearly one-third of instances and significantly reduces amputation rate.
Fate of Retained Capsule: A Pathognomonic for Surgery
Authors: Agaba Emmanuel A. , Shamseddeen Hazem , Sasthakonar Venketesh , Sivalingham Vadamalayan , Shah Kavin G. , Ravikumar Thanjavur S. , Nadjari Howard , Denoto George
Published: June 2020

Since its introduction in 2001, Wireless Video Capsule enteroscopy is gaining acceptance due to its high diagnostic potential and minimal risk. In some centers, it offers an alternative approach to visualize the small intestine and to evaluate patients with suspected small bowel disease. We present a series of known complications of this procedure and call for a more proactive role in the management of retained capsule.
Perioperative Myocardial Infarction and Risk of Death with and without Preoperative Beta Blockers
Authors: Goldfarb Michael A. , Cavaretta Mark , Baker Thomas
Published: June 2020

This study compares patients who have had a myocardial infarction in the perioperative period who were on perioperative beta blockers with those who had a myocardial infarction and were not on perioperative beta blockers. The charts of 68 patients were reviewed retrospectively. The timing and diagnosis of the myocardial infarction, gender, age, type of surgery, type of anesthesia, diabetics, preoperative medical clearance, and deaths were recorded. A subgroup of patients who had significant bleeding perioperatively or postoperatively were compared with patients with no bleeding problems. From 1998 through 2006, there were 46,003 patients who had surgery and 68 perioperative infarcts. Of the 68 patients, 25 received perioperative beta blockers and 11 died. Of the 43 patients who did not receive beta blockers, 22 died. There was no statistically significant difference when the patients were analyzed for concomitant bleeding or nonbleeding with regards to survival and beta blockers.
Intestinal Obstruction and Ileus: Role of Computed Tomography Scan in Diagnosis and Management
Authors: Sebastian Vinod A. , Nebab Kevin J. , Goldfarb Michael A.
Published: June 2020

A significant proportion of patients with intestinal obstruction will be evaluated with a CT scan of the abdomen. This study presents a group of 97 patients diagnosed with mechanical obstruction or ileus on CT scan over a 16-month period at a community based teaching hospital and follows the further management of these patients. Our study shows that 43.3 per cent of patients with mechanical obstruction, diagnosed by CT scan, eventually needed surgical treatment. On the other hand, even when CT indicates ileus, 20 per cent of these patients may still require surgical intervention.
Laparoscopic Anterior Semifundoplication in Patients with Intrathoracic Stomach
Authors: Gockel Ines , Heintz Achim , Tong Trinh Tran , Domeyer Mario , Dahmen Anja , Junginger Theodor
Published: June 2020

The laparoscopic management of the intrathoracic stomach is still controversial. Laparoscopic semifundoplication in gastroesophageal reflux disease results in effective long-term reflux control and is, as compared with 360° Nissen fundoplication, associated with less frequent side effects such as dysphagia and gas bloat syndrome. The aim of our study was to evaluate the results of laparoscopic anterior semifundoplication in patients with intrathoracic stomach. Enrolled in this study are 19 patients (67.1 years of age; range, 37.5–83.7 years) with intrathoracic stomach undergoing laparoscopic anterior semifundoplication and a minimal follow up of 5 months postoperatively. The study covers the interval between August 1999 and March 2006. Including criterion was a minimum percentage of herniated intrathoracic stomach of 33 per cent. A standardized questionnaire was used for follow up and the modified symptomatic DeMeester score (0–9) was assessed. The median percentage of herniated stomach in the chest was 87.5 per cent (range, 33–100%). Seven patients revealed organo-axial volvulus of the stomach. Duration of preoperative symptoms was 24 months (range, 1–266 months) with a median follow up of 18 months (range, 5–76 months) postoperatively. The modified symptomatic DeMeester score was 0 (0–3). Thirteen of 19 patients were on no postoperative proton pump inhibitor medication. One patient had anatomic recurrence on late follow up at 27 months. The overall contentment with the surgical treatment on an analog scale from 0 to 10 was a median of 9. Although laparoscopic anterior semifundoplication yields satisfactory symptomatic results in patients with intrathoracic stomach, the incidence of failures and anatomical recurrences is higher than expected from subjective data. Prospective, randomized long-term studies are essential to gain further information about the “ideal” type of laparoscopic repair in large hiatal hernia with intrathoracic stomach.
Early Surgical Intervention for Fulminant Pseudomembranous Colitis
Authors: Ali Syed O. , Welch John P. , Dring Robert J.
Published: June 2020

The objective of this study of a retrospective case series was to determine factors associated with survival after surgical intervention in pseudomembranous colitis (PMC). The study was conducted at a tertiary care medical center and comprised 36 patients who underwent colectomy for fulminant PMC from 1995 to 2006. Patients including 21 females ranged from 40 to 89 years of age (mean, 70 years). Comorbidities included diabetes (39%), cardiovascular disease (77%), chronic obstructive pulmonary disease (47%), and intake of immunosuppressive medications (45%). Seventy-two per cent received antibiotics in the previous 2 months. Only patients with a confirmation of PMC on pathology specimens were included in the study. All patients underwent colectomy. Patients were stratified into two groups: survivors and nonsurvivors. Various clinical factors/parameters used in the management of patients with PMC were studied in these two groups. Survival was correlated with mean white blood cell count (23,000 survivors versus 40,000 nonsurvivors, P < 0.01); multisystem organ failure (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05); and preoperative pressors (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05). Overall mortality for the study period was 47 per cent. Mortality rate analysis revealed a lower rate for the more recent years (32 per cent for 2000 to 2006 versus 65 per cent for 1995 to 1999, P < 0.05). In the more recent years, the time elapsing before colectomy was also lower (1.4 days versus 2.5 days, nonsignificant), and patients had less preoperative hemodynamic instability (70 per cent versus 31 per cent, P < 0.03). In one institution, survival after surgery for PMC was found to be associated with a mean white blood cell count (<37,000), nondependence on preoperative vasopressors, and surgical intervention before the onset of hemodynamic instability.
Urinoma and Urinothorax: Report of a Case
Authors: Izzo Luciano , Caputo Maria , De Toma Giorgio , Izzo Paolo , Bolognese A. , Basso Luigi
Published: June 2020

The case of a 47-year-old female who presented with urinoma and urinothorax due to left ureteral calculus obstruction is reported. The left kidney was surgically resected, while the urinothorax was evacuated by therapeutic thoracentesis, which resulted in withdrawal of 18 liters of straw-colored pleural fluid.
Ruptured Mycotic Aneurysm Presenting Initially with Bacterial Meningitis
Authors: Mincheff Thomas V. , Cooler Arthur W.
Published: June 2020

Infections of the major vessels can result in the formation of mycotic aneurysms, which can ultimately rupture and can be associated with a high mortality rate. Mycotic aneurysms can pose a diagnostic dilemma for the clinicians and successful treatment of this condition often requires a very high index of suspicion. We report an unusual case of a 65-year-old black female who initially presented with bacterial meningitis due to Streptococcus pneumoniae and 1 week later died from a ruptured undetected mycotic aneurysm. A similar case, in which a mycotic aneurysm initially presented with bacterial meningitis, could not be found in the literature.
Gastric Duplication Cysts Expressing Carcinoembryonic Antigen Mimicking Cystic Pancreatic Neoplasms in Two Adults
Authors: Johnston Jeffrey , Wheatley Grayson H. , El Sayed Hosam F. , Marsh William B. , Ellison E. Christopher , Bloomston Mark
Published: June 2020

Gastric duplication cysts in adults are very rare and usually found incidentally during evaluation for an unrelated ailment. When they are found in close proximity to the pancreas, they can be confused with cystic neoplasms of the pancreas, which are typically also asymptomatic yet more common. As part of the evaluation of cystic pancreatic lesions, cyst fluid analysis for carcinoem-bryonic antigen (CEA) is undertaken to determine malignant potential. Herein we present two cases of cystic lesions thought to arise from the pancreas found to have elevated preoperative cystic CEA levels. At operation, they were found to be gastric duplication cysts and were resected. We report the histologic findings and review of the current literature.
Leukoreduction is Associated with a Decreased Incidence of Late Onset Acute Respiratory Distress Syndrome after Injury
Authors: Plurad David , Belzberg Howard , Schulman Ira , Green Donald , Salim Ali , Inaba Kenji , Rhee Peter , Demetriades Demetrios
Published: June 2020

Transfusions are known to be associated with Acute Respiratory Distress Syndrome (ARDS). Transfusion of leukoreduced products may be associated with a decreased incidence of late posttraumatic ARDS (late ARDS). Data from ventilated and transfused trauma patients were analyzed. Key variables in the first 48 hours of admission were studied for their associations with late ARDS and examined for changes over the 6 year study period. Late ARDS developed in 244 of the 1488 patients studied (16.4%). The incidence in patients given nonleukoreduced (NLR) product was 30.4 per cent (75/247) versus 13.6 per cent (169/1241) for patients not exposed [2.77 (2.02–3.73), P < 0.001]. Exposure to NLR products (50.9% in 2000 vs 1.9% in 2005) and incidence of ARDS (26.3% in 2000 vs 6.3% in 2005) significantly decreased. Treatment variables independently associated with late ARDS were NLR product exposure, Total Parenteral Nutrition exposure, Peak Inspiratory Pressure ≥ 30 mm Hg, fluid balance ≥ 2 liters at 48 hours, and transfusion of ≥ 10 units of any product. NLR product exposure has an association with an increased incidence of late onset posttraumatic ARDS which is independent of large volume transfusions. Leukoreduction should be routinely included in an overall treatment strategy to furthermore mitigate this complication in critically ill trauma patients.
A Unique Case of Thrombosed Giant Popliteal Aneurysm
Authors: Vijaya Nirujogi , Satish Khaneja , Ehrlich Frank , Patetsios Peter , Raynato Berroya
Published: June 2020

We report a unique case of a giant, thrombosed, and ruptured popliteal aneurysm measuring 13.8 cm x 14.0 cm x 14.0 cm in a 93-year-old man. The patient is a hypertensive smoker with asymptomatic swelling behind the knee for several years who developed pain in the swelling with ecchymosis for 2 weeks before presentation. Despite rupture of the aneurysm, this patient exhibited no ischemic symptoms. The patient underwent emergency surgery in which most of the aneurysmal sac was excised and because of satisfactory collateral circulation, the proximal and distal popliteal artery was suture-ligated. Remarkably, the patient did not require a bypass graft and at follow up is pain-free and ambulating with no clinical signs or symptoms of ischemia. This case is unique in several ways: 1) to our knowledge, this is the largest popliteal aneurysm compared with any case that has been documented in the literature, 2) this is also the oldest reported age ever associated with a popliteal aneurysm, and 3) exclusion suture ligation proximally and distally has resulted in an exceptional outcome.
Nonfunctioning Pancreatic Endocrine Neoplasm Presenting as Asymptomatic, Isolated Pancreatic Duct Stricture: A Case Report and Review of the Literature
Authors: Powell Anathea C. , Hajdu Cristina H. , Megibow Alec J. , Shamamian Peter
Published: June 2020

Morphologic irregularities of the pancreatic duct are often noted on abdominal imaging studies obtained for unrelated symptoms or conditions. We report the case of a patient who was found to have an incidental, isolated pancreatic duct dilatation on multiple imaging studies and who was found to have a nonfunctioning pancreatic endocrine neoplasm at resection. His prognosis is excellent based on the histology of the lesion and a curative resection. This case highlights the importance of fully investigating incidental pancreatic duct abnormalities regardless of the setting in which they are found.
Attitudes of Surgical Specialists toward Venous Thromboembolism Prophylaxis in Surgical Patients
Authors: Polk Hiram C. , Mccafferty Michael H. , Mahid Suhal S. , Naidu Deepak K. , Lewis John N.
Published: June 2020

Venous thromboembolism (VTE) and pulmonary embolism are serious and potentially life-threatening complications in surgical patients; however, the risk can effectively be lessened using appropriate pharmaceutical and mechanical prophylaxis. Due to the variability in opinions and indications for VTE prophylaxis, proposed guidelines for VTE prophylaxis stratified according to patient- and procedure-oriented risk factors were widely circulated. We investigated to what extent these guidelines were accepted by 147 university and community-based surgeons in mid-America and how the recommendations for prophylaxis compared with recent past surgical practice performed on 5285 patients in Kentucky in 2004. Attitudes varied widely with respect to practice sites, modes, and specialty. Actual practices used in the Surgical Care Improvement Project 2004 varied even more widely and were at substantial variance from recommendations and current Centers for Medicare and Medicaid Services quality measures.
A Knot in the Heart
Authors: Ahmed Hesham , Kaufman Daniel , Zenilman Michael E.
Published: June 2020

Few diagnostic modalities in medicine have been the subject of greater debate for as long after their inception as the pulmonary artery catheter. Placement of a Swan-Ganz catheter is associated with various complications, one of which is knotting. Complications of usage of these catheters are numerous and can have devastating effects. Knotting of Swan-Ganz catheters is a rare complication that can often be managed successfully using interventional radiological techniques. The case reported is a rare case of Swan-Ganz catheter knotting resulting from inserting an excessive length of Swan-Ganz catheter into the heart. Knotting can be prevented by following the principle rule in floating Swan-Ganz catheters by correlating the inserted length of pulmonary artery catheter (PAC) with the expected change in waveform.
Superior Lymph Node Resection is Achievable with Laparoscopic Colectomy: Even in Initial 30 Cases
Authors: Wright Robert C. , Kim C. Anthony , Horner Ian , Wright Richard
Published: June 2020

Recent studies demonstrated the validity of the laparoscopic technique in colon cancer resection. Recent node resection data for open colectomies show inadequate nodal removal is common. In this study, two experienced laparoscopic surgeons evaluated their initial outcomes with laparoscopic colectomy, including resections for malignancies. This retrospective review of clinic and hospital records involved 69 consecutive patients subjected to laparoscopic colectomies from July 2000 through December 2005. Outcomes were compared with 1000 patients from Senagore and Delaney. Adequacy of oncologic resection was compared with the published National Cancer Institute database. Sixty-nine resections were performed. Overall complication and conversion rates were comparable to Senagore and Delaney except for days of hospitalization at 6.0 compared with 3.7 (P < 0.01) and readmission of 4.2 per cent compared with 9.1 per cent (P < 0.01). Adequate node resection occurred in 26 of 32 patients (81%) compared with 37 per cent of open colectomies in the National Cancer Institute nationwide database (P < 0.05). The overall median number of nodes resected was 18. For veteran laparoscopic surgeons in a community hospital, the initial experience with laparoscopic colectomy can provide excellent results, meeting standards set in large published series. In addition, the resection of nodes in colon cancer can be significantly better when performed laparoscopically or by hand-assisted laparoscopy.
Computed Tomographic Evidence of Hepatic Portal Venous Gas after Blunt Abdominal Trauma Does Not Necessitate Surgery
Authors: Vercruysse Gary A. , Adams Sasha D. , Feliciano David V.
Published: June 2020

Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery.
Disruption of the Costal Margin with Transdiaphragmatic Abdominal Herniation Induced by Coughing
Authors: Ochoa Chaar Cassius Iyad , Attanasio Philipp , Detterbeck Frank
Published: June 2020

We present a case of disruption of the cartilage of the costal margin resulting in herniation of abdominal contents across the diaphragm into the chest and across a gap between the ribs into the subcutaneous tissues. The literature on this condition and its management is reviewed.
Proposed Staging System for Gastrointestinal Carcinoid Tumors
Authors: Landry Christine S. , Mcmasters Kelly M. , Scoggins Charles R. , Martin Robert C.G.
Published: June 2020

Gastrointestinal carcinoid tumors are rare neuroendocrine tumors with no staging system in existence. The goal of this study was to establish a staging system consistent with the American Joint Commission on Cancer Staging Systems using the TNM strategy. A retrospective review of our prospective database of 990 hepatopancreaticobiliary patients and our tumor registry identified 108 patients with gastrointestinal carcinoid tumors from June 1990 to September 2006. Tumors were classified into our staging system by depth of penetration, size of primary tumor, nodal status, and the presence/absence of distant metastasis. Patients were staged as Stage 1, 22 per cent; Stage II, 29 per cent; Stage 3, 12 per cent; and Stage 4, 35 per cent. There were 41 men and 57 women with a median age of 58.5 years (range, 19–86 years). Primary tumors included 52 small bowel, 12 colon, 19 rectum, nine stomach, and seven of unknown primary origin. The use of our initial staging system demonstrated a trend in differences in survival across all four stages. The use of our initial staging proposal delineates the biology of the disease with accurate overall survival estimates. The addition of a dedicated American Joint Commission on Cancer staging system is needed for gastrointestinal carcinoids. Widespread use of this staging system may contribute to the future management and treatment of gastrointestinal carcinoid tumors.
Clinical Results Using Bioabsorbable Staple Line Reinforcement for Circular Staplers
Authors: Jones Wesley B. , Myers Katherine M. , Traxler L. Brannon , Bour Eric S.
Published: June 2020

Although linear surgical staple line reinforcement has been shown to increase anastomotic tensile strength in animal models and reduce the incidence of staple line bleeding and anastomotic leaks in colorectal surgery, the benefits of staple line reinforcement on circular stapled anastomoses in bariatric surgery remain unreported in the literature. The purpose if this study was to compare the incidence of anastomotic bleeding, leak, and stricture in patients undergoing laparoscopic gastric bypass with circular staple line reinforcements with those with no circular staple line reinforcements. Since May 2006, 138 consecutive patients (Group B) have undergone laparoscopic Roux-en-Y divided gastric bypass with a 25-mm circular stapled gastrojejunal anastomosis using GORE SEAMGUARD® bioabsorbable circular staple line reinforcement (CBSG) with a mean follow up of 9 months. The incidence of anastomotic bleeding, leak, and stricture was compared with 255 similar patients (Group A) who underwent surgery before May 2006 without gastrojejunal reinforcement with a mean follow up of 22 months. The rates of anastomotic bleeding, leak, and stricture for Group B versus Group A were 0.7 per cent versus 1.1 per cent ( P = 0.64); 0.7 per cent versus 1.9 per cent ( P = 0.34); and 0.7 per cent versus 9.3 per cent ( P = 0.0005), respectively. The use of CBSG reduced the incidence of anastomotic stricture by 93 per cent and the incidence of a composite end point of all anastomotic complications by 85 per cent. Our results indicate that the use of circular staple line reinforcement at the gastrojejunal anastomosis in patients undergoing laparoscopic gastric bypass significantly decreases the incidence of anastomotic stricture and a composite end point of all anastomotic complications. On this basis, strong consideration should be given to the routine use of CBSG staple line reinforcement in patients undergoing laparoscopic divided gastric bypass with a circular stapled gastrojejunal anastomosis.
Prosthetic Vascular Conduit in Contaminated Fields: A New Technology to Decrease ePTFE Infections
Authors: Fischer Peter E. , Fabian Timothy C. , Derijk Waldemar G. , Edwards Norma M. , Decuypere Michael , Landis Ryan M. , Barnard Danielle L. , Magnotti Louis J. , Croce Martin A.
Published: June 2020

Vascular reconstruction using prosthetic materials in contaminated fields can lead to infection, graft loss, and subsequent amputation. We hypothesized that minocycline and rifampin bound to an ePTFE graft using a unique methacrylate technology would provide for resistance from infection and controlled antibiotic elution. Kirby Bauer susceptibility testing was performed on plates overlaid with Staph aureus (SA) and Staph epidermidis (SE) using 6 mm diameter discs of uncoated graft or antibiotic coated graft (ABX). Zones of inhibition (ZIH) were determined after 24 hours. ABX grafts were then placed in a continuous water bath and a recirculating, pulsatile flow device. Susceptibility testing and high performance liquid chromatography with mass spectroscopy was performed to determine graft performance and antibiotic elution rate. ABX grafts had an average ZIH of 35 mm for SA and 44 mm for SE (each P < 0.0001). After the 1 week water bath, the ZIH of the ABX grafts was 23 mm on both the SA and SE plates. The high performance liquid chromatography with mass spectroscopy revealed that after 24 hours, 50 per cent of the antibiotics remained on the graft, and there was a sustained elution for 7 days. Minocycline and rifampin can be bound to ePTFE vascular grafts using a unique methacrylate method. In vitro, the grafts provide a slow elution of antibiotics that provide resistance from infection by SA and SE for up to 2 weeks after graft insertion.
The Role of CT Angiography in the Diagnosis of Blunt Traumatic Thoracic Aortic Disruption and Unsuspected Carotid Artery Injury
Authors: Methodius-Ngwodo Walaya C. , Burkett Allison B. , Kochupura Paul V. , Wellons Eric D. , Fuhrman George , Rosenthal David
Published: June 2020

We have replaced aortography and open thoracic surgery to diagnose and treat blunt traumatic thoracic aortic disruption (TTAD) in favor of CT angiography (CTA) and endovascular repair. The purpose of this study is to review our experience with the management and outcomes of TTAD and associated carotid artery injuries. In January 2003, we initiated a protocol that used CTA to evaluate all patients with suspected TTAD from blunt trauma. When TTAD was diagnosed, patients were managed by endovascular repair using abdominal aortic extension cuffs. Twenty-nine patients with TTAD were managed by endovascular repair. In all patients, abdominal endograft extension cuffs successfully excluded the traumatic disruptions. Six (21%) of these patients had concomitant, unsuspected carotid artery injury diagnosed by CTA. One patient had bilateral carotid artery dissections, sustained irreversible brain injury, and died. Four patients with common carotid dissections were successfully treated by anticoagulation and made uneventful recoveries. One patient with a common carotid–innominate artery dissection and pseudoaneurysm underwent endovascular repair. This study indicates that CTA and endovascular repair provide accurate diagnostic and therapeutic results in the management of blunt TTAD. Furthermore, CTA should include arch and cervical views to detect an unsuspected, concomitant carotid artery injury.
Combined Open and Laparoscopic Approach to Chronic Pain after Inguinal Hernia Repair
Authors: Keller Jennifer E. , Stefanidis Demitrios , Dolce Charles J. , Iannitti David A. , Kercher Kent W. , Heniford B. Todd
Published: June 2020

Chronic groin pain is the most frequent long-term complication after inguinal hernia repair affecting up to 34 per cent of patients. Traditional surgical management includes groin exploration, mesh removal, and neurectomy. We evaluate outcomes of a combined laparoscopic and open approach to chronic pain after inguinal herniorrhaphy. All patients undergoing surgical exploration for chronic pain after inguinal herniorrhaphy were analyzed. In most, the operation consisted of mesh removal (open or laparoscopic), neurectomy, and placement of mesh in the opposite location of the first mesh (laparoscopic if the first was open and vice-versa). Main outcome measures included pain status, numbness, and hernia recurrence. Twenty-one patients (16 male and 5 female) with a mean age of 41 years (22–51 years) underwent surgical treatment for unilateral (n = 18) or bilateral (n = 3) groin pain. Percutaneous nerve block was unsuccessful in all patients. Four had previous surgery for pain. There were no complications. With a minimum of 6 weeks follow-up, 20 of 21 patients reported significant improvement or resolution of symptoms. A combined laparoscopic and open approach for postherniorrhaphy groin pain results in excellent patient satisfaction with minimal morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after hernia repair.
Clopidogrel and Bleeding after General Surgery Procedures
Authors: Ozao-Choy Junko , Tammaro Yolanda , Fradis Martin , Weber Kaare , Divino Celia M.
Published: June 2020

Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix®) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions ( P = 0.12, 0.53), decreases in hematocrit ( P = 0.21), hospital stay ( P = 0.09), intensive care unit stay ( P = 0.41), late complications ( P = 0.45), or mortality ( P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.