bluuebunny/crossref_metadata_2025 huggingface dataset:
Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis
Authors: Hashmi Ammar , Kozick Zachary , Fluck Marcus , Hunsinger Marie A. , Wild Jeffrey , Arora Tania K. , Shabahang Mohsen M. , Blansfield Joseph A.
Published: June 2020

There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099–1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547–3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.
Hemodynamic Effects of Propofol for Induction of Rapid Sequence Intubation in Traumatically Injured Patients
Authors: Dietrich Scott K. , Mixon Mark A. , Rogoszewski Ryan J. , Delgado Stephanie D. , Knapp Vanessa E. , Floren Michael , Dunn Julie A.
Published: June 2020

Present guidelines for emergency intubation in traumatically injured patients recommend rapid sequence intubation (RSI) as the preferred method of airway management but specific pharmacologic agents for RSI remain controversial. To evaluate hemodynamic differences between propofol and other induction agents when used for RSI in trauma patients. Single-center, retrospective review of trauma patients intubated in the emergency department. Patients were divided in two groups based on induction agent, propofol or nonpropofol. The primary outcome was incidence of hypotension within 30 minutes of intubation. Secondary outcomes included hospital length of stay and inhospital mortality. The study protocol was approved by the Institutional Review Board. Of the 744 patients identified, 83 were analyzed, 43 in the propofol group and 40 in the nonpropofol group. Groups were similar at baseline in terms of pre-RSI hemodynamics, injury mechanism, initial Glasgow Coma Score, and Injury Severity Score. On univariate analysis, although not statistically significant, postintubation hypotension was more common in patients who received propofol compared with those who did not, 39.5 per cent versus 22.5 per cent (P = 0.9). When adjusted for age, Injury Severity Score, and pre-RSI hemodynamics, the risk of hypotension among propofol-treated patients was significantly higher (OR = 3.64; 95% Confidence interval 1.16–13.24). There were no significant differences between groups in hospital length of stay or mortality. Propofol increases the odds of postintubation hypotension in traumatically injured patients. Considerable caution should be used when contemplating the use of propofol the for induction of injured patients requiring RSI because other agents possess more favorable hemodynamic profiles.
Impact of Children's Hospital Designation on Outcomes and Costs after Cholecystectomy in Adolescent Patients
Authors: Tom Cynthia M. , Won Roy P. , Friedlander Scott , Sakai-Bizmark Rie , Virgilio Christian De , Lee Steven L.
Published: June 2020

Variations in the management of adolescents at children's hospitals (CHs) and nonchildren's hospitals (NCHs) have been well described in the trauma literature. However, the effects of CH designation on outcomes after common general surgical procedures have not been investigated. The purpose of this study was to compare the outcomes and costs of adolescent cholecystectomies performed at CHs and NCHs. Within the California State Inpatient Database (2005–2011), we identified 8117 cholecystectomy patients aged 13 to 18 years at CHs and NCHs. Outcomes (laparoscopy, intraoperative cholangiogram, length of stay (LOS), and complications) and costs were analyzed. CHs cared for younger patients, more uninsured patients, and more black patients. NCHs were associated with higher laparoscopy use (95.7% vs 88.3%, P < 0.01), higher intra-operative cholangiogram rates (28.8% vs 11.9%, P < 0.001), shorter LOS (3.2 vs 5.0 days, P < 0.01), and lower costs by $5797 per patient ($11,219 vs $17,016, P < 0.01). Although there was no significant difference in overall complication rates, CHs had higher rates of infectious complications (2.0% vs 1.0%, P = 0.004). Adolescent cholecystectomies are safely performed at NCHs while achieving increased laparoscopy use, shorter LOS, and lower costs compared with CHs.
Utility of Repeat Head CT in Patients on Preinjury Antithrombotic Medications
Authors: Marcia Lobsang , Moazzez Ashkan , Plurad David S. , Putnam Brant , Kim Dennis Y.
Published: June 2020

Presently, there are no standardized guidelines regarding the necessity or timing of repeat head imaging in patients on antithrombotics (antiplatelet agents, warfarin, or novel oral anticoagulants) with suspected traumatic brain injury. This is a two-year single institutional retrospective analysis of patients with suspected traumatic brain injury on antithrombotic medications. Patients with a stable or negative repeat head CT were compared with patients who developed a new bleed or demonstrated progression of intracranial hemorrhage (ICH). Of 110 patients, 55 patients (50%) had a positive initial CT, two patients (1.8%) developed a new bleed after initially normal head CT, and 21 patients (19.1%) demonstrated worsening ICH. Patients with worsening or delayed ICH had a higher median Injury Severity Score (14 vs 5, P < 0.001), higher head/neck and face Abbreviated Injury Severity scores (both P < 0.05), and were more likely to be receiving combination therapy with warfarin and clopidogrel (4.3% vs 0%, P = 0.05). On multivariate analysis, lower face and head/neck Abbreviated Injury Severity scores were associated with a decreased risk for delayed or worsening hemorrhage (odds ratio = 0.21 and 0.46, respectively, P < 0.05). Repeat head CT in patients on a preinjury antithrombotic has a low yield. The use of combination therapy may result in an increased risk for delayed hemorrhage or hemorrhage progression.
Helicopter Transport Use for Trauma Patients Is Decreasing Significantly Nationwide but Remains Overutilized
Authors: Dhillon Navpreet K. , Linaval Nikhil T. , Patel Kavita A. , Colovos Christos , Ko Ara , Margulies Daniel R. , Ley Eric J. , Barmparas Galinos
Published: June 2020

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 ( P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period ( P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.
Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place
Authors: Alizadeh Reza Fazl , Chaudhry Haris H. , Li Shiri , Jafari Mehraneh D. , Mills Steven D. , Carmichael Joseph C. , Pigazzi Alessio , Monson John R.T. , Stamos Michael J.
Published: June 2020

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46–0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46–0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49–0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.
Early FAST Examinations during Resuscitation May Compromise Trauma Outcomes
Authors: Kleinman John , Inaba Kenji , Pott Emily , Matsushima Kazuhide , Demetriades Demetrios , Strumwasser Aaron
Published: June 2020

Focused assessment with Sonography for trauma (FAST) examination is essential to trauma triage. We sought to determine whether FASTs completed early in sequencing portend worse outcomes. A two-year review (2014–2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST times were compared. Outcomes included resuscitation time (RESUS-h), ventilation days (d), hospital length of stay (HLOS-d), ICU length of stay (LOS-d), survival (%), nosocomial infection rate (%), and venous thromboembolism complication rate (%). ED interventions included transfusions, crystalloid, antibiotics, central line placement, intubation, thoracostomy, thoracotomy, pelvic X-ray, and binder. One thousand, three hundred and twelve patients were included for analysis (mean age = 38 ± 19 years, mean Injury Severity Score = 12 ± 11, 21% penetrating). Compared with FASTs completed after the primary survey, early FASTs led to significantly more ventilation days ( P < 0.01), longer ICU length of stay ( P < 0.01), and a greater incidence of nosocomial infections ( P = 0.03). In the ED, early FASTs led to significantly more intubations ( P < 0.01) and transfusions ( P < 0.01) compared with late FASTs. FASTs completed before primary survey portend worse outcomes, with more ED interventions and equivocal results. FAST as a true adjunct to primary survey is recommended.
Old Hickory's Violent Past Medical History
Authors: Nakayama Don K.
Published: June 2020

The past medical history (PMH) of Andrew Jackson (1767–1845) reflects one of the emblematic nicknames in Americana, “Old Hickory.” As a 14-year-old Rebel volunteer in the Revolutionary War, he survived a blow from a British saber and smallpox that he contacted in a prison camp epidemic. In 1806, Jackson challenged a rival who had made the mistake of maligning his beloved wife Rachel. He deliberately allowed his opponent to shoot him in the chest, and then killed him when he took his turn. A gunshot shattered his arm in an 1813 street fight that involved Thomas Hart Benton, who later became his ally in the United States Senate during his presidency. His PMH would not include a duel in 1787, where both parties shot and somehow missed; an escape from a party of Indians in 1791; a shootout in 1796 with the future governor of Tennessee; and in 1833 and 1835, the first two assassination attempts on a United States President. Wracked from a lifetime of maladies and wounds, he sought relief through heavy doses of nostrums laced with heavy metals and self-phlebotomy. He likely hastened his own death. The PMH gives perspective on a patient's present condition. In Jackson's case, it reveals traits that allowed him to survive and thrive in a dangerous age. His belligerence, fiery temper, and intransigence were qualities that led to success in war against the British and the Native American tribes of the southern United States, and in a political career that climaxed as the seventh United States President.
Paying the Price: Understanding the Opportunity Cost of Dedicated Research Time during Surgical Training
Authors: Dewane Michael P. , Thomas Daniel C. , Longo Walter E. , Yoo Peter S.
Published: June 2020

The pursuit of dedicated research time during surgical residency prolongs training and delays entry into practice. Currently, there is a lack of research quantifying the financial implication of this delay and trainees’ understanding of its impact on career earnings. An opportunity cost analysis was performed regarding the impact of delay due to training within general surgery and selected subspecialties. An anonymous survey was distributed to general surgery categorical junior trainees in 2017 at a large academic hospital in the Northeast to determine understanding and beliefs regarding dedicated training on career earnings. For all specialties analyzed, dedicated research time was shown to negatively affect career earnings. The net cost was highest among those intending to pursue cardiothoracic surgery and lowest for those intending to pursue surgical oncology. A total of 26 of 35 (74%) present research residents and clinical residents intending to perform dedicated research time responded to an anonymous survey. On average, survey respondents underestimated the impact of dedicated research time on career earnings by $1.4 million. Dedicated research time during general surgery residency carries a substantial opportunity cost to overall career earnings. General surgery residents lack understanding of both the direction and the magnitude of this opportunity cost.
Serotonin-Modulating Antidepressants and Risk of Bleeding after Trauma
Authors: Wilson Lindsay B. , Cox Mark R. , Benns Matthew V. , Pinkston Christina M. , Scherrer Leigh A.
Published: June 2020

Serotonin-modulating antidepressants have been associated with increased risk of gastrointestinal bleeding and increased blood loss during elective surgery. This study sought to investigate the effect of preinjury selective-serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) use on transfusion requirements after trauma, and to evaluate whether resumption of SSRI/SNRI after trauma may worsen bleeding risk. This was a retrospective matched-cohort study evaluating patients with solid organ injury. Preinjury SSRI/SNRI users were matched to non-SSRI/SNRI users based on age, preinjury aspirin use, Injury Severity Score, and abdominal Abbreviated Injury Severity Score. The primary endpoint was transfusion requirement during hospitalization. The absolute need for transfusion was higher in SSRI/SNRI users throughout hospitalization (50.9% vs 37.3%, P = 0.02). After logistic multivariate analysis, SSRI/SNRI users were more likely to require transfusion at 24 hours (odds ratio (95% confidence interval): 2.73 (1.41, 5.29), P = 0.003), but this difference did not persist for overall hospitalization (odds ratio (95% confidence interval): 1.32 (0.74, 2.36), P = 0.35). Fewer patients restarted on SSRI/SNRI therapy within 72 hours required packed red blood cell transfusion compared with those who were restarted later or not at all (43.2% vs 60.3%; P = 0.04). Preinjury use of serotonin-modulating antidepressants led to an increased requirement of blood transfusions after solid organ injury. Although clinicians should weigh bleeding risk before reinitiation of SSRI/SNRI, the results of this study indicate that reasonable efforts to restart these medications after stabilization do not result in further risk for transfusion.
Redo Surgery after Failure of Antireflux Surgery
Authors: Vilar Alberto , Priego Pablo , Puerta Ana , Cuadrado Marta , Angarita Francisco GarcÍA , GarcÍA-Moreno Francisca , Galindo Julio
Published: June 2020

Surgery for refractory gastroesophageal reflux disease (GERD) has a satisfactory outcome for most patients; however, sometimes redo surgery is required. The Outcome and morbidity of a redo are suggested to be less successful than those of primary surgery. The aim of this study was to describe our experience, long-term results, and complications in redo surgery. From 2000 to 2016, 765 patients were operated on for GERD at our hospital. A retrospective analysis of 56 patients (7.3%) who underwent redo surgery was conducted. Large symptomatic recurrent hiatal hernia (50%) and dysphagia (28.6%) were the most frequent indications for redo. An open approach was chosen in 64.5 per cent of patients. Intraoperative and postoperative complication rates were 18 per cent and 14.3 per cent, respectively. Mortality rate was 1.8 per cent. Symptomatic outcome was successful in 71.3 per cent. Patients reoperated because of dysphagia and large recurrent hiatal hernia had a significantly higher failure rate (32.3% and 31.2%, respectively; P = 0.001). Complication rate was significantly lower in the laparoscopic group (0% vs 22.2%; P = 0.04). There were no statistical differences between expert and nonexpert surgeons. Laparoscopic approach has increased to 83.3 per cent in the last five years. Symptomatic outcome after redo surgery was less satisfactory than that after primary surgery. Complications were lower if a minimally invasive surgical approach was used.
Expeditious Diagnosis and Laparotomy for Patients with Acute Abdominal Compartment Syndrome May Improve Survival
Authors: Nguyen Jonathan , Noory Mary , Capano-Wehrle Lisa , Gaughan John , Hazelton Joshua P.
Published: June 2020

Causes of abdominal compartment syndrome (ACS) are varied and can result from both medical and surgical diseases. Early recognition of ACS and prompt surgical treatment has been shown to improve mortality. We hypothesize that earlier recognition of ACS and earlier involvement by surgical specialists may improve mortality. A retrospective review between July 2010 and July 2015 was performed of adult patients who underwent decompressive laparotomy for ACS. Patients were divided into surgical and medical intensive care units (SICU and MICU) arms. Twenty patients were included (MICU = 12; SICU = 8) without significant difference between the groups. Median time from admission to suspicion for MICU patients was 60 hours versus 13 hours for SICU patients ( P = 0.013). Time from suspicion to surgical consult was 60 minutes versus 0 minutes, respectively ( P = 0.003), however, time from surgical consult to intervention was not different. Mortality rate in the MICU was 83 per cent versus 12.5 per cent in the SICU ( P = 0.005). Patients in the SICU who developed ACS were more quickly diagnosed than those in the MICU. These patients had a shorter time from suspicion of ACS to surgical consultation and eventual surgical intervention, and was associated with improved survival. A multidisciplinary approach, including early surgical consultation, for patients in whom there is a suspicion of ACS may contribute to improved mortality.
Solid-Organ Transplantation and the Affordable Care Act: Accessibility and Outcomes
Authors: Trivedi Jaimin R. , Ising Mickey , Fox Matthew P. , Cannon Robert M. , Van Berkel Victor H. , Slaughter Mark S.
Published: June 2020

The objective of the study is to evaluate the impact of the Affordable Care Act (ACA) on accessibility to solid organ transplant and outcomes. Data source registry: United Network of Organ Sharing database. Patients aged ≥18 years listed for kidney, liver, heart, and lung transplant between years 2010 and 2016 were classified by insurance and status of Medicaid adoption under ACA to evaluate insurance distribution. Between 2010 and 2016, states that adopted Medicaid had 2 to 4 per cent point increase in the proportion of patients listed with Medicaid across all organs. One-year waiting list survival of Medicaid patients was better in the ACA era. States that expanded Medicaid under the ACA had a significant increase in the proportion of patients listed with Medicaid and better one-year waiting list survival.
Use of Aerosolized Antibiotics in Gram-Negative Ventilator-Associated Pneumonia in Trauma Patients
Authors: Gibson Brian H. , Sharpe John P. , Lewis Richard H. , Newell Joshua S. , Swanson Joseph M. , Wood G. Christopher , Fabian Timothy C. , Croce Martin A. , Magnotti Louis J.
Published: June 2020

Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either Acinetobacter baumannii or Pseudomonas aeruginosa VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, P = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.
Assessing the Safety and Efficacy of Converting Laparoscopic Gastric Band to Sleeve Gastrectomy: A Rural Tertiary Center's Experience
Authors: Danthuluri Vishwanath , Smith Craig , Baysinger Katherine , Merideth Leslie , Clayton Eric , Whipple Oliver
Published: June 2020

Gastric banding for surgical treatment of morbid obesity has a complication rate of 20 to 50 per cent. Complications include band erosion, band slippage, and failed weight loss. One salvage procedure used is the laparoscopic sleeve gastrectomy. We aimed to compare our results between single-stage and two-stage conversation of gastric band with sleeve gastrectomy. We performed a retrospective review of 27 gastric band patients converted to sleeve gastrectomy. Hospital length of stay, surgical complications, and weight loss were compared. Twelve patients had a two-stage conversion and 15 patients had a single-stage conversion. There were no surgical complications in either group. There was a significant reduction in BMI after conversion, starting at one month and continuing forward to 12 months. The average BMI reduction over the two-year follow-up period was 8.19. There was no significant difference in length of hospital stay between the groups. Single-stage conversion of gastric band to sleeve gastrectomy does not lead to increased hospital length of stay or surgical morbidity. In the presence of gastric band slip or erosion, a two-stage approach is preferable. Conversion resulted in statistically significant weight loss in all patients.
Combination Technique Is Superior to Dye Alone in Identification of the Sentinel Lymph Node in Male Breast Cancer
Authors: Simsek Osman , Belli Ahmet K. , Aydogan Fatih , Karatas Adem , Canbay Emel , Kepil Nuray , Selcukbiricik Fatih , Celik Varol , Uras Cihan
Published: June 2020

Sentinel lymph node (SLN) biopsy is the main method in staging the axilla. There are insufficient data available regarding the accuracy of an SLN biopsy in male breast cancer. The aim of this study is to evaluate whether the combination of dye and radiotracer would improve the detection rate of SLNs versus dye alone in male breast cancer patients. From February 2009 to January 2012, our SLN biopsy database was retrospectively reviewed to identify male breast cancer cases. Of the 890 SLN procedures contained in the database, 10 male breast cancer patients were identified. Patient age, body mass index, SLN biopsy technique, SLN identification, number of SLN excised, and pathology reports were reviewed. Mean age was 57.2 (34–85) years with a mean tumor size was 2.2 (1.0–4.0) cm. SLN detection ratios were two in four with blue dye and six in six with the combination technique. Overall, SLNs were identified in 8 of the 10 patients. SLN biopsy is applicable in male breast cancer cases. The addition of a radiotracer to the dye in SLN biopsy increases the detection rate of sentinel nodes in male breast cancer patients.
Radiation and Its Impact on Local Recurrence in Extremity and Trunk Well-Differentiated Liposarcomas
Authors: Fonseca Annabelle L. , Roland Christina L. , Cormier Janice N. , Torres Keila E. , Hunt Kelly H. , Bishop Andrew J. , Guadagnolo Ashleigh , Feig Barry W.
Published: June 2020

Patients with well-differentiated liposarcomas (WDLPS) of the extremity and trunk are treated primarily with surgical resection, with radiation used for a number of anecdotal reasons, including large size and positive margins. In this study, we evaluate the appropriate role for radiation in these tumors. A retrospective chart review of patients with extremity and trunk soft tissue liposarcomas referred to a free-standing cancer center from January 1995 to December 2011 was performed. One hundred eighty-three patients with extremity and trunk soft tissue WDLPS were identified: 61 per cent were female, median age was 60 years (range, 19–84 years) and 2 per cent had a focal area of dedifferentiation, margin status was positive in 57 per cent. Fourteen per cent of patients received radiation. Fifty patients developed recurrent disease; 28 per cent of these received radiation. Median time to recurrence was 18 years (range, 0.7–22 years). Of the 50 patients who recurred, 14 (28%) received radiation. Radiation was associated with decreased second recurrence when administered for recurrent disease (P = 0.03). On multivariable analysis, tumor size ≤ 10 cm (P = 0.014) and anatomically difficult area of resection (P = 0.008) were predictive of increased risk of recurrence. Older age (P = 0.02), dedifferentiated liposarcomas (P < 0.001), and difficult area of resection (P = 0.02) were associated with the administration of radiotherapy. Administration of radiation therapy was not associated with decreased time to recurrence in WDLPS overall; however, it should be considered in patients with recurrent disease.
The Cost of Surgical Site Infections after Colorectal Surgery in the United States from 2001 to 2012: A Longitudinal Analysis
Authors: Gantz Owen , Zagadailov Pavel , Merchant Aziz M.
Published: June 2020

Surgical site infections (SSIs) are among the most common types of postoperative complications in the United States and are associated with significant prevalence of morbidity and mortality in patients undergoing surgical interventions, especially in colorectal surgery (CRS) where SSI rates are significantly higher than those of similar operative sites. SSIs were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2012 based on the specification of an ICD-9 code. Propensity score matching was used to compare costs associated with SSI cases with those of non-SSI controls among elective and nonelective admissions. Results were projected nationally using Healthcare Cost and Utilization Project sampling methodology to evaluate the incidence of SSIs and ascertain the national cost burden retrospectively. Among 4,851,359 sample-weighted hospitalizations, 4.2 per cent (203,597) experienced SSI. Elective admissions associated with SSI-stayed hospitalized for an average of 7.8 days longer and cost $18,410 more than their counterparts who did not experience an SSI. Nonelective admissions that experienced an SSI had an 8.5-day longer hospital stay and cost $20,890 more than counterparts without perioperative infections. This represents a 3 per cent annual growth in costs for SSIs and seems to be largely driven by cost increases in treatment of SSIs for elective surgeries. Current efforts of SSI management after CRS focused on compliance with guidelines and tracking of infection rates would benefit from some improvements. Considering the growing costs and increase in resource utilization associated with SSIs from 2001 to 2012, further research on costs associated with management of SSIs specific to CRS is necessary.
Cosmesis in Patients after Multiport Laparoscopic Colorectal Surgery: Does the Extraction Incision Matter?
Authors: Rabbany Jessica , Kim Teresa , Koh Sharon , Zaghiyan Karen , Fleshner Phillip
Published: June 2020

The ideal incision for specimen extraction during laparoscopic colorectal surgery is controversial. The objective of this study was to compare incision types (Pfannenstiel, periumbilical, lower midline, and right upper quadrant transverse) with regard to postoperative scar appearance, symptoms, preference, and satisfaction. This study is a retrospective survey review performed in an urban teaching hospital. The study participants were patients undergoing multiport laparoscopic colorectal surgery. Two web-based questionnaires, the Patient Scar Assessment Questionnaire and Photo-Series Questionnaire, were used to assess study parameters. The main outcome measures were incision symptoms and cosmetic satisfaction. The 112 study patients included 54 patients with a Pfannenstiel incision (Group P) and 58 patients with an alternate incision (Group A). Of the 58 patients in Group A, 19 (33%) had a periumbilical incision, 10 (17%) a lower midline incision, and 29 (50%) a right upper quadrant transverse incision. Although Groups P and Awere comparable in all five subscales of the Patient Scar Assessment Questionnaire, more Group P participants (n = 12; 22%) said their incision felt “fairly numb” than Group A participants (n = 2; 3%) (P = 0.008). There was no significant difference between study groups in all Photo-Series Questionnaire domains; however, after comparing patients’ own incisions with photographs of various alternative incisions, 36 (62%) Group A patients would choose an alternative incision compared with only 11 (19%) Group P patients (P = 0.001). Selection bias, recall bias, external validity, and variability of scar lengths were the limitations of the study. It was concluded that although a Pfannenstiel incision seems to be the optimal cosmetic choice, it is associated with a higher incidence of wound numbness than alternate extraction incisions.
Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis
Authors: Van Dalen Anne Sophie H. M. , Ali Usama Ahmed , Murray Alice C. A. , Kiran Ravi Pokala
Published: June 2020

The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.
The Role of the American Board of Surgery in the Development of Surgical Residencies in Post–World War II America
Authors: Barr Justin , Pappas Theodore N.
Published: June 2020

The creation of Boards fundamentally altered the American medical landscape and transformed the process of educating physicians. The American Board of Surgery, founded in 1937, epitomized this role. It established expectations, implemented an inspection system to enforce those standards, and ultimately collaborated with other professional organizations to create the Residency Review Committee that endures today. Using surgery as an example, we show how the appeal of board certification imbued Boards with the power and authority to reshape graduate medical education in their image in post–World War II America.
Laparoscopic Sleeve Gastrectomy Outcomes in Patients with Polycystic Ovary Syndrome
Authors: Yheulon Christopher G. , Millard Anthony J. , Balla Fadi M. , Jonsson Arinbjorn , Constantin Tinav , Singh Arvinpal , Srinivasan Jahnavi , Stetler Jamil , Patel Ankit , Lin Edward , Davis S. Scott
Published: June 2020

Polycystic ovary syndrome (PCOS) is a common disease among the bariatric population. However, there are limited data regarding the impact of laparoscopic sleeve gastrectomy (SG) on these patients. The study was conducted at University Hospital, United States. The purpose of this study was to examine per cent excess body weight loss (%EWL) and diabetes control in patients who have PCOS compared with those without PCOS. A total of 550 female patients underwent SG between December 2011 and October 2016. Retrospective analysis was completed to include follow-up data at 1, 3, 6, and 12 months and yearly after that. Outcomes measured were %EWL and hemoglobin A1c (HgbA1c). The mean and median follow-up for the entire cohort was 21 and 15 months, respectively. Seventy-eight per cent of patients completed at least 12 months of follow-up for %EWL, although only 21 per cent had similar follow-up for HgbA1c. PCOS patients had similar age (36.3 vs 36.2 years, P = 0.90), preoperative BMI (47.2 vs 47.2, P = 0.99), preoperative HgbA1c (6% vs 5.8%, P = 0.31), conversion rate to gastric bypass, and other associated comorbidities compared with non-PCOS comparisons. There was no difference in %EWL at 12-month (49.7% vs 53.1%, P = 0.53) or 24-month (43% vs 49.8%, P = 0.46) postoperative intervals. There was no difference in absolute change of HgbA1c at 12 months (-0.47% vs -0.67%, P = 0.39). SG has equivalent short-term results in %EWL and reduction in HgbA1c for patients who have PCOS and those who do not.
Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes
Authors: Arnold Michael R. , Schlosser Kathryn A. , Otero Javier , Prasad Tanu , Lincourt Amy E. , Gersin Keith S. , Heniford B. Todd , Colavita Paul D.
Published: June 2020

In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups ( P < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% vs 9.1%; P < 0.0001) and major complications (2.2% vs 6.3%; P < 0.0001), and 30-day mortality (0.1% vs 0.5%; P = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.
Early Use of a Chest Trauma Protocol in Elderly Patients with Rib Fractures Improves Pulmonary Outcomes
Authors: Kelley Katherine M. , Burgess Jessica , Weireter Leonard , Novosel Timothy J. , Parks Krista , Aseuga Michelle , Collins Jay
Published: June 2020

Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our “elderly” (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.
Screening for Harassment, Abuse, and Discrimination among Surgery Residents: An EAST Multicenter Trial
Authors: Fitzgerald Caitlin A. , Smith Randi N. , Luo-Owen Xian , Turay David , Ferrada Paula , Han Jinfeng , Williams Brian H. , Hussain Munira , Ekeh A. Peter , Herzing Karen , Zakrison Tanyal , Gelbard Rondib
Published: June 2020

Estimating the prevalence of harassment, verbal abuse, and discrimination among residents is difficult as events are often under-reported. The purpose of this study was to determine the prevalence of discrimination and abuse among surgical residents using the HITS (Hurt, Insulted, Threatened with harm or Screamed at) screening tool. A multicenter, cross-sectional, survey-based study was conducted at five academic teaching hospitals. Of 310 residents, 76 (24.5%) completed the survey. The HITS screening tool was positive in 3.9 per cent. The most common forms of abuse included sexual harassment (28.9%), discrimination based on gender (15.7%), and discrimination based on ethnicity (7.9%). There was a positive correlation between individuals who reported gender discrimination and racial discrimination (r = 0.778, n = 13, P = 0.002). Individuals who experienced insults were more likely to experience physical threats (r = 0.437, n = 79, P < 0.001) or verbal abuse (r = 0.690, n = 79, P < 0.001). Discrimination and harassment among surgical residents in academic teaching hospitals across the United States is not uncommon. Further research is needed to determine the impact of these findings on resident attrition.
Data-Driven Opportunity to Reduce Elderly Pedestrian Trauma
Authors: Patel Deven C. , Dhillon Navpreet K. , Linaval Nikhil , Patel Kavita , Margulies Daniel R. , Ley Eric J. , Barmparas Galinos
Published: June 2020

Elderly patients are at high risk for mortality after injury, and prevention is imperative. Several studies have captured the value of traffic calming or environmental modifications; however, limited data support its use during focused times of the day to reduce pedestrian trauma. This study's aim was to identify when the elderly are more likely to be injured from pedestrian trauma. The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for all adult pedestrians who were struck by vehicles from 2000 to 2015. Elderly (≥65 years) patients were compared with nonelderly (range, 18–64 years) patients with respect to the time of admission and mortality. The proportion of elderly pedestrian injuries peaked between 9 and 10 am (23%). Compared with their nonelderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤8 (11% vs 7%, P < 0.01), be hypotensive (6% vs 3%, P < 0.01), and have a higher Injury Severity Score (median 9 vs 5, P < 0.01). Mortality was significantly higher in the elderly (14% vs 4%, P < 0.01). Elderly pedestrians had an almost 5-fold higher adjusted odds ratio for death: 4.72 ( P < 0.01). Preventative strategies with lower speed limits or high surveillance during these hours in highly populated areas may result in a decreased incidence of these injuries.
Surgical Results of Laparoscopic Cholecystectomy for Gallbladder Torsion
Authors: Ezaki Sayuri , Tomimaru Yoshito , Noguchi Kozo , Noura Shingo , Imamura Hiroshi , Dono Keizo
Published: June 2020

Gallbladder torsion (GT) causes ischemia of the gallbladder, which potentially leads to a fatal condition. Consequently, GT requires urgent treatment. An urgent laparoscopic cholecystectomy (LC) might be the optimal approach, in view of the anatomical abnormality, “floating gallbladder,” which is associated with GT. However, the feasibility of LC for GT has not been well investigated. Thus, in this study, we investigated the feasibility of LC for GT in a case series. A total of 393 patients underwent urgent LC for acute gallbladder diseases at our institution during the study period. Among these patients, six had GT (1.5%) and were enrolled in this study. We retrospectively analyzed the surgical results of LC. Of the six cases, four (66.7%) were correctly diagnosed with GT preoperatively. There were two cases of Type I and four cases of Type II, based on the Gross classification for GT. The median operation time and intraoperative bleeding volume were 64 minutes and 18 mL, respectively. No cases required conversion to open surgery. All six cases experienced an uneventful postoperative course. The median postoperative hospital stay was six days. The surgical results of LC were favorable for six cases of GT. These results showed that LC was feasible for GT.
Rectal Cancer Complete Response Outcomes in a Community-Based Hospital Comparable with Large Cancer Centers When Multidisciplinary Approach to Rectal Cancer is Used
Authors: Geiser Andrew J. , Al-Khamis Ahmed , Patel Supriya , Sugrue Jeremy , Borsuk Daniel J. , Marecik Slawomir , Kochar Kunal , Park John J.
Published: June 2020

Achievement of pathologic complete response (pCR) in patients with locally advanced rectal cancer correlates with improved prognosis relative to non-pCR counterparts. Such correlations are not well established in the context of a community-based hospital. This study aims to examine pCR rates, recurrences, and survival data for locally advanced rectal cancer patients in community settings. A single-center retrospective chart review was performed at a community-based hospital. Study population consisted of 119 patients with locally advanced rectal cancer treated with neo-adjuvant chemoradiotherapy, followed by surgical resection. Patients with a history of metastasis, inflammatory bowel disease, hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded. Twenty-four patients (20.2%) achieved pCR. Across both groups, all demographics and perioperative characteristics were comparable. The five-year survival was 73.7 per cent in the non-pCR group and 95.8 per cent in the pCR group ( P = 0.0243). At five years, 27.7 per cent of the non-pCR group had a recurrence, as compared with none in the pCR group ( P = 0.0018). Based on our study, we believe that a multidisciplinary approach to rectal cancer used at a community-based hospital can achieve oncological outcomes and survival benefits similar to those of larger academic tertiary care institutions.
Is Opioid Prescribing Driving Trauma Recidivism or is Trauma Driving Opioid Use?
Authors: Harmon Laura , Sukri Leah , Kufera Joseph A. , Nguyen Andrew , Grunnagle Meilin , Ramirez Christine L. , Botwinick Isadora , Cucher Daniel , Feather Cristina B. , Scalea Thomas M. , Stein Deborah M.
Published: June 2020

In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission ( P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.