bluuebunny/crossref_metadata_2025 huggingface dataset:
Complicated Appendicitis–Is the Laparoscopic Approach Appropriate? A Comparative Study with the Open Approach: Outcome in a Community Hospital Setting
Authors: Pokala Naveen , Sadhasivam S. , Kiran R.P. , Parithivel V.
Published: June 2020

Good outcome has been reported with the laparoscopic approach in uncomplicated appendicitis, but a higher incidence of postoperative intraabdominal abscesses has been reported after laparoscopic appendectomy in complicated appendicitis. This retrospective comparative study compares outcome after laparoscopic (LA) and open appendectomy (OA) in complicated appendicitis. All patients who had LA or OA for complicated appendicitis between January 2003 and February 2006 were included in the study. Data collection included demographics, operative time, estimated blood loss, length of stay (LOS), complications, readmission, and reoperative rates. The primary end points for analysis were postoperative intraabdominal abscess and complication rates and secondary end points were LOS and operative time. All data were analyzed on an intent-to-treat basis. Of 104 patients, 43 patients underwent LA and 61 had OA. The mean age (24.8 ± 16.5 versus 31.3 ± 18.9, P = 0.08) in the LA group was lower than the OA group because there was a significantly higher proportion of pediatric patients (34.8% versus 14.8%, P = 0.02) who had LA. There was no significant difference in gender (female/male, 14/29 versus 27/34, P = 0.3) or American Society of Anesthesiologists class distribution (American Society of Anesthesiologists 1/2/3/4/, 35/7/1/0 versus 45/12/3/1, P = 0.68) between the two groups. The operative time (100.5 ± 36.2 versus 81.5 ± 29.5 minutes, P = 0.03) was significantly longer and the estimated blood loss (21 mL versus 33 mL, P = 0.01) was lower in LA when compared with OA, but there was no significant difference in the number of patients with preoperative peritonitis versus abscesses (7/36 versus 13/48, P = 0.6) in both groups. There was no difference in the median LOS (6 [interquartile range 5–9] versus 6 [interquartile range 4–8], P = 0.7) in the two groups. The conversion rate in LA was 18.6% (n = 8). There was also no significant difference in the complication (17/43 [39.5%] versus 21/61 [34.4%], P = 0.54), reoperative (3/43 [7%] versus 0/61 [0%], P = 0.07), and 30-day readmission (5/41 [11.6%] versus 3/61 [4.9%], P = 0.23) rates between the two groups. The rate of postoperative intraabdominal abscesses was significantly higher in the LA group when compared with the OA group (6/43 [14%] versus 0/61 [0%], P = 0.04) and the wound infection (1/43 [2.3%] versus 5/61 [8.2%], P = 0.4) and pulmonary complication (0/43 [0%] versus 3/61 [4.9%], P = 0.26) rate was higher in the OA group. There was no mortality in the LA group, but there was one mortality in the OA group resulting from postoperative myocardial infarction. Laparoscopic appendectomy can be performed in patients with complicated appendicitis with a comparative operative time, LOS, and complication rates but results in a significantly higher intraabdominal abscess rate and lower wound infection rate when compared with OA.
Ten-Year Follow up after Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease
Authors: Cowgill Sarah M. , Gillman Rachel , Kraemer Emily , Al-Saadi Sam , Villadolid Desiree , Rosemurgy Alexander
Published: June 2020

Laparoscopic Nissen fundoplication was first undertaken in the early 1990s. Appreciable numbers of patients with 10-year follow up are only now available. This study assesses long-term outcome and durability of outcome after laparoscopic Nissen fundoplication for treatment of gastro-esophageal reflux disease. Since 1991, 829 patients have undergone laparoscopic fundoplications and are prospectively followed. Two hundred thirty-nine patients, 44 per cent male, with a median age of 53 years (± 15 standard deviation) underwent laparoscopic Nissen fundoplications at least 10 years ago; 28 (12%) patients were “redo” fundoplications. Before and after fundoplication, among many symptoms, patients scored the frequency and severity of dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before versus after fundoplication were compared using a Wilcoxon matched-pairs test. Data are reported as median, mean ± standard deviation, when appropriate. After fundoplication, length of stay was 2 days, 3 days ± 4.8. Intra-operative inadvertent events were uncommon and without sequela: 1 esophagotomy, 1 gastrotomy, 3 cardiac dysrhythmias, and 3 CO2 pneumothoraces. Complications after fundoplication included: 1 postpneumonic empyema, 3 urinary retentions, 2 superficial wound infections, 1 urinary tract infection, 1 ileus, and 1 intraabdominal abscess. There were two perioperative deaths; 88 per cent of the patients are still alive. After laparoscopic Nissen fundoplication, frequency and severity scores dramatically improved for all symptoms queried (P < 0.001), especially for heartburn frequency (8, 8 ± 3.2 versus 2, 3 ± 2.8, P < 0.001) and severity (10, 8 ± 2.9 versus 1, 2 ± 2.5, P < 0.001). Eighty per cent of patients rate their symptoms as almost completely resolved or greatly improved, and 85 per cent note they would again have the laparoscopic fundoplication as a result of analysis of our initial experience, thereby promoting superior outcomes in the future. Nonetheless, follow up at 10 years and beyond of our initial experience documents that laparoscopic fundoplication durably provides high patient satisfaction resulting from long-term amelioration of the frequency and severity of symptoms of gastroesophageal reflux disease. These results promote further application of laparoscopic Nissen fundoplication.
Pneumoperitoneum after Percutaneous Endoscopic Gastrostomy in Patients in the Intensive Care Unit
Authors: Alley Joshua B. , Corneille Michael G. , Stewart Ronald M. , Dent Daniel L.
Published: June 2020

Percutaneous endoscopic gastrostomy (PEG) has been associated with up to a 55 per cent incidence of pneumoperitoneum in the literature. A review was conducted of 120 consecutive PEG tube insertions in patients in the intensive care unit (ICU) to determine the incidence and significance of postprocedural pneumoperitoneum in this population. One hundred twenty consecutive PEG insertions in patients in the ICU were retrospectively reviewed. Chest radiographs were reviewed for 48 hours postprocedure, noting if any pneumoperitoneum was apparent on radiologic examination. If present, the time to resolution was noted. Documented PEG complications were also examined. Post-PEG pneumoperitoneum was detected in 6.7 per cent of patients in the ICU. Mean time to resolution was 2.7 days. The complication rate was 10.8 per cent, including dislodgement requiring laparotomy, transcolonic placement, and upper gastrointestinal bleeding. There were no complications resulting from PEG placement in patients with postprocedural pneumoperitoneum. Two transcolonic PEGs were undetected by postprocedure chest radiographs. The incidence of post-PEG pneumoperitoneum in our ICU population was 6.7 per cent. We believe that this incidence, although lower than historical rates, accurately reflects the current rate of detectable pneumoperitoneum in patients in the ICU. PEG-related complications were not associated with postprocedure pneumoperitoneum.
Scout Anteroposterior and Lateral CT Scans as a Screening Test for Thoracolumbar Spine Injury in Blunt Trauma
Authors: Sroka Nicole L. , Combs James , Mood Rochella , Henderson Vernon
Published: June 2020

Anteroposterior and lateral radiographs have traditionally been required to clear the thoracolumbar spine (TLS) after blunt trauma. The routine use of CT scans led to a pilot trial to determine if CT scout images can accurately evaluate the TLS after blunt trauma. The purpose of the study was to determine the sensitivity, specificity, positive and negative predictive values of CT scout images for the evaluation of the TLS. Patients admitted to our level II trauma center requiring CT evaluation of the chest, abdomen, and pelvis were considered for this study. Patients with blunt trauma, without neurologic deficits, or other evidence of spinal trauma on physical examination were included. Charts were reviewed for demographics, scout CT image findings, and full CT scan findings. Scout CT images were compared with reconstructed spine CT scans from chest, abdomen, and pelvis CT scans. Injuries to the TLS were defined as compression fractures, burst fractures, and subluxation. One hundred seventeen patients were included. Average Injury Severity Score was 25.1 (±9.4) and average age was 42.5 years. Twenty-three patients had diffuse back tenderness, three had ecchymosis, and 64 had distracting injuries. Twelve injuries to the TLS were present; 11 were seen on scout images. Sensitivity was 92 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 99 per cent. Scout CT images provide an accurate assessment of the TLS after blunt trauma. We are encouraged by the results and will continue to investigate to identify the criteria that allow scout CT images to safely replace anteroposterior and lateral radiographs in the evaluation of the TLS in blunt trauma.
An Individualized Approach to Appendectomy in Children Based on Anatomico-Laparoscopic Findings
Authors: Gauderer Michael W.L.
Published: June 2020

Whether an appendectomy should be performed “open” or laparoscopically is the subject of considerable debate. This study in children was undertaken to test the hypothesis that an individualized approach, based on disease stage, body habitus, and laparoscopic findings should dictate the removal technique. Data on 108 consecutive pediatric appendectomies were prospectively recorded. Except in complex cases, a 5 mm laparoscope was inserted umbilically, the findings were evaluated, and the best removal approach was selected. Depending on the degree of inflammation and mobility, the appendix was fully delivered and resected, either through the initial umbilical trocar site or, more commonly, through a second right lower quadrant (RLQ) trocar site. The second RLQ trocar incision was enlarged for limited or full conversion to an open approach, if needed. In overweight children, three trocars and a stapler were used. Children (63 boys, 45 girls) ranged in age from 3 to 18 years (mean, 11 years). A single umbilical port was used in 16 patients with low-grade appendiceal inflammation. A two trocar, laparoscopically-assisted appendectomy was used in 63 cases. Of these 63, a limited extension of the RLQ trocar incision was necessary in 4 patients and conversion to an open incision was needed in 4 children. The three trocar technique was used 21 times. Twelve of these were cases involving obese patients. A stapler was used 13 times. Four trocars were needed once. Seven patients with complex appendicitis did not undergo laparoscopy. Twenty-nine appendices were perforated, and there were 3 complications: 2 intra-abdominal abscesses and one trocar site wound infection. Because appendiceal disease is a spectrum, and children encompass a wide range of ages and sizes, an individualized approach, based on the anatomical parameters and the clinical and laparoscopic findings, allows for an efficient, patient-specific appendectomy: single trocar for minimally inflamed appendices, two trocars for the most common types, three trocars plus a stapler for overweight children, and an “open” procedure for complex cases.
Conservative Management of Nongangrenous Esophageal and Gastric Pneumatosis
Authors: Mclaughlin Sarah A. , Nguyen Justin H.
Published: June 2020

Pneumatosis intestinalis, or air within the wall of the gastrointestinal tract, has been documented from the esophagus to the rectum. Its presence can suggest gangrenous changes of the stomach or colon and represents a surgical emergency. However, pneumatosis intestinalis can also occur as a result of a benign, nongangrenous condition. We report the conservative management of a patient with nongangrenous gastric and esophageal pneumatosis.
Rural versus Non-Rural Differences in Surgeon Performed Endoscopy: Results of a National Survey
Authors: Zuckerman Randall , Doty Brit , Bark Kenneth , Heneghan Steven
Published: June 2020

The ongoing decline in the number of general surgeons practicing in rural areas of the United States is concerning. Existing data show that rural surgeons perform a broad spectrum of cases including procedures that are not considered to be in the repertoire of most general surgeons. In particular, rural surgeons seem to be performing a sizeable number of endoscopic procedures. A sixty-item survey was mailed to 1700 rural surgeons while a random sample of 154 urban surgeons were telephoned and administered the same questionnaire. The general surgeons were identified using a list obtained from the American Medical Association Masterfile. The response rate was 25 per cent and 74 per cent among rural and nonrural surgeons respectively. Seventy four per cent of rural surgeons performed more than 50 flexible endoscopies a year in contrast to 33 per cent of nonrural surgeons (P < 0.05). Approximately 42 per cent of rural surgeons reported doing more than 200 procedures annually, whereas only 12 per cent of the nonrural surgeons did so. Additionally, 63 per cent of rural surgeons wished they had further training in endoscopy before starting practice as compared with 46 per cent (P < 0.05) of nonrural surgeons. Rural surgeons perform flexible endoscopy at a much higher rate than their nonrural counterparts. The majority of rural surgeons feel they would have benefited from additional flexible endoscopy training before entering practice.
Factors Affecting Attrition in Graduate Surgical Education
Authors: Kohanzadeh Som , Hayase Yukiharu , Lefor Maarten K. , Nagata Yasuhiro , Lefor Alan T.
Published: June 2020

This study was undertaken to identify characteristics of residents who left their training program before the end of the program. A survey was sent to 248 Program Directors in the United States, after institutional review. Anonymous responses were received from 27 (11%) programs. Data was received on 166 residents, including 111 males and 55 females. The group included 146 categorical residents and 20 preliminary residents. Of these, 60 residents left in the middle of the year and 105 left at the end of the year. Of the 164 residents for whom data was reported, 30 (21%) used counseling services. Of 110 residents who left before 2004, 54 (49%) left to choose another specialty. In 2004, of 25 residents who left, 13 (52%, P > 0.05) pursued training in another specialty, and in 2005 of 31 residents who left, 23 (74%, P < 0.025) chose another specialty. Significantly more residents who started a career in surgery after 2004 left to train in another specialty. This may be due to implementation of work hour restrictions in 2003 leading residents to enter surgery who would not have done so previously. Strategies for better retention of matched residents are necessary to reverse this worrisome trend.
The Predictive Value of Sentinel Lymph Node Biopsy in Locally Advanced Breast Cancer Patients who Have Undergone Neoadjuvant Chemotherapy
Authors: Yamamoto Maki , Mehta Rita S. , Baick Choong H. , Su Min-Ying , Lane Karen T. , Butler John A. , Hsiang David J.
Published: June 2020

With the increasing usage of neoadjuvant chemotherapy (NAC) in locally advanced breast cancer (LABC), there is the need to investigate the routine axillary node dissections performed in this group of patients. Controversy exists about the utility of sentinel node biopsy (SNB), either before or after NAC. With the addition of trastuzumab in the treatment of Her2/neu-positive LABC patients, the validity of SNB in this subset population needs to be investigated. A retrospective study of 20 patients who underwent NAC for LABC was undertaken. The pathology of the axillary nodes, sentinel nodes, and primary tumor after neoadjuvant chemotherapy were examined. Twenty patients underwent NAC with doxorubicin and cyclophosphamide, followed sequentially by paclitaxel and carboplatin, with or without trastuzumab based on Her2/neu status. Post chemotherapy, 20 patients underwent mastectomy or lumpectomy with SNB with axillary node dissections. The overall accuracy of SNB was 95 per cent with a false-negative rate of 14 per cent (1/7). In Her2/neu-positive patients, overall accuracy was 100 per cent (8/8) and a false-negative rate of zero per cent. Sentinel node biopsy is a viable option in patients who have undergone NAC. Her2/neu-positive patients who had undergone NAC with trastuzumab had comparable accuracy for sentinel node biopsy in predicting axillary node status.
Outcome Analysis of Patients Undergoing Colorectal Resection for Emergent and Elective Indications
Authors: Kim Justin , Mittal Raj , Konyalian Viken , King Justin , Stamos Michael J. , Kumar Ravin R.
Published: June 2020

Despite advances in perioperative care and operative techniques, urgent colorectal operations are associated with higher morbidity and mortality. To evaluate our rate of complications in elective and urgent colorectal operations, we performed retrospective chart review of 209 consecutive patients who underwent colorectal resection between 1998 and 2002 at Harbor-UCLA Medical Center. One hundred, forty-three (71%) patients underwent elective colorectal resection. A total of 19 (13.3%) complications occurred in the elective group, compared with 24 (38.1%) in the urgent group ( P = 0.003). Both right-sided and left-sided operations were associated with higher incidence of complications when performed urgently. Wound infection occurred in 7.7 per cent of patients undergoing an elective operation and 14.3 per cent in an urgent setting ( P = 0.21). Intra-abdominal abscess occurred in 1.4 per cent of patients undergoing elective operation, compared with 11.1 per cent in the urgent operation group. Four (1.9%) patients developed wound dehiscence, 1 in elective and 3 in the urgent group ( P = 0.09). Anastomotic leak occurred in 1.9 per cent of patients, 2 in each group ( P = 0.6). There were six deaths, 3 in elective and 3 in urgent cases ( P = 0.4). Urgent operation of the colon and rectum is associated with higher incidence of complications. Both right- and left-sided resections have a higher complication rate when performed in a nonelective setting.
Abdominal Computed Tomography in the Evaluation of Acute and Perforated Appendicitis in the Community Setting
Authors: Vu Huynh D.O. , Lalezarzadeh Fariborz , Lawandy Shokry , Wong David T. , Joe Victor C.
Published: June 2020

Several studies report sensitivity and specificity of abdominal computed tomography scans (CT) for the evaluation of acute appendicitis as high as 98 per cent. Despite increased utilization of CT, the rate of negative appendectomy has remained constant at 10 to 20 per cent. The objective of this study was to assess the effectiveness of CT in the evaluation of acute and perforated appendicitis in an academic community-based setting. A retrospective review of 550 patient charts with International Classification of Diseases-9 (ICD-9) codes for acute and perforated appendicitis from January 2002 to October 2005 was performed. Sensitivity of CT was 87 per cent with a positive predictive value of 92 per cent. Specificity was 42 per cent with a negative predictive value of 29 per cent. Negative appendectomy rates were similar with or without CT (11% vs 13%, respectively). Our data suggests that CT used liberally in everyday practice in a community-based setting to evaluate acute appendicitis may not have as strong of a diagnostic value as those used in protocol-driven research studies. Further prospective studies are needed to formulate criteria to better delineate the role of CT in the evaluation of acute appendicitis.
Laparotomy for Visceral Ischemia and Gangrene
Authors: Woo Karen , Major Kevin , Kohanzadeh Som , Allins Alexander D.
Published: June 2020

In the six centuries since mesenteric ischemia was first described, multiple factors have been investigated as predictors of bowel viability with little consensus. We retrospectively examined all cases of exploratory laparotomy for suspected bowel ischemia over an 8.5-year period. Patients were grouped into those who had a “positive laparotomy” with findings of bowel ischemia, bowel gangrene, or both (PL) and those who had a “negative laparotomy” with no evidence of compromised bowel (NL). Of the 114 patients, 86 (75%) were in the PL group and 28 (25%) in the NL group. The significant differences between the two groups were the higher prevalence of females in the PL group versus the NL group [71% vs 50% ( P = 0.04)] and the younger age in the NL group versus the PL group [64 ± 19 vs 76 ± 14 ( P = 0.0002)]. The groups did not significantly differ with respect to preoperative comorbidities and results of laboratory studies. Two patients in NL group had pneumatosis intestinalis on abdominal CT. One patient in PL group had a negative visceral angiogram. There was no difference in mortality between the groups. No single preoperative study reliably predicted positive findings at laparotomy in our series.
Computed Tomographic Brain Density Measurement as a Predictor of Elevated Intracranial Pressure in Blunt Head Trauma
Authors: Inaba Kenji , Teixeira Pedro G.R. , David Jean-Stephane , Brown Carlos , Salim Ali , Rhee Peter , Browder Timothy , Dubose Joseph , Demetriades Demetrios
Published: June 2020

There are no independent computed tomography (CT) findings predictive of elevated intracranial pressure (ICP). The purpose of this study was to evaluate brain density measurement on CT as a predictor of elevated ICP or decreased cerebral perfusion pressure (CPP). A prospectively collected database of patients with acute traumatic brain injury was used to identify patients who had a brain CT followed within 2 hours by ICP measurement. Blinded reviewers measured mean density in Hounsfield Units (HU) within a 100-mm2 elliptical region at four standardized positions. Brain density measurement was compared for patients with an ICP of 20 or greater versus less than 20 mm Hg and CPP of 70 or greater versus less than 70 mm Hg. During a 2-year period, 47 patients had ICP monitoring after brain CT. Average age was 40 ± 18 years old; 93.6 per cent were male; mean Injury Severity Score was 25 ± 10; and Glasgow Coma Scale was 6 ± 4. There was no difference in brain density measurement for observer 1, ICP less than 20 (26.3 HU) versus ICP 20 or greater (27.4 HU, P = 0.545) or for CPP less than 70 (27.1 HU) versus CPP 70 or greater (26.2, P = 0.624). Similarly, there was no difference for observer 2, ICP less than 20 (26.8 HU) versus ICP 20 or greater (27.4, P = 0.753) and CPP less than 70 (27.6 HU) versus CPP 70 or greater (26.2, P = 0.436). CT-measured brain density does not correlate with elevated ICP or depressed CPP and cannot predict patients with traumatic brain injury who would benefit from invasive ICP monitoring.
Retained Foreign Bodies after Emergent Trauma Surgery: Incidence after 2526 Cavitary Explorations
Authors: Teixeira Pedro G.R. , Inaba Kenji , Salim Ali , Brown Carlos , Rhee Peter , Browder Timothy , Belzberg Howard , Demetriades Demetrios
Published: June 2020

Trauma patients are thought to be at high risk for iatrogenic retained foreign bodies (RFBs). The objective of this study was to evaluate this incidence. All cases of RFB after cavitary trauma surgery were identified by review of Morbidity and Mortality reports at a Level 1 trauma center from January 1998 to December 2005 and confirmed by the Octagon Risk Management System. Over 8 years, 10,053 trauma operations were performed (2075 laparotomies, 377 thoracotomies, and 74 sternotomies). Three cases (0.1%) of RFB (all sponges) occurred during one single-stage and two damage control laparotomies. The counts were correct before definitive closure in two of three cases. No postoperative x-rays were obtained in any of the cases. RFB diagnosis occurred between days 3 and 9, one on a routine chest x-ray and the other two on abdominal computed tomography scans during a septic workup. Four-month to 8-year follow up documented one pleural effusion and one abscess resulting from the RFB. Iatrogenic RFBs after emergent cavitary trauma surgery occur at a rate of 0.12 per cent and are associated with significant morbidity. In addition to standard preventive strategies, in emergent cases with risk factors such as requiring damage control, before final cavity closure, even with a correct sponge count, radiographic evaluation is warranted.
Article Commentary: Retained Intra-abdominal Surgical Instruments: Time to Use Nascent Technology?
Authors: Berkowitz Seth , Marshall Harry , Charles Anthony
Published: June 2020

Retention of surgical instruments is a possible complication of surgery; moreover, its occurrence has typically been used to denote poor surgical care on the part of the individual surgeon and the healthcare system. In the literature, it is not surprising that instances of retained foreign bodies are underreported to minimize exposure to possible litigation.
Developing a New Bariatric Surgery Program
Authors: Angstadt John , Whipple Oliver
Published: June 2020

We initiated a new bariatric surgery program in February 2004. Before starting the program, we initiated a systemic planning process to design, develop, and implement a comprehensive, multidisciplinary program. Between May 2004 and June 2006, 178 patients underwent Roux-en-Y gastric bypass to treat morbid obesity at our institution. We have had no pulmonary emboli and no deaths. Twenty-one patients (11.8%) developed wound infection after surgery. Thirteen patients (7.3%) developed stenosis at the gastrojejunostomy. Five patients (2.8%) bled from the gastrojejunostomy. Four patients (2.2%) developed atelectasis. Three patients (1.6%) developed an internal hernia after surgery. One patient (0.5%) developed deep venous thrombosis. Two patients (1.1%) developed small bowel obstruction from adhesions. One patient developed a leak (0.6%). By 6 months after surgery, our patients have lost an average of 85 pounds (53% excess weight loss). By 12 months, they have lost an average of 104 pounds (65% excess weight loss). A focused effort to reduce infection has dropped our wound infection rate to 0 per cent in the past 6 months. Our results indicate that with proper planning, it is possible to initiate a new program and achieve excellent outcomes. Proper planning, systematic implementation, and a focus on patient education are critical to success.
Timing of Laparoscopic Cholecystectomy for Acute Cholecystitis: Evidence to Support a Proposal for an Early Interval Surgery
Authors: Low Jee K. , Barrow Paul , Owera Anas , Ammori Basil J.
Published: June 2020

We evaluated the safety and feasibility of delayed urgent laparoscopic cholecystectomy (LC) performed beyond 72 hours to overcome the logistical difficulties in performing early urgent LC within 72 hours of admission with acute cholecystitis (AC), and to avoid earlier readmission with recurrent AC in patients awaiting delayed interval. Patients admitted with AC were scheduled for urgent LC. Patients who underwent early urgent LC were compared with those who had delayed urgent surgery. Fifty consecutive patients underwent urgent LC for AC within 2 weeks of admission. There were no conversions and no bile duct injuries. Delayed surgery (n = 36) neither prolonged operating time (90 vs 85 minutes), nor increased operative morbidity (9.7% vs 7.7%) or mortality (2.4% vs 7.7%) compared with early surgery (n = 14). Although delayed surgery was associated with shorter postoperative hospital stay (1 vs 2 days, P = 0.029), it prolonged total hospital stay (9 vs 5 days, P < 0.0001). Delay of LC beyond 72 hours neither increases operative difficulty nor prolongs recovery. It might be more cost effective to schedule patients who could not undergo early urgent LC but are responding to conservative treatment for an early interval LC within 2 weeks of presentation with AC.
Bullet Embolus to the Heart after Gunshot Wound to the Neck: A Case Report
Authors: Breeding Jacob M. , Smith R. Stephen , Dort Jonathan M.
Published: June 2020

A 43-year-old woman presented with gunshot wounds to the neck, chest, and left thigh. Computed tomography of the neck and chest with intravenous contrast revealed a left common carotid pseudoaneurysm and a foreign body in the right atrium. Preoperative chest x-ray and CT scan confirmed a metallic foreign body in the right heart. At median sternotomy, the intracardiac foreign body could not be located using fluoroscopy. The foreign body (bullet) was subsequently removed in the cardiac catheterization laboratory using a percutaneous transvenous basket extraction through a right femoral vein cutdown.
Is There a Role for Secondary Thoracic Ultrasound in Patients with Penetrating Injuries to the Anterior Mediastinum?
Authors: Simmons Jon D. , Haraway A. Neal , Schmieg Robert E. , Burgdorf Michael , Duchesne Juan
Published: June 2020

Pericardial tamponade (PT) after penetrating thoracic injury can be lethal if not diagnosed and treated promptly. Most patients present with PT shortly after their injuries occur, but delayed presentation of PT (delayed pericardial tamponade [DPT]) has occurred as late as 73 days after initial injury. Initial evaluation of patients with an anterior mediastinal penetrating injury includes physical examination, chest x-ray, and echocardiography. CT scans of the chest can clarify the tracts of penetrating injuries in stable patients. With increased accessibility to these radio-graphic modalities, PT has been diagnosed in a more timely fashion, and the incidence of DPT has decreased. However, the absence of pericardial effusions on all of these studies at initial presentation does not clear the patient from risk for developing DPT.
Laparoscopic and Selective Open Resection for Adrenal and Extraadrenal Neuroendocrine Tumors
Authors: Phitayakorn Roy , Mchenry Christopher R.
Published: June 2020

Laparoscopic resection is preferred for most adrenal tumors. From 1996 to 2007, 54 consecutive patients who underwent resection of an adrenal tumor or extraadrenal pheochromocytoma were reviewed to determine the outcome of laparoscopic resection and the rate of conversion and indications for open resection. Adrenalectomy was performed in 51 patients and resection of a pheochromocytoma of the organs of Zuckerkandl in three patients. Laparoscopic adrenalectomy was initiated in 42 patients, three (7.3%) of whom underwent conversion to an open approach because of bleeding from an accessory vein (one), tumor invasion (one), or adhesions (one) (median American Society of Anesthesiologists score = 2, estimated blood loss = 186 ± 235 mL, size = 5 ± 3 cm). Open resection was performed in 12 patients, six at the time of another procedure, three for pheochromocytoma of the organs of Zuckerkandl, two for bilateral adrenalectomy, and one for tumor invasion (median American Society of Anesthesiologists score = 3, estimated blood loss = 1525 ± 978 mL, size = 8 ± 4 cm). With proper patient selection, laparoscopic adrenalectomy can be successfully performed with a low conversion rate. When unrecognized, an accessory right adrenal vein may be a source of significant bleeding requiring conversion to an open approach. Open resection is indicated for tumor invasion, for extraadrenal pheochromocytoma, when laparoscopic resection cannot be performed safely, and for concomitant open procedures.
Carcinoid of the Extra-Hepatic Bile Duct: A Case Report with Long-Term Follow-up and Review of Literature
Authors: Gusani Niraj J. , Marsh J. Wallis , Nalesnik Michael A. , Tublin Mitchell E. , Gamblin T. Clark
Published: June 2020

Extrahepatic bile duct tumors, 80 per cent of which are adenocarcinomas, are rare neoplasms accounting for less than two per cent of all cancers. Carcinoid tumor of the extrahepatic bile ducts is a reportable lesion, with only approximately 50 cases described in the literature since 1959. We present a case of a primary extrahepatic bile duct carcinoid tumor resected for cure with the longest reported follow-up time (11 years) after surgery. We also summarize the existing literature with regard to this rare tumor. Our case lends strong support to the notion that extrahepatic biliary carcinoids are generally indolent lesions that, if aggressively resected, can result in excellent long-term survival. Complete excision with clear margins seems to provide the best chance of obtaining long-term survival and cure.
Practical Approaches to the Surgical Management of Achalasia
Authors: Finley Richard J. , Rattenberry Jennifer , Clifton Joanne C. , Finley Christian J. , Yee John
Published: June 2020

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.
Concomitant Cholecystoduodenal Fistula and Cholecystocholedochal Fistula Due to Actinomyces
Authors: Bledsoe Samuel E. , Oliver Adrienne E. , Delgado Dennis G. , Kent Raleigh B.
Published: June 2020

This report describes a patient with a cholecystoduodenal fistula and cholecystocholedochal fistula who was found to have Actinomyces contained within the gallbladder upon pathologic examination. The cholecystocholedochal fistula was repaired using a flap of gallbladder over a T-tube, and the actinomycosis was successfully eradicated with 6 weeks of intravenous doxycycline followed by an additional 6 months of oral doxycycline.
Splenic Embolization for Splenic Laceration in a Patient with Mononucleosis
Authors: Sweat Jeffrey A. , Dort Jonathan M. , Smith R. Stephen
Published: June 2020

Splenomegaly is a sequela of infectious mononucleosis. The potential for traumatic rupture of an enlarged spleen is well recognized. Recently, splenic artery embolization has gained popularity for the treatment of splenic injury. However, embolization has not been described for splenic injury in an enlarged spleen secondary to mononucleosis. We report the case of a 15-year-old girl who was the restrained passenger in a motor vehicle crash. On examination at an American College of Surgeons-verified Level 1 trauma center, the patient was found to have abdominal pain. A focused assessment with sonography for trauma examination revealed fluid in Morison's pouch. A subsequent spiral CT scan with intravenous contrast revealed a markedly enlarged spleen with a shattered upper pole. The patient denied symptoms of mononucleosis; however, a spot mononucleosis test was positive. The patient was admitted to the pediatric intensive care unit for observation. She remained hemodynamically stable, but her initial hemoglobin of 9.2 g/dL fell to 7.1 g/dL 6 hours later. Splenic artery embolization was performed and the upper pole of the spleen was selectively embolized. The hemoglobin remained stable and the patient was transferred to the pediatric ward. On postembolization day five, the patient was dismissed with a hemoglobin of 9.7 g/dL. This case demonstrates that splenic embolization is a viable alternative to operative treatment even in the presence of splenomegaly secondary to mononucleosis.
Transverse Mesocolonic Hernia of the Jejunum Mimicking Pancreatic Neoplasm
Authors: Nauta Russell J. , Nauta Allison C.
Published: June 2020

A patient admitted repetitively for vomiting was found to have a radiologic abnormality in the lesser sac, initially interpreted as a pancreatic mass. At exploration, intestinal obstruction due to transmesocolonic herniation of the jejunum explained both the symptoms and the radiologic finding.
One Snake or Two: The Symbols of Medicine
Authors: Froman Carol R. , Skandalakis John E.
Published: June 2020

In antiquity, Asklepios was portrayed with a stout staff around which was coiled a snake. Hermes (Mercury), the messenger of the gods, was portrayed with a wand, often with wings, around which were coiled two snakes. During the Renaissance and up to modern times, in varied locales, each icon has been termed the caduceus and afforded the status of the symbol of medicine. It is proposed that this confusion did not arise from ignorance, but from the loss of the deeper significance of the symbols, and from the replacement of religious iconographic constraints by aesthetic and decorative considerations.
Mixed Ductal–Endocrine Carcinoma of the Pancreas with Synchronous Papillary Carcinoma-In-Situ of the Common Bile Duct: A Case Report and Literature Review– Synchronous Pancreatic and Bile Duct Tumors
Authors: Carter Robert R. , Woodall Charles E. , Mcnally Megan E. , Talboy Glenn E. , Lankachandra Kamani M. , Van Way Charles W.
Published: June 2020

This report is a case of a 58-year-old woman with a mixed ductal–endocrine carcinoma of the pancreas and a synchronous carcinoma-in-situ of the common bile duct. She presented with intractable itching from obstructive jaundice. Magnetic resonance imaging scan showed dilated intrahepatic biliary and common bile ducts. Endoscopic retrograde cholangiopancreatography revealed an ulcerated lesion of the ampulla. Biopsies from this lesion showed adenocarcinoma. Subsequently, pancreatoduodenectomy was performed for the diagnosis of peri-ampullary carcinoma. Gross examination revealed a 2-cm irregular, ulcerated lesion obstructing the distal 0.5 cm of the common bile duct within the head of the pancreas. On histopathological examination, it was discovered that this lesion contained two separate neoplasms: papillary carcinoma-in-situ of the intraparenchymal portion of the common bile duct and a mixed ductal–endocrine carcinoma of the pancreas. Mixed ductal–endocrine carcinoma of the pancreas is very rare. Finding it in conjunction with a synchronous, overlying papillary carcinoma carcinoma-in-situ of the common bile duct has not been previously described.
Is Splenectomy after Trauma an Endangered Species?
Authors: Harbrecht Brian G. , Franklin Glen A. , Miller Frank B. , Richardson J. David
Published: June 2020

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 ± 0.9 days, 10.9% mortality) compared with trauma (11.0 ± 0.5 days, 7.7% mortality) or medical (9.7 ± 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training.
Rare Anatomic Variation of Left Gastric Artery and Right Hepatic Artery in a Female Cadaver
Authors: Troupis Theodore , Chatzikokolis Stamatis , Zachariadis Michael , Troupis George , Anagnostopoulou Sofia , Skandalakis Panayiotis
Published: June 2020

The present report describes a rare case in which the left gastric artery arises directly from the abdominal aorta and the right hepatic artery from the superior mesenteric artery, as observed during the dissection of a female cadaver. The left gastric artery usually rises as one of the three branches of the celiac trunk, which was originally described by Haller in 1756, whereas the right hepatic artery usually originates from the proper hepatic artery. The knowledge of the typical anatomy of the abdominal arteries, and their variations, is especially important due to the numerous interventions performed in the abdominal area.
Impact of Acute Care General Surgery Coverage by Trauma Surgeons on the Trauma Patient
Authors: Schenarts Paul J. , Phade Sachin V. , Goettler Claudia E. , Waibel Brett H. , Agle Steven C. , Bard Michael R. , Rotondo Michael F.
Published: June 2020

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days ( P < 0.0001), intensive care unit length of stay ( P < 0.0001), and hospital length of stay ( P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.
Intra-abdominal Sepsis following Pancreatic Resection: Incidence, Risk Factors, Diagnosis, Microbiology, Management, and Outcome
Authors: Behrman Stephen W. , Zarzaur Ben L.
Published: June 2020

Intra-abdominal sepsis (IAS) following pancreatectomy is associated with the need for therapeutic intervention and may result in mortality. We retrospectively reviewed patients developing IAS following elective pancreatectomy. Risk factors for the development of sepsis were assessed. The microbiology of these infections was ascertained. The number and type of therapeutic interventions required and infectious-related mortality were recorded. One hundred ninety-six patients had a pancreatectomy performed, 32 (16.3%) of who developed IAS. Infected abdominal collections were diagnosed and therapeutically managed at a mean of 11.8 days after the index procedure (range, 4–33). Eleven of 32 (34%) of these infections were diagnosed on or before postoperative day 6, 10 of who had Whipple procedures. Statistically significant risk factors included an overt pancreatic fistula (18.8% vs 5.5%) and a soft pancreatic remnant (74.2% vs 42.3%), but not the lack of intra-abdominal drainage, an antecedent immunocompromised state, postoperative hemorrhage, or the preoperative placement of a biliary stent. Fifty-five per cent had polymicrobial infections and 26 per cent of isolates were resistant organisms. Nineteen per cent and 48 per cent of patients had an isolate positive for fungus and a Gram-positive organism, respectively. Forty-seven therapeutic interventions were used, including 10 reoperations. Length of stay was significantly prolonged in those with IAS (28.5 vs 15.2 days) and mortality was higher (15.6% vs 1.8%). We conclude: 1) septic morbidity after pancreatectomy is associated with a soft pancreatic remnant and an overt pancreatic fistula and in this series resulted in a prolonged length of stay and a significant increase in procedure-related mortality; 2) infected fluid collections may occur very early in the postoperative period before frank abscess formation, and an early threshold for diagnostic imaging and/or therapeutic intervention should be entertained in those with clinical deterioration; and 3) these infections are often polymicrobial and frequently include resistant and nonenteric organisms.
Receptor Characteristics of the Second Tumor in Synchronous versus Metachronous Breast Cancer
Authors: Bu-Ali Hanadi , Solh Melhem , Kapur Arthi , Mittal Vijay
Published: June 2020

Presently, there is no consensus on whether synchronous breast cancer has the same disease origin as the primary tumor, or if it is a completely independent second primary. This study explores this concept in both synchronous and metachronous breast cancer looking specifically at their receptor characteristics and level of differentiation. A retrospective chart analysis of 114 patients with synchronous or metachronous breast cancer treated at a single institution between January 1991 and March 2004 was done. Sixty-three per cent of the patients were diagnosed with metachronous breast cancer. Synchronous breast cancer was histologically more aggressive ( P < 0.05) with a significantly higher number of patients having poorly differentiated tumors, a greater number of metastases involving a larger number of organs ( P < 0.05), and lower average survival compared with the metachronous group ( P < 0.005). Both the first and second tumor in both groups were similar in hormone receptor status, histologic subtype, and grade. Synchronous breast cancer is more aggressive and has a poorer outcome than metachronous breast cancer. Concordance in hormone receptor status, grade, and histologic subtype between different tumors within the same patient suggests, but does not completely support, a monoclonal origin. Analysis applied here is crude and more specific methods of analysis such as DNA microarray would be required to infer such a conclusion.