bluuebunny/crossref_metadata_2025 huggingface dataset:
The Incidence of Thromboembolism in the Surgical Intensive Care Unit
Authors: Major Kevin M. , Wilson Matthew , Nishi Gregg K. , Farber Alik , Chopra Ritu , Chung Alice , Mcvay Carie , Spivak Jacob , Shabot M. Michael
Published: November 2022

The clinical diagnosis of deep venous thrombosis (DVT) is unreliable. Studies have been performed examining the utility of frequent duplex scans. However, these studies included patients outside of the intensive care unit. The incidence of venous thromboembolism and the effect of a less intense surveillance protocol was prospectively examined at a level-1 urban trauma center for a 6 month period. During the study period there were 726 admission to the surgical intensive care unit. Sequential compression devices (SCDs) were used for DVT prophylaxis in 93 per cent of the admissions. A total of 114 duplex scans were ordered: 42 per cent for surveillance and the rest for evaluation of a clinical indication. Twelve DVTs were discovered (11% overall DVT rate). No patient on subcutaneous heparin or low-molecular-weight heparin developed a DVT or pulmonary embolism (PE). Four patients suffered a PE; however, none were found to have a lower extremity DVT on duplex ultrasound and all received SCD prophylaxis. Overall, proper use of DVT prophylaxis for intensive care unit days 1–14 was 77 per cent. The incidence of venous thromboembolism in a group of patients at overall high risk was low. A program of DVT surveillance with duplex ultrasound was not cost-effective.
Rates of Colon and Rectal Cancers are Increasing in Young Adults
Authors: O'Connell Jessica B. , Maggard Melinda A. , Liu Jerome H. , Etzioni David A. , Livingston Edward H. , Ko Clifford Y.
Published: November 2022

Incidence rates for colorectal cancer are decreasing in the United States, possibly due to preventative cancer screening. Because these programs target older patients, their beneficial effects may not apply to young patients. The purpose of this study was to compare incidence rates and tumor characteristics of colon and rectal cancers for young versus older patients using a population-based cancer registry. Colon and rectal cancer patients reported in the Surveillance, Epidemiology, and End Results registry (1973–1999) were separately analyzed. Incidence rates over time, stage, and grade were compared for two age groups: young patients (20–40 years, n = 5383) and older patients (60+ years, n = 256,401). For older patients, colon cancer incidence remained stable while rectal cancer incidence decreased 11 per cent to 72.1/100,000 persons ( P < 0.05). For the young, colon cancer incidence increased 17 per cent to 2.1 ( P < 0.05), and rectal incidence rose 75 per cent to 1.4 ( P < 0.05). Young patients had less localized tumors than older patients: colon (25.8% vs. 35.3%, P < 0.001); rectal (38.4% vs. 41.7%, P = 0.005). Young patients also had more poorly differentiated tumors: colon (22.2% vs. 14.7%, P < 0.001); rectal (16.4% vs. 12.3%, P < 0.001). Incidence rates for colon and rectal cancers in young patients are rising, and they have more advanced disease. Although the overall prevalence is low in this population, the increasing incidence suggests health-care providers should have heightened awareness when caring for this population.
Laparoscopic Resection of Gastric Stromal Tumor: A Tailored Approach
Authors: Nguyen Ninh T. , Jim Jeffrey , Nguyen Andre , Lee John , Chang Ken
Published: November 2022

Many different laparoscopic approaches to resection of gastric stromal tumor have been described in the literature. We reviewed our experience of laparoscopic approaches to surgical resection of gastric stromal tumors seven in six consecutive patients. The tumor locations were the gastric cardia (n = 2), gastroesophageal junction (n = 1), gastric fundus (n = 2), and gastric antrum (n = 2). Laparoscopic localization of endoluminal tumors included intraoperative endoscopy, laparoscopic ultrasound, and laparoscopic palpation. There were five males with a mean age of 57 years. Laparoscopic approaches to resection were laparoscopic wedge resection (n = 4) for tumors in the gastric fundus and antrum, laparoscopic enucleation (n = 2) for tumors in the gastric cardia, and transgastric endoluminal resection (n = 1) for a tumor located at the gastroesophageal junction. There was no conversion to laparotomy. The mean operative time was 143 ± 54 minutes and mean blood loss was 57 ± 27 mL None of the patients required intensive care stay. The mean length of hospital stay was 3 days. There were no major or minor complications and no mortality. Surgical pathology demonstrated gastric stromal tumor with less than 2/50 mitosis per high power field in all seven specimens. Tumor size ranged from 2.8 cm to 7.1 cm in greatest diameter. There has been no tumor recurrence with a mean follow-up of 9 months. Laparoscopic resection of benign gastric stromal tumor is safe and feasible. The laparoscopic approaches to surgical resection should be tailored based on the location and characteristics of the tumor.
Elderly Patients in Surgical Workloads: A Population-Based Analysis
Authors: Etzioni David A. , Liu Jerome H. , O'Connell Jessica B. , Maggard Melinda A. , Ko Clifford Y.
Published: November 2022

Elderly (80+ year old) individuals are the fastest-growing segment of the U.S. population. The objective of this study was to use population-based data to examine trends in the number of elderly undergoing major general, vascular, and cardiothoracic surgical procedures. California inpatient data from 1990–2000 was used to identify patients undergoing six procedures: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), carotid endarterectomy (CEA), colon resections, lung resections, and pancreatic resections. Despite comprising only 2.7 per cent of the California population, elderly patients were a significant percentage (6–22%) of the caseloads for the six procedures examined. For all six procedures, the percentage of patients that were elderly increased during the study period. The age-specific incidence rates for elderly individuals increased significantly for three of these procedures (CABG, CEA, lung resection), remained unchanged for two (AAA, pancreas resection), and decreased for one (colon resection). Elderly patients are a large and growing part of surgical caseloads. In the near future, the number of elderly individuals in the California state and the U.S. populations will increase dramatically (41% and 35% between 2000 and 2020). To provide the best quality of care, surgeons should embrace research, training, and educational opportunities regarding the treatment of elderly patients.
Radiated Groin Wounds: Pitfalls in Reconstruction
Authors: Payne Wyatt G. , Walusimbi Mbaga S. , Blue Martin L. , Mosiello Gerald , Wright Terry E. , Robson Martin C.
Published: November 2022

Reconstruction procedures of soft tissue defects created after tumor excision in the ilioinguinal region which have received prior radiation therapy are associated with serious morbidities. Despite the availability of muscle or myocutaneous flaps, wound infection, wound breakdown, and necrosis occur with relative frequency. Changes in tissues secondary to radiation therapy are chronic and permanent and adversely affect wound healing. Tumors in this region should be considered for primary excision and reconstruction, followed by radiation, if necessary.
False-Negative Plain Cervical Spine X-Rays in Blunt Trauma
Authors: Besman Anatole , Kaban Jody , Jacobs Lenworth , Jacobs Lenworth M.
Published: November 2022

Although considered very accurate, false-negative plain cervical radiographs of blunt trauma patients will occur with potentially devastating complications. We sought to define the population of patients who fall into this category and the overall accuracy of adequate three-view cervical spine radiography in the blunt trauma population. A retrospective search was carried out of blunt trauma patients entered into our trauma registry. All patients with the ICD-9 codes indicating cervical spine injury with a negative three-view cervical spine radiograph reading had their charts and radiographs reviewed. Institutional statistics for blunt cervical trauma evaluation and injury were obtained from the trauma registry. Fifty-eight of 936 blunt trauma patients (6.2%) were diagnosed with cervical spine injury over the 9-month study period. Of 649 patients with adequate three-view plain radiographs, three patients were identified with negative plain radiographs and significant cervical spine injury, a false-negative rate of 0.5 per cent. Sensitivity was 90.3 per cent, specificity was 96.3 per cent, positive predictive value was 54.9 per cent, and negative predictive value was 99.5 per cent. Three-view plain radiograph series of the cervical spine remains a highly sensitive and specific test for cervical spine injury following blunt trauma. However, the fact that we identified three patients with significant fractures after negative plain radiographs suggests that serious consideration of computed tomography must be applied in treating symptomatic, high-risk blunt trauma patients when plain radiographs do not reveal an injury.
Hormonal Changes after Roux-en Y Gastric Bypass for Morbid Obesity and the Control of Type-II Diabetes Mellitus
Authors: Clements Ronald H. , Gonzalez Quintin H. , Long Calvin I. , Wittert Gary , Laws Henry L.
Published: November 2022

Morbid obesity (MO) is associated with diabetes mellitus-type II (DM-II). Roux- en Y gastric bypass (RNY) has been shown to normalize glucose intolerance in these patients through an incompletely understood mechanism. Gastrointestinal hormonal changes have been suggested as an explanation for resolution of DM II. Preoperatively, 20 MO patients with DM-II were evaluated for demographics and fasting levels of the following: glucose, insulin, C-peptide, glucagon, Cortisol, gastric inhibitory polypeptide (GIP), and glucagon-like peptide-1 (GLP-1). Each patient underwent RNY with a 15-cc gastric pouch and 150-cm Roux limb. Postoperatively, each of the variables was measured at 2 weeks, 6 weeks, and 12 weeks and compared with the preoperative result using Student t test with significance, P = 0.05. Results are expressed as mean ± SD. Twenty patients (5 male and 15 female), age 40.3 ± 7.9 years, weight 146.3 ± 34.0 kg, height 158.7 ± 18.7 cm, and BMI 52.7 ± 8.8, were enrolled in this IRB-approved protocol. Weight and BMI decreased progressively (117.5 ± 26.9 kg and 47.0 ± 7.4, P = 0.01, respectively) during the study but reached significance only at 12 weeks. Fasting plasma glucose decreased significantly within 2 weeks after RNY. Insulin and Cortisol both approached, but never achieved, significant changes over 12 weeks. GLP-1 increased initially, but not significantly. GIP and C-peptide both decreased significantly. Glucagon remained essentially unchanged over 12 weeks. RNY rapidly normalizes fasting plasma glucose in morbidly obese patients with DM-II. GIP, a gactor in the enteroinsulin axis, decreases and may play a role in the correction of DM-II after gastric bypass.
Serum Lactic Acid Determines the Outcomes of CT Diagnosis of Pneumatosis of the Gastrointestinal Tract
Authors: Hawn Mary T. , Canon Cheri L. , Lockhart Mark E. , Gonzalez Quintin H. , Shore Gregg , Bondora Anthony , Vickers Selwyn M.
Published: November 2022

Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) >2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21–75.92] and serum creatinine >1.5 mg/dL (OR = 3.05; 95% C.I., 1.25–7.42) with mortality. Age was suggestive but not a significant risk factor for mortality ( P = 0.09). Multivariate analysis found serum LA >2.0 (OR = 30.37; 95% CI., 7.31–126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level >2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.
Solid-Pseudopapillary Tumor of the Pancreas: Two Cases in Male Patients
Authors: Mancini Gregory J. , Dudrick Paul S. , Grindstaff Alan D. , Bell John L.
Published: November 2022

Solid-pseudopapillary tumor (SPT) of the pancreas is a rare lesion with low malignant potential occurring predominantly in young women. This is a report of two cases in young male patients. Clinical data were retrieved retrospectively from a prospective database of patients with pancreatic tumors. The two patients were Caucasian males, ages 34 years (Pt1) and 41 years (Pt2) at the time of diagnosis. Pt1 presented with intermittent epigastric pain, nausea, and vomiting. Computed tomography (CT) scan showed a 9-cm mass involving the pancreatic head. He underwent pancreaticoduodenectomy, with en bloc segmental colectomy due to mesocolon involvement. Pt2 was asymptomatic, diagnosed with abdominal mass by screening ultrasound. He had an 11-cm tumor involving the pancreatic tail encasing the splenic vessels on CT. He underwent distal pancreatectomy with splenectomy en bloc. Pathology in both cases was reviewed by staff pathologists as well as outside consultants. SPT is a rare tumor of the pancreas that is diagnosed primarily in young women. The cases presented here demonstrate SPT of the pancreas in two men. In both cases, the clinical presentation was relatively unremarkable. Both have had benign late postoperative courses, consistent with the low malignant potential of this lesion.
Seatbelt Injury Causing Perforation of the Cervical Esophagus: A Case Report and Review of the Literature
Authors: Gill Satinderjit S. , Dierking Jason M. , Nguyen Khang T. , Woollen Claude D. , Morrow Charles E.
Published: November 2022

Blunt trauma to the head and neck is a rare cause of cervical esophageal perforation. We report a cervical esophageal perforation caused by compression by a shoulder-harness seatbelt during a high-speed motor vehicle crash. We are not aware of a similar case in the trauma literature.
Clinical Studies of Strangulating Small Bowel Obstruction
Authors: Takeuchi Kunio , Tsuzuki Yasushi , Ando Tetsu , Sekihara Masao , Hara Takashi , Yoshikawa Minako , Kuwano Hiroyuki
Published: November 2022

Reliable preoperative diagnosis of intestinal necrosis in strangulating small bowel obstruction (SSBO) is difficult, and, as yet, no reliable marker has been described. We, therefore, retrospectively examined clinical symptoms and hematobiochemical data of patients with SSBO in our surgical wards. Thirty-seven patients with SSBO were analyzed in this study. They were divided into two groups: group A (13 patients), the presence of gangrenous intestine; and group B (24 patients), the absence of it. By means of χ2 test, Student t test, or Welch t test, peritoneal signs, white blood cell count (leukocytosis or leukopenia), systemic inflammatory response syndrome (SIRS), shock, and base deficit were significantly associated with whether gangrenous intestine existed or not. Next, in simple regression analysis, base deficit was significantly correlated with the length of gangrenous intestine. In stepwise logistic regression analysis, SIRS was independently correlated with the presence of gangrenous intestine. If SIRS or metabolic acidosis is seen in patients with SSBO, the intestine is certainly gangrenous
Independent Predictors of Morbidity and Mortality in Blunt Colon Trauma
Authors: Ricciardi R. , Paterson C.A. , Islam S. , Sweeney W.B. , Baker S.P. , Counihan T.C.
Published: November 2022

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I–V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.
The Language of Modern Medicine: It's All Greek to Me
Authors: Lewis Kristopher N.
Published: November 2022

The Greek language has shaped and formed the lexicon of modern medicine. Although medical terminology may seem complex and difficult to master, the clarity and functionality of this language owe a great debt to the tongue of the classical Greeks.
Evaluation of Gastrointestinal Stromal Tumors for Recurrence Rates and Patterns of Long-Term Follow-Up
Authors: Samiian Laila , Weaver Mitchell , Velanovich Vic
Published: November 2022

Retrospective chart review of 33 patients with gastrointestinal stromal tumors (GISTs) over the past 14 years was performed. Clinicopathologic variables were analyzed for patterns affecting tumor recurrence and need for long-term follow-up. No recurrence was found in the benign group and tumors <5 cm. In the malignant group, recurrence rate was 53 per cent with a mean follow-up of 34 months. Mean time to diagnosis of recurrence was 16 months. Eighty per cent of recurrences occurred within 2 years of surgical resection. Sixty per cent of recurrences were asymptomatic. Systematic follow-up consisted of physical examination and CT scans at 6-month intervals for 2 years after surgery. Time to diagnosis of a recurrence after surgery was 13 months for systematic follow-up and 18 months for sporadic follow-up. Mean survival was 24 months in both groups. Most recurrences occur within 2 years of surgical resection. Symptomatology does not provide early diagnosis. Patients who had systematic follow-up were diagnosed sooner with recurrence. Therefore, we recommend systematic follow-up after surgical resection of a malignant GIST to include physical examination and CT scan at 6-month intervals for up to 2 years after surgery with repeat CT scan at 3 years.
Laparoscopic Appendectomy in Children: Technically Feasible and Safe in All Stages of Acute Appendicitis
Authors: Vegunta Ravindra K. , All Alya , Wallace Lizabeth J. , Switzer Diane M. , Pearl Richard H.
Published: November 2022

This is a retrospective outcomes analysis of pediatric open and laparoscopic appendectomy in a children's hospital. One hundred three children underwent appendectomy for appendicitis by two pediatric surgeons from August 1998 to December 2002. Patients were divided into two groups, laparoscopic appendectomy (LAP) and open appendectomy (OAP), and were further subdivided by diagnosis: normal (NL), acute (AA), and ruptured (RA). There were no differences in age, sex, race, or zip codes between groups. Median age was 10 years. In the acute phase, 28 patients underwent OAP and 65 underwent LAP whereas 10 patients underwent interval appendectomy (IA) 6 weeks after percutaneous drainage of established abscesses (eight were LAP vs two OAP). In the remaining patients, the appendix was normal in 17 (18.4%) and ruptured in 24 (25.8%) pathologically. LAP took longer to perform (57 minutes vs 34.5 minutes) at higher cost ($3718 vs $1858) than OAP. Overall complications were lower in the LAP group (17% vs 29%), and LAP for RA had significantly fewer total complications (25% vs 62.5%). Intra-abdominal abscess increased following LAP: 9.2 per cent versus 3.6 per cent. Length of stay was shorter for LAP versus OAP in both AA (2.0 vs 2.5 days) and RA (5.5 vs 7 days).
Pneumoretroperitoneum in Two Patients with Clostridium perfringens Necrotizing Pancreatitis
Authors: Anderson Chris M. , Kerby Jeffrey D. , Perry William B. , Sorrells Donald L.
Published: November 2022

Pancreatic gas gangrene is an uncommon and often fatal complication of acute pancreatitis, due to the sporulating anaerobe Clostridium perfringens. C. perfringens is a normal constituent of colonic flora, but infects the pancreas by either transmural spread from the colon or via the biliary tree. Only three reported cases in the world literature describe acute pancreatitis with pneumoretroperitoneum and clostridial infection. Two separate cases, at the same institution, of acute pancreatitis complicated by C. perfringens were analyzed. The records of patients were reviewed for admission history, laboratory and radiology results, intensive care support, surgical intervention, and outcome. Retroperitoneal air was visualized early in the clinical course of both patients by computed tomography. Early surgical debridement, drainage, parental antibiotics, and re-exploration resulted in an uncomplicated recovery. Early computed tomography in patients with suspected necrotizing pancreatitis contributes to early intervention and may advantageously enhance survival.
Incisional Hernia after Repair of Wound Dehiscence: Incidence and Risk Factors
Authors: Van ‘T Riet Martijne , De Vos Van Steenwijk Peggy J. , Bonjer H. Jaap , Steyerberg Ewout W. , Jeekel Johannes
Published: November 2022

The true incidence of incisional hernia after wound dehiscence repair remains unclear because thorough long-term follow-up studies are not available. Medical records of all patients who had undergone wound dehiscence repair between January 1985 and January 1999 at the Erasmus University Medical Center Rotterdam were reviewed. Long-term follow-up was performed by physical examination of all patients in February 2001. One hundred sixty-eight patients underwent wound dehiscence repair. Of those, 42 patients (25%) died within 60 days after surgery. During a median follow-up of 37 months (range, 3–146 months), 55 of the remaining 126 patients developed an incisional hernia. The cumulative incidence of incisional hernia was 69 per cent at 10 years. Significant independent risk factors were aneurysm of the abdominal aorta (10-year cumulative incidence of 84%, P = 0.02) and severe dehiscence with evisceration (10-year cumulative incidence of 78%, P = 0.01). Wound dehiscence repair by interrupted sutures had no better outcome than repair by continuous sutures. Suture material did not influence incidence of incisional hernia. Incisional hernia develops in the majority of patients after wound dehiscence repair, regardless of suture material or technique. Aneurysm of the abdominal aorta and severe dehiscence with evisceration predispose to incisional hernia.
Clear Cell Sarcoma: An Institutional Review
Authors: Jacobs Ira A. , Chang C.K. , Guzman Grace , Salti George I.
Published: November 2022

Clear cell sarcoma of the tendons and aponeuroses (CCSTA) is an aggressive, rare soft-tissue tumor representing approximately 1 per cent of all soft tissue sarcomas. Although it appears to be histogenetically related to melanoma, its clinical behavior resembles soft tissue sarcoma with a propensity for lymph node metastases. We report our experience at a tertiary referral center. Eight cases of CCSTA evaluated at the University of Illinois at Chicago's Medical Center between 1980 and 2002 were retrospectively reviewed. Patient data analyzed included age, gender, anatomic location, size of tumor, development of local, regional, and distant recurrence, and patient status at last follow-up. Local recurrence did not develop in any patient. Metastases developed in three patients with median time to presentation of metastases of 23 months (range, 8–36 months) from the time of initial diagnosis. Two of these three patients died of their disease with an average interval until death of 22 months from the time of initial diagnosis. The disease-free 2- and 5-year survivals were 68 per cent and 50 per cent, respectively. The overall 2- and 5-year survivals were 86 per cent and 68 per cent, respectively. CCSTA is an aggressive tumor of the soft tissues. These tumors present a high risk for development of distant disease and therefore warrant aggressive surgical management and treatment. Neither aggressive multiagent chemotherapy nor radiotherapy appeared to have an impact on outcome.
Central Pancreatectomy as an Indication for Various Benign Pancreatic Tumors
Authors: Chan Carlos , Podgaetz Eitan , Torres-Villalobos Gonzalo , Javier Anthón Francisco , Herrera Miguel F.
Published: November 2022

Standard pancreatic resections, either proximal or distal ones, result in a considerable loss of pancreatic parenchyma and may cause impairment of the exocrine and endocrine functions. Central pancreatectomy has been indicated for small benign lesions located in the neck or body of the pancreas. It has the potential advantage of lowering the risk of functional impairment of the pancreatic parenchyma, biliary tract, upper gastrointestinal tract, and spleen. We present three cases of patients with benign, isolated pancreatic tumors who underwent a successful central pancreatectomy. From this small series, we believe that central pancreatectomy is an excellent therapeutic option for benign, localized pancreatic tumors.
Gunshot Wounds: Bullet Caliber is Increasing, 1998–2003
Authors: Adibe Obinna O. , Caruso Robert P. , Swan Kenneth G.
Published: November 2022

In 1999, Caruso reported data from the level 1 trauma center in Newark, New Jersey, documenting “. . . an ominous trend toward the use of larger caliber firearms in accidents, homicides and suicides.” Those data were derived from measurements of bullets removed from our trauma patients and submitted to the Surgical Pathology laboratory from 1981 through 1997. We further document this trend with measurements of similar source bullets from 1998 through 2002. During the same time, we recorded mortality among gunshot wound victims treated at our trauma center. Bullets submitted to surgical pathology during the years 1998 through 2002 were measured with a millimeter rule to determine caliber or transverse diameter. A total of 367 bullets were studied in this 5-year period. Bullets deformed beyond measurability (∼22%) and shotgun pellets (<5%) were excluded from our study. Bullet calibers were expressed in terms of mean plus or minus standard error ([Formula: see text] ± SE). Mortality figures were derived from analysis of medical records concerning the outcomes all victims of gunshot wounds (E 922, E 965) treated at our hospital during the years studied and expressed as percentages. Linear regression of mean bullet caliber over time was performed, and analysis of variance was used to assess statistical significance of apparent differences in mortality. Bullet caliber continued to increase from 8.47 ± 0.22 to 9.16 ± 0.15 mm during the 5-year observation period. Linear regression reveals R = 0.9649, P < 0.01. Mortality ranged from 4.7 per cent to 10.7 per cent but the differences were not significant ( P > 0.20). These data support a continued trend toward the use of larger caliber firearms in accidents, homicides, and suicides. Mortality does not change during this time and presumably because of improvements in treatment, from resuscitation to definitive surgery and its convalescence.
Endoscope-Assisted Laparoscopic Repair of Perforated Peptic Ulcers
Authors: Lee Kun-Hua , Chang Hung-Chi , Lo Chong-Jeh
Published: November 2022

Laparoscopic repairs for perforated peptic ulcer (PPU) are likely to fail in patients with shock, gastric outlet obstruction, or large perforations. This prospective study was performed to evaluate a revised approach of laparoscopic repair with endoscopic assistance to treat these patients. Between April 2001 and February 2002, 30 consecutive patients with PPU were enrolled in this study. The mean age was 43.1 ± 12.2 years. Male to female ratio was 27:2. One patient was excluded from laparoscopic repair due to a gastric outlet obstruction. The other 29 patients were managed according to a protocol of preoperative upper endoscopy and laparoscopic intracorporeal suture repair with an omental patch. The average operative time was 58.1 ± 13.5 minutes (range, 36–96 min). The average diameter of perforation was 4.2 ± 2.0 mm (range, 1–12 mm). The average time to resume oral fluids was 3.2 ± 0.8 days (range, 2–8 days). The average hospital stay was 4.7 ± 1.1 days (range, 3–10 days). There was no leakage or mortality. Most patients did not receive parenteral analgesics postoperatively. We conclude that endoscope-assisted laparoscopic repair for PPU is safe and effective. This revised technique allows surgeons to exclude patients who are likely to fail the laparoscopic repair.
Congenital Diaphragmatic Hernia Repair on Extracorporeal Life Support: A Decade of Lessons Learned
Authors: Austin Mary T. , Lovvorn Harold N. , Feurer Irene D. , Pietsch Joshua , Earl T. Mark , Bartilson R. , Neblett Wallace W. , Pietsch John B.
Published: November 2022

Congenital diaphragmatic hernia (CDH) is a vexing anomaly that manifests with variable pulmonary compromise in neonates. More than one-third of neonates with CDH require extracorporeal membrane oxygenation (ECMO) for refractory pulmonary hypertension (PHN). To assess the outcome of neonates having CDH repair on ECMO, we reviewed our experience for babies treated between 1992 and 2003. Of 97 neonates with CDH, 40 required ECMO, and 30 were repaired on bypass. Eighteen were supported by veno-venous bypass (VV) and 12 by veno-arterial bypass (VA). While on ECMO, transfusion requirements increased twofold postoperatively (15 to 33 cc · kg-1 · day-1, P = 0.03) and then significantly decreased after decannulation (1.5 cc · kg-1 · day-1, P < 0.01). Non-intracranial hemorrhage occurred in 7 (23%) infants and intracranial hemorrhage in 3 (10%). Twelve (40%) infants died; one (3%) on ECMO secondary to refractory PHN. The mean length of stay for the 18 (60%) survivors was 48 days. Comparisons between survivors and nonsurvivors showed a significantly increased mortality for infants placed on VA bypass ( P < 0.01). However, no other variable was predictive of survival. We conclude that CDH repair on ECMO is technically feasible, shows similar survival to the Extracorporeal Life Support Organization (ELSO) registry, and is associated with few bleeding complications.
The Use of Frozen Section and Immunohistochemistry for Sentinel Lymph Node Biopsy in Breast Cancer
Authors: Chao Celia
Published: November 2022

Intraoperative pathologic evaluation of the sentinel lymph node (SLN) may guide immediate (synchronous) completion axillary lymph node dissection (ALND) for up to two-thirds of patients with nodal disease for breast cancer. The false-negative rates average one-third of cases, and one must be aware of false-positive results as this would result in unnecessary and morbid completion ALND. Currently, the use of immunohistochemistry (IHC) is controversial. There is no question that cytokeratin staining improves the sensitivity; however, there is no evidence that any of these “positive” cells are clinically significant and warrant therapy. Prospective randomized trials will be necessary to confirm or debunk the hypothesis that “sub-micrometastatic” disease has clinical significance.
Augmentation of Ischemia/Reperfusion Injury to Endothelial Cells by Cyclosporin A
Authors: Azizian Maria , Ramenaden E. Radhika , Shah Gaurang , Wilasrusmee Chumpon , Bruch David , Kittur Dilip S.
Published: November 2022

Ischemia/reperfusion (I/R) carries significant injury to endothelial cells in transplanted organs and is an important factor in chronic rejection. Immunosuppressive drugs, notably cyclosporin A (CyA) and FK506, can potentially augment this injury. Here, our goal was to determine the combined effects of I/R and CyA or FK506 on endothelial cells. Transformed mouse endothelial cells (SVEC 4–10) were subjected to ischemia or I/R for 2–24 hours by incubating cells in 100 per cent N2(ischemia) followed by 5 per cent CO2and 95 per cent O2(reperfusion) for 24 hours. In separate experiments, CyA or FK506 was added to cells subjected to ischemia or I/R. Nonviable cells were determined by Trypan blue exclusion assay. All experiments (done in triplicate) were analyzed by Student's t test. Increasing ischemia times resulted in a greater number of nonviable cells (2% nonviable cells at 0 hours and 57% at 24 hours of I/R). Addition of CyA significantly increased the number of nonviable cells when compared with the control (I/R only) group ( P = 0.014). Interestingly, FK506 did not increase the percentage of nonviable cells compared with the control group ( P = 0.2). Unlike FK506, CyA augments I/R injury to endothelial cells in vitro. These findings could be relevant in chronic rejection and transplantation.
Prognostic Factors of Insular versus Papillary/Follicular Thyroid Carcinoma
Authors: Falvo Laura , Catania Antonio , D'Andrea Vito , Grilli Paola , D'Ercole Claudia , De Antoni Enrico
Published: November 2022

The study aims were to characterize patients with insular thyroid cancer and to provide data on patient outcome after surgical therapy. We compared nine patients with insular thyroid cancer at the Department of Surgical Science of “La Sapienza” University of Rome with 27 patients of similar age and tumor size who had follicular and papillary cancer, for a minimum follow-up period of 24 months (range, 24–72 months). All of the patients examined underwent total thyroidectomy. Vascular invasion was observed in 44.4 per cent of insular carcinomas ( P < 0.05 vs papillary carcinomas). No significant differences were observed regarding diagnostic method, multifocality, tumor nodes metastases (TNM), or stage. The death rate of patients with insular carcinoma (33.3%) was found to be higher than that of patients with follicular carcinoma ( P < 0.05) and papillary carcinoma ( P < 0.01). Relapsing lymph-node pathologies were observed in 4 patients (44.4%) with insular carcinoma ( P < 0.05 vs those with follicular and papillary carcinomas). Distant metastases were observed in 66.6 per cent of insular carcinomas ( P < 0.005 vs follicular carcinoma and P < 0.001 vs papillary carcinoma). At the end of follow-up, 2 patients (22.2%) with insular carcinoma were disease-free ( P < 0.001 vs those with follicular and papillary carcinomas). Our study demonstrates an unfavorable prognostic role of the insular phenotype of thyroid cancer, such that this tumor can be classified as an autonomous clinical and pathological entity.
Breast Cancer in a Patient with Poland's Syndrome
Authors: Khandelwal Anjay , O'Hea Brian J. , Garguilo Gerard
Published: November 2022

Poland's syndrome is a congenital anomaly that occurs in 1 of every 32,000 live births. Only two published cases of breast cancer in patients with this congenital anomaly have been previously reported. We describe a case of breast cancer in a 71 year-old female with a clinical diagnosis of Poland's syndrome. A detailed description of the clinical manifestations is provided.
Adenocarcinoid of the Appendix: Is Right Hemicolectomy Necessary? A Meta-analysis of Retrospective Chart Reviews
Authors: Varisco Brian , Mcalvin Brian , Dias James , Franga Dion
Published: November 2022

The purpose of this study was to determine the efficacy of simple appendectomy versus right hemicolectomy in the treatment of localized adenocarcinoid of the appendix. A literature review of retrospective chart reviews from 1966 to March 1, 2003, was performed. Outcomes of retrospective chart reviews were assessed on the basis of treatment modality. Meta-analysis of studies by determining odds ratios for appendectomy versus extended resection using the Hunter-Schmidt meta-analytic method was performed. One hundred patients from 13 studies met inclusion criteria. Seven per cent failure rate with appendectomy alone and 10 per cent with extended resection were observed [OR 1.9 (0.6–5.8); association χ2 1.15, 1 df, P = 0.28]. Our data supports the use of appendectomy alone in localized cases of adenocarcinoid of the appendix provided there is no cecal involvement and the tumor's histology is low grade.
Contralateral Portal Vein Embolization for Hepatectomy in the Setting of Hepatic Steatosis
Authors: Anderson Christopher D. , Meranze Steve , Bream Peter , Gorden D. Lee , Wright J. Kelly , Pinson C. Wright , Chari Ravi S.
Published: November 2022

Portal vein embolization is evolving as an important adjunctive tool in hepatic surgery. In select patients, preoperative hypertrophy of the future remnant liver via contralateral portal vein embolization decreases postoperative liver dysfunction. Hepatic steatosis is the most common liver parenchymal disorder in Western populations. Moderate and severe degrees of hepatic steatosis convey an increased risk of postoperative liver dysfunction following major hepatic resections, but no studies exist examining the role of preoperative portal vein embolization in patients with hepatic steatosis. In this manuscript, we review the indications for portal vein embolization currently supported by the literature and present a patient with moderate to severe steatosis who successfully underwent portal vein embolization and a subsequent major liver resection.
Unusual Cases of Jaundice Secondary to Non-neoplastic Bile Duct Obstruction
Authors: Peyré Christian G. , Wakim Mark , Mateo Rod , Genyk Yuri , Singh Gagandeep , Rick Selby Robert , Jabbour Nicolas
Published: November 2022

Obstructive jaundice secondary to common bile duct stricture is most commonly attributed to malignancy. Here we present three unusual cases that mimicked carcinoma in presentation but were histologically diagnosed as benign inflammatory processes during operative care. The first case was attributed to obstruction-induced chronic pancreatitis secondary to Crohn's disease of the head of the pancreas, the second was due to sarcoidosis within periportal and extrahepatic biliary lymph nodes and distal common bile duct, and the third case was due to tuberculosis of biliary lymph nodes. All were successfully managed surgically, but potentially these patients may have been effectively treated pharmacologically, without the need for invasive surgical intervention, if an earlier diagnosis were available to the clinicians. A retrospective and comparative review of the data of each case demonstrated subtle clues such as multiple enlarged biliary lymph node involvement and only moderately elevated bilirubin levels that pointed toward possible nonmalignant processes.
Pinch-off Syndrome: Case Report and Collective Review of the Literature
Authors: Mirza Brian , Vanek Vincent W. , Kupensky Diane T.
Published: November 2022

Pinch-off syndrome (POS) occurs when a long-term central venous catheter is compressed between the clavicle and the first rib. The compression can cause transient obstruction of the catheter and may result in a tear or even complete transsection and embolization of the catheter. POS may be preceded by a finding of “pinch-off sign” on chest X-ray (CXR) films in which the catheter is indented as it passes beneath the clavicle. We performed a collective review of the 109 cases of POS in the medical literature and report 3 new cases. On average, POS occurs 5.3 months after the insertion of the catheter but has ranged from immediately after insertion to 60 months later. If the subclavian vein is used for access, then an upright CXR should be obtained after the procedure and periodically thereafter to rule-out POS. Treatment of POS is removal of the catheter. If the tip of the catheter has embolized, it can usually be retrieved percutaneously with a transvenous snare. POS can be prevented by using the internal jugular vein for access rather than the subclavian vein.
Abdominal Wall Hernia Repair: A Long-Term Comparison of Sepramesh and Dualmesh in a Rabbit Hernia Model
Authors: Johnson Eric K. , Hoyt Christopher H. , Dinsmore Robert C.
Published: November 2022

Surgeons are faced with a wide variety of mesh products, which they can use to perform tension-free abdominal wall hernia repair. The purpose of this study is to compare Sepramesh (SM) and Dualmesh (DM) in terms of strength of tissue incorporation, mesh shrinkage, and adhesiogenesis. We conducted a prospective, randomized trial using 24 New Zealand White rabbits. Each animal underwent creation of a standardized ventral hernia defect and was randomized to receive either SM or DM repair. There were 12 animals in each study arm. Five months postoperatively, the animals were sacrificed and the hernia repairs were analyzed. Specimens were evaluated for strength of incorporation (SOI), mesh shrinkage, as well as the type and amount of adhesions. SOI for DM was not statistically different from SM (37.2N vs 40.8N). DM underwent significantly more shrinkage than did SM (50.8% vs 32.6%, P < 0.0001). Adhesions were predominantly omental in nature. DM demonstrated a greater amount of adhesed area as a percentage of the mesh (30.7% vs 25.2%), but fewer adhesions in terms of absolute area involved (636 mm2vs 717 mm2). This difference was not statistically significant. Previous studies, terminated at 30 days, demonstrated an increased SOI for SM as compared to DM. This study shows that SOI for DM continues to increase over time such that it is equivalent to DM at 5 months. Though there is increased mesh shrinkage for DM, adhesions to the two materials are equivalent.
Management of Women who Present with T4 Breast Cancer
Authors: Poole Galen V. , Thigpen J. Tate , Vance Ralph B. , Barber W. Henry
Published: November 2022

The purpose of this study was to review the clinical presentation and outcome of women who present with large or locally invasive (T4) breast carcinoma. This retrospective study was conducted at the University of Mississippi Medical Center, a state tertiary care referral institution. One hundred twenty-nine women between the ages of 28 and 85 years (mean, 55 years) presented with T4 breast carcinoma. Follow-up was available for 128 women. Only 23 women have survived (18%), 5 of whom (21.7%) have metastatic disease. Mean survival for those who died was 21.6 months, compared to 76.3 months for survivors. Survival was not influenced by tumor characteristics ( P > 0.5), but was strongly influenced by nodal status ( P < 0.001) and by the presence of metastases at the time of diagnosis ( P < 0.001). Survival was strongly related to mode of therapy ( P < 0.01), but this was principally related to very high mortality rates in women who received no therapy (100%), surgery only (92.3%), or chemotherapy only (95%). The best survival was seen in women who received chemotherapy prior to surgery (40%); their survival was superior to that of women treated initially by surgery, followed by chemotherapy (16.3%, P = 0.04). However, when women who presented with metastatic disease were excluded, survival was not different between these two groups ( P = 0.18). Despite public education efforts and the wide availability of screening programs for breast carcinoma, many women still present with locally advanced disease. Outcome can be favorable in the absence of node involvement or metastatic disease, even in the presence of large, fungating tumors. Multimodality therapy gives the best results, but early surgery may be required for progression of disease during chemotherapy or because of extensive ulceration at initial presentation.
Laparoscopic Approach Reduces Likelihood of Perioperative Complications in Patients Undergoing Adrenalectomy
Authors: Gonzalez Rodrigo , Smith C. Daniel , Mcclusky David A. , Ramaswamy Archana , Branum Gene D. , Hunter John G. , Weber Collin J.
Published: November 2022

Laparoscopy has been reported advantageous over the conventional open technique for adrenalectomy. However, most comparative series include the relatively more challenging cases in the open group. The aim of this study is to assess the actual role of laparoscopy in reducing perioperative complications compared to open surgery in patients undergoing adrenalectomy. Between January 1992 and December 2002, we performed 148 adrenalectomies in 138 patients. Depending on the approach, patients were divided into laparoscopic (LA) or open adrenalectomy (OA) groups. Demographics, tumor characteristics, operative data, and outcomes were analyzed. Linear and logistic regressions identified factors influencing perioperative outcomes. Multivariate-adjusted logistic regression assessed independent relationship between factors and perioperative outcomes. A total of 78 cases were performed laparoscopically and 70 open. Patients were matched for age and sex. Tumor size was smaller (3 ± 2 vs 5 ± 3 cm), operative time was shorter (133 ± 65 vs 165 ± 100 min), estimated blood loss was less (114 ± 152 vs 350 ± 417 cc), length of stay was shorter (3 ± 2 vs 7 ± 3 days), and overall complication rate was lower (7% vs 20%) in the LA compared to the OA group. The incidence of cancer in tumors ≥6 cm (31%) was higher than in those <6 cm (4%). All patients with cancer underwent OA. LA was the only factor independently associated with a decreased likelihood of intraoperative bleeding and postoperative pulmonary complications. Large and malignant adrenal tumors are more frequently removed through an open approach. However, this fact has no influence on the advantages of the LA over the OA. Laparoscopy reduces perioperative adrenalectomy perioperative complication rates. It has a positive impact on intraoperative bleeding and postoperative pulmonary complications.
Heterotopic Gastric Mucosa of the Anus: A Case Report and Review of the Literature
Authors: Steele Scott R. , Mullenix Philip S. , Martin Matthew J. , Ormseth Eric , Weppler Eric , Graham James , Place Ronald J.
Published: November 2022

Ectopic gastric mucosa has been described at various locations of the body, including all levels of the gastrointestinal tract. However, this finding is rare in the rectum and anus, with 38 reported cases. In only six cases, including the present one, has the heterotopic tissue been located within 2 cm of the dentate line. We report a case of gastric heterotopia discovered in a 21-year-old male who presented with anal pain and pruritis. Flexible sigmoidoscopy demonstrated an anal polyp, and biopsy confirmed fundic-type gastric tissue. A 99mtechnetium-pertechnetate scan confirmed increased uptake in the anus. After minimal clinical improvement with proton-pump inhibitors, the patient underwent local surgical excision and remains symptom-free at a follow-up of 9 months. We review the potential etiologies, clinical manifestations, treatment options, and patient outcomes.