bluuebunny/crossref_metadata_2025 huggingface dataset:
Choledocholithiasis: Endoscopic versus Laparoscopic Management
Authors: Heili Michael J. , Wintz Nancy K. , Fowler Dennis L.
Published: November 2022

Choledocholithiasis is present in 6 to 10 per cent of patients who have cholelithiasis. In the era of laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography with endoscopic retrograde sphincterotomy (ERCP/ERS) and laparoscopic common bile duct exploration (LSCBDE) have been used to treat choledocholithiasis. The purpose of this study is to compare ERCP/ERS with LSCBDE. A retrospective review of 913 patients undergoing laparoscopic cholecystectomy identified 61 patients who had ERCP/ERS or LSCBDE to treat choledocholithiasis at a community medical center between 1990 and 1996. Outcome parameters were hospital length of stay (LOS), hospital cost, and complications. The results were: ERCP (n = 26; LOS, 5.0 ± 3.6 days; cost, $11,823 ± $7,000; complications, 23.1%); LSCBDE (n = 35; LOS, 3.4 ±2.4 days; cost, $9,100 ± $2,884; complications, 2.9%); and P value (LOS, 0.028; cost, 0.066; complications, 0.034). LSCBDE results in a significantly shorter LOS and significantly fewer complications, and is less costly than ERCP/ERS. LSCBDE, when feasible, should be considered the gold standard for the management of choledocholithiasis.
Primary Aortojejunal Fistula: A Case Report
Authors: Brown Preston W. , Sailors David M. , Headrick James R. , Burns R. Phillip
Published: November 2022

Primary aortoenteric fistulae (AEFs) are extremely rare vascular entities, with fewer than 250 cases reported in the world medical literature as of 1996. Incidence is less than 1 per cent, with a mortality ranging from 33 to 85 per cent. Atherosclerosis remains the most common etiology, accounting for more than two-thirds of the cases reported. Other etiologies include carcinoma, ulcers, gallstones, diverticulitis, appendicitis, and foreign bodies. Early diagnosis is crucial for survival and mandates recognition of the typical “herald bleed.” Additional findings on initial presentation frequently include flank pain, abdominal pain, hematemesis, melena, and an abdominal mass. More than 80 per cent of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Successful management of primary AEF requires a high index of suspicion for diagnosis and prompt surgical intervention for survival.
Management of Adrenal Cysts
Authors: Neri Linda M. , Nance F. C.
Published: November 2022

Adrenal cysts have been traditionally managed by excision to rule out malignancy. We reviewed the 613 cases of adrenal cysts (including 6 new cases of our own) to evaluate whether this is still appropriate. Descriptive statistics and distribution of each pathologic type have been updated, based on 515 cases, and have changed from statistics compiled on 155 cases by G. A. Absehouse et al. Only seven per cent of all adrenal cysts are malignant or potentially malignant. There is only one reported case of a malignancy found in a nonfunctioning adrenal cyst that was initially thought to be benign. In this case, no CT or aspiration was performed. There have been 19 cases of adrenal cysts managed with aspiration. All were nonfunctioning and benign. One had a bloody aspirate. Reaccumulation occurred in 32 per cent of the cases (six cases); six per cent were symptomatic, four per cent were excised. Follow up was available in 15 cases from 4 months to 3.5 years. Management of the patient with a suspected adrenal cyst should include a careful history and physical and biochemical screening to rule out a functioning lesion. A CT scan, and aspiration of the cyst with a cystogram should be performed to confirm a simple cyst of the adrenal. If the suspicion of malignancy is low, and the lesion is nonfunctional, the adrenal cyst may be managed by aspiration alone. If the cyst recurs and is asymptomatic, it may be observed. If a symptomatic cyst recurs, it may be reaspirated or excised.
Efficacy of Routine Preoperative Computed Tomography Scans in Colon Cancer
Authors: Mcandrew Mark R. , Saba Alexander K.
Published: November 2022

A retrospective review of 180 patients who underwent surgery for primary colon carcinoma from August 1989 to August 1994 was performed to evaluate the necessity of preoperative CT scans in patients with known colon cancer. Sixty-seven patients had preoperative CT scans. Data were collected to evaluate the ability of the scan to detect hepatic metastases, lymph node involvement, and incidental findings that would possibly alter the planned surgical approach. In this study, CT had a sensitivity and specificity of 75 per cent and 88 per cent, respectively, in detecting hepatic metastases. Only 19 per cent of patients with lymph node involvement were correctly staged with CT scans as having lymphadenopathy. Only 3 of 67 patients had incidental findings on CT scans that ultimately changed the surgical approach. It is apparent that because CT scans detect only 75 per cent of hepatic and 19 per cent of hepatic and lymph node involvement and does not seem to alter the planned approach, it is not justified for routine preoperative evaluation of all patients. We, therefore, recommend a more selective approach to patients suspected of having advanced disease if the surgeon suspects that the information may alter the surgical approach.
Breast Cancer and HIV: What Do We Know?
Authors: Guth Amber A.
Published: November 2022

The present acquired human immunodeficiency syndrome-defining neoplasms are Kaposi's sarcoma, non-Hodgkins lymphoma, and cervical cancer. However, other malignancies have recently been associated with human immunodeficiency virus (HIV) infection. Is there also a link between breast cancer and HIV infection? Breast cancer seems to be more aggressive in the setting of immunocompromise by HIV infection, as demonstrated by the clinical course of two patients recently treated at this institution and review of the available literature. As the acquired human immunodeficiency syndrome epidemic affects increasing numbers of women and survival improves, surgeons will be frequently called on to diagnose and treat breast cancer in the HIV+ patient.
Initial Resuscitation Volume in Uncontrolled Hemorrhage: Effects on Organ Function
Authors: Haizlip Thomas M. , Poole Galen V. , Falzon Andrew L.
Published: November 2022

Conventional resuscitation of hypovolemia due to hemorrhage has consisted of aggressive fluid administration. Recent studies have suggested that surgical control of bleeding before fluid resuscitation might improve early survival. The effects of limited resuscitation on organ function have not been assessed in these studies. We developed a model of moderate intraperitoneal hemorrhage designed to evaluate long-term end-organ function after various resuscitation protocols. Male Sprague-Dawley rats underwent ketamine anesthesia, followed by placement of femoral artery and vein lines. Intraperitoneal hemorrhage was induced by division of distal branches of the ileocolic artery and vein. After 5 minutes of bleeding, the animals were randomized to one of three resuscitation groups: Group 1 received no fluid resuscitation before surgical control of the hemorrhage; Group 2 received 0.5 mL of lactated Ringer's solution (LR) every 5 minutes for a mean arterial pressure (MAP) of less than 80 mm Hg; Group 3 received 2.0 mL of LR every 5 minutes for a MAP of less than 80 mm Hg. In all three groups, after 20 minutes, the bleeding was surgically controlled. All rats were then resuscitated with LR to a MAP of 80 mm Hg. The intravascular lines were removed, and the rats were allowed to recover from anesthesia and were returned to animal holding. On the 7th day, survivors were sacrificed, and their blood was assayed for hematocrit and serum levels of bilirubin, alanine aminotransferase, urea nitrogen, and creatinine. Kidneys, lungs, and liver were harvested for microscopic examination. Survival was lower in Group 2 than in the other groups (90%, 60%, and 100%, respectively; P = 0.04), but all deaths occurred within 3 hours of hemorrhage and were due to either hypovolemia or anesthetic complications. No histologic abnormalities were identified in the livers of the animals that survived, but pulmonary atelectasis and mild-to-moderate renal tubular necrosis were identified uniformly. No histologic differences could be discerned between the groups. Hematocrit and indices of liver and renal function were similar in all groups, and no animal developed organ dysfunction. In this model of moderate uncontrolled intraperitoneal hemorrhage, the volume of fluid resuscitation, or the absence of resuscitation, had an inconsistent effect of 7-day survival and did not influence function or histologic appearance of the liver, lungs, or kidneys 7 days after hemorrhage.
Preoperative Chemoradiotherapy in the Treatment of Gallbladder Cancer
Authors: De Aretxabala Xabier , Roa Ivan , Burgos Luis , Cartes Raul , Silva Jorge , Yañez Eduardo , Araya Juan Carlos , Villaseca Miguel , Quijada Ingrid , Vittini Cecilia
Published: November 2022

Gallbladder cancer is generally associated with a poor prognosis, with local recurrence being the main pattern of failure. In an attempt to improve on the present status of management, we evaluated a prospective Phase II study involving preoperative 5-fluorouracil and radiation. Among 27 eligible patients with a potentially resectable gallbladder cancer detected after cholecystectomy, 18 were treated with preoperative radiation (4500 cGy; 180 cGy/fraction, 5 days/week) concurrent with a continuous infusion of 5-fluorouracil (350 mg/m2/day, days 1–5 and 21–25). Toxicity included leukopenia (8 patients) and thrombocytopenia (7 patients). Delay in surgery due to hematological toxicity was seen in 6 patients. Of the 18 patients, 15 underwent a reoperation. Resection was performed in 13 (86%). Pathologic findings after reoperation revealed residual tumor in both liver and lymph nodes in 3 patients. At a median follow-up of 24 months, 7 patients are alive. Among the patients who died after curative resection, local recurrence was demonstrated in only 1. This is the first report concerning preoperative chemoradiation in gallbladder cancer. To assess its effect on survival, a prospective randomized trial will be necessary.
Unilateral Male Breast Masses: Cancer Risk and Their Evaluation and Management
Authors: Volpe Carmine M. , Raffetto Joseph D. , Collure Don W. , Hoover Eddie L. , Doerr Ralph J.
Published: November 2022

Breast cancer is an uncommon cause of breast enlargement in the adult male. Overall, it accounts for <1 per cent of all male cancers. Although most male breast carcinomas are clinically apparent, distinguishing early breast cancer from gynecomastia, the most common cause of male breast enlargement, is considered a difficult task. To overcome this difficulty, many surgeons proceed directly to surgery as their initial diagnostic test. Although appropriate in some cases, the infrequent occurrence of male breast cancer and the diagnostic accuracy of mammography and fine-needle aspiration cytology suggest a modification of our present management. The aim of this study was to assess the incidence of breast cancer in men with unilateral breast masses and to propose a treatment algorithm for unilateral male breast masses. The medical records of 36 male patients who underwent subcutaneous mastectomy for a unilateral breast mass at the Buffalo Veterans Administration Medical Center between 1989 and 1996 were retrospectively reviewed. Data was collected on a standard data form. The median age was 63-years-old (range, 22–82). Gynecomastia was diagnosed in 30 patients (83%), lipoma in 4 patients (11%), invasive breast cancer in 1 patient (3%), and melanoma in situ in 1 patient (3%). Of the 30 patients with gynecomastia, 60% (18 patients) gave a history of a medical condition or use of medications known to cause gynecomastia, compared with 16 per cent (1 of 6) of the patients without gynecomastia (P = 0.08). Half of the patients with gynecomastia presented with an asymptomatic mass compared with 67 per cent of the patients without gynecomastia (P = not significant). The median duration of symptoms for patients with gynecomastia was 3 months. Men with unilateral breast masses have a low incidence of breast cancer. A male patient with a palpable unilateral breast mass consistent with gynecomastia on the basis of historical, physical and mammographic findings does not require surgical biopsy unless other clinical indications prevail. Lack of symptoms (pain) related to the mass is probably not helpful in deciphering gynecomastia from breast cancer.
Current Clinical Concepts in Perioperative Anticoagulation
Authors: Hewitt Robert L. , Chun Kendra L. , Flint Lewis M.
Published: November 2022

Management of patients with significant risks for thromboembolism in the perioperative period requires consideration of both risks of thromboembolism and risks of anticoagulant therapy. Patients who are receiving warfarin therapy because of recent venous thromboembolism, nonvalvular atrial fibrillation, and mechanical heart valves are at increased risk during the interval when the warfarin is discontinued and when the international normalized ratio is at a subtherapeutic level. In patients with an acute venous thromboembolic event within the past month, the use of intravenous heparin appears to be justified both preoperatively and postoperatively. If the venous thromboembolic event was within the past 2 to 3 months, use of intravenous heparin appears justified in the postoperative period. More than 3 months after an acute episode of venous thrombophlebitis, the relatively low risk of recurrence does not appear to justify the risks of complications from intravenous heparin. Patients with increased risks of arterial embolism, specifically those with nonvalvular atrial fibrillation and mechanical heart valves, are generally not at sufficient risk of arterial embolism to justify use of intravenous heparin during the perioperative subtherapeutic international normalized ratio interval when warfarin is withheld. A potential increased risk of recurrent arterial embolism when the preceding event was within a month suggests that elective surgery should be deferred beyond a month whenever possible in such patients. The use of fixed-dose, subcutaneous low molecular weight heparin has been observed to have advantages over use of unfractionated intravenous heparin both in terms of safety and efficiency. Further refinements in management of patients with significant risks of thromboembolism may occur with increased experience with low molecular weight heparin.
Nonendarterectomy Procedures of the Carotid Artery: A Vive-Year Review
Authors: Taylor Spence M. , Langan Eugene M. , Snyder Bruce A. , Cull David L. , Crane Martin M.
Published: November 2022

Although the efficacy of carotid endarterectomy has been well established, nonendarterectomy procedures of the carotid bifurcation have only sporadically been reported. Of 334 consecutive nontraumatic carotid procedures performed on 321 patients from July 1992 until May 1997, 306 (91.6%) were carotid endarterectomies, 14 (4.2%) were carotid-subclavian bypasses/transpositions, and 14 (4.2%) were nonendarterectomy procedures of the carotid artery. These latter 14 cases (nine females and five males; mean age, 63 years) were all symptomatic (neurological or painful mass) and included carotid kink/coil resection (n = 3; 0.9%), endarterectomy and vertebral transposition (n = 2; 0.6%), carotid aneurysm resection (n = 2; 0.6%), carotid body tumor resection (n = 2; 0.6%), carotid stump ligation/external endarterectomy (n = 1; 0.3%), infected/bleeding carotid patch removal with vein graft replacement (n = 1; 0.3%), saphenous vein graft replacement (n = 1; 0.3%), carotid dilatation for fibromuscular dysplasia (n = 1; 0.3%), and descending aorta to carotid bypass (n = 1; 0.3%). With 30 day follow-up complete for all 334 carotid operations, 10 perioperative strokes (2.9%) and five deaths (1.5%) occurred for a combined stroke/death rate of 3.3 per cent. Of the 14 nonendarterectomy carotid artery operations, there were no strokes or deaths; with mean follow-up of 13 months, 13 patients (92.9%) are asymptomatic, patent, and disease-free. Three severe transient cranial nerve (CN) neuropraxias (21.4%), one myocardial infarction (7.1%), and one late death (mesenteric ischemia at 2 months), however, occurred. Although no statistical differences in stroke, death, and stroke/death occurred between the endarterectomy versus the nonendarterectomy group, transient CN injury was more common in the nonendarterectomy group (21.4% versus 4.1%; P = 0.027). Although nonendarterectomy procedures of the carotid bifurcation are infrequently needed, they seem safe, effective, and indicated in selected patients, despite a higher incidence of transient CN injury.
Pulmonary Embolus after Vena Cava Filter Placement
Authors: David Whitney , Gross William S. , Colaiuta Elizabeth , Gonda Roger , Osher David , Lanuti Stephen
Published: November 2022

This report characterizes risk factors in patients who suffer pulmonary embolus (PE) after insertion of vena caval filter (VCF) and formulates an organized diagnostic and therapeutic plan of management. Three hundred eighteen patients were included in a review of patients undergoing insertion of VCF from 1989 to 1995. Ten patients (six men and four women, ages 25–72 years) from this group (3.1%) experienced PE after VCF insertion. Risk factors for deep venous thrombosis were documented in these ten patients. Venacavography was performed after diagnosis of PE. Thrombus length measured from the apex of the filter was used to determine further therapy. Thrombus 5 cm or greater in length was treated with a second VCF (VCF-2). Smaller clots were treated with anticoagulation (AC). All patients treated with AC underwent repeat vena caval study (CT scan or venacavagram) 10 days to 18 months after treatment. PE occurred from 8 days to 5.5 years after original VCF insertion. Five patients suffered PE longer than 6 months (range, 21–66 months; mean, 39 months) after VCF insertion. Venacavagrams demonstrated thrombus in all ten patients with PE. Six patients were treated with VCF-2 and four patients with AC. Dissolution of thrombus was seen on follow-up in all patients given AC. All 10 patients harbored at least two risk factors for deep venous thrombosis. Malignancy was found in only two patients. Five patients were found to have procoagulant states characterized by decreased levels of anti-thrombin III or protein C or S. No postoperative deaths or early recurrent PE occurred. One patient experienced another PE 5 years after treatment with AC when she discontinued warfarin. Contraindications to AC appeared to be self-limited, and all patients were discharged on warfarin. No significant bleeding occurred during early follow-up. Our findings confirm the reliability and low complication rate for VCF. Patients experiencing PE after insertion of VCF mandate an aggressive diagnostic approach that should include venacavography and a search for identifiable risk factors including procoagulant state. Treatment with AC and insertion of a second VCF both give favorable results. All patients appear to benefit from short- or long-term warfarin therapy, and contraindications to AC frequently are self-limited. Therapy based on clot size warrants further study.
Emergency Surgery for Generalized Peritonitis Caused by Cytomegalovirus Colitis in a Patient with AIDS
Authors: Albu Eugene , Mukherjee Asish , Rao Devaguptapu , Sehonanda Antonius , Pai B. Narayan , Gerst Paul H.
Published: November 2022

Cytomegalovirus infection of the colon is a late and severe complication in human immunodeficiency virus patients. Despite availability of medical treatment, occasional life-saving emergency surgery must be performed. The controversial surgical aspects of treatment are discussed based upon an unusual case of aseptic generalized peritonitis without perforation. The feasibility and value of limited resection are emphasized.
Cryosurgery for Unresectable Primary Hepatocellular Carcinoma: A Case Report and Review of Literature
Authors: Pergolizzi Joseph V. , Auster Martin , Conaway Gail L. , Sardi Armando
Published: November 2022

Primary liver cancers are a significant cause of both morbidity and mortality. Although surgical resection remains the treatment of choice for these tumors, only 10 to 20 per cent of the primary liver tumors are found to be resectable. Presently, the options for these patients include liver transplantation, cryosurgery, or nonsurgical therapy, such as transarterial chemoembolization. Techniques such as alcohol injection, interstitial radiotherapy, laser hypothermia, and radiofrequency electrodissection have all been attempted with limited success. We present a case of a 68-year-old woman with a 10-year history of liver cirrhosis secondary to chronic active hepatitis C. A lateral segmentectomy was recommended but could not be done due to severe underlying cirrhosis. Cryosurgery aided by intraoperative ultrasonography was performed successfully. The patient developed recurrent disease at 58 months and died with disease at 62 months. Advances in instrumentation and intraoperative ultrasonography are making cryosurgery a viable surgical therapeutic alternative in the management of patients with unresectable hepatocellular carcinoma. The procedure can be performed safely with low morbidity.
Acute Pancreatitis after Aortic Surgery
Authors: Hashimoto Luis , Walsh R. Matthew
Published: November 2022

Acute pancreatitis (AP) after aortic surgery has rarely been reported. A retrospective review of all abdominal and thoracoabdominal aortic operations complicated with AP from January 1982 to March 1992 was performed to study the presentation and outcome of this infrequently recognized complication. Thirteen cases of AP were found among 1965 abdominal aortic operations (0.7% incidence). The distribution of the original aortic operations was as follows: eight elective abdominal aortic aneurysm repairs, two aortoiliac grafts for aortoiliac occlusive disease, and three aortorenal bypasses. Two cases of pancreatitis complicated 170 thoracoabdominal aortic operations (1.2% incidence). Ten patients had mild pancreatitis, nine were discharged without any pancreatic complications after receiving supportive treatment. Five patients with severe AP died of multisystem organ failure despite aggressive surgical treatment; 4 had infected necrosis. The overall mortality was 40 per cent; severe AP resulted in a 100 per cent mortality. The diagnosis of severe AP was usually made in the second postoperative week, significantly later (P < 0.01) than for patients with mild disease. Typically, patients with mild AP presented with hyperamylasemia at a median of 5 postoperative days, and severe AP was found at reoperation or autopsy after a period of unexplained sepsis. Five patients with mild AP were found to have biliary tract stones, with one requiring endoscopic stone extraction. In conclusion, pancreatitis is an uncommon, although perhaps underreported complication. Underreporting may be due to a lack of hyperamylasemia when severe pancreatitis is diagnosed. The severe form is diagnosed late in patients with postoperative sepsis, associated with infected necrosis, and lethal. The complication may be reduced by incidental cholecystectomy for cholelithiasis.
Biological Effects of Preoperative Radiotherapy on Metastatic Lymph Nodes from Rectal Cancer
Authors: Ibi Italo , Saito Yukio , Agnifili Alessio , De Bernardinis Giancarlo , Citone Giorgio , Muto Tetsuichiro
Published: November 2022

The quantitative description of the proliferative activity of cancer cells correlates with the aggressiveness of malignant tumors. The aim of this retrospective study was to determine the biological effect of adjuvant therapy on metastatic lymph nodes from rectal cancer and to compare the results between patients treated with surgery alone and patients treated with preoperative radiotherapy. Expression of the proliferating cell nuclear antigen (PCNA) was examined in metastatic lymph node samples of 12 rectal cancer patients receiving and 14 patients not receiving preoperative radiotherapy. PCNA immunostaining was performed by an avidin-biotin complex immunoperoxidase technique. The results of the mean proliferation index (PI) between the two groups were compared. A semiquantitative PCNA grading system was also estimated. In patients receiving preoperative radiotherapy, the PI was 22.8 per cent, and only one patient had high proliferative grade. On the contrary, the PI in nonirradiated patients was 67.6 per cent, and nine patients showed high proliferative grade. Although not sufficient to reach significance in terms of prognosis, the present study confirms the clinical value of radiation therapy, and it supports the suggestion to treat Dukes’ C patients with preoperative radiotherapy to decrease the risk of local recurrence.
Surgical Treatment of Benign Hepatic Mass Lesions
Authors: Arnoletti Juan P. , Brodsky Jeffrey
Published: November 2022

Benign hepatic mass lesions may require surgical treatment for symptomatic relief or prevention of hemorrhage. The most common benign hepatic mass lesions in the United States are hemangioma, focal nodular hyperplasia, hepatic adenoma, and congenital liver cyst. We report a series of liver resections performed for benign hepatic masses at our institution. All liver resections were performed with total inflow occlusion during the parenchymal transection time. None of our patients received perioperative blood products. No postoperative complications occurred, and the average length of hospital stay was 6 days. Surgeons performing hepatic resections for benign mass lesions should be able to complete these procedures with low operative blood loss and low operative morbidity.
Bilateral Recurrent Nerve Paralysis Associated with Multinodular Substernal Goiter: A Case Report
Authors: Souza John W. , Williams John T. , Ayoub Macram M. , Jerles Matthew L. , Dalton Martin L.
Published: November 2022

Substernal goiter is an infrequent occurrence and is found in two to five per cent of all patients undergoing thyroid surgery. These lesions are well known to cause respiratory symptoms and alterations in phonation due to direct compression of airway structures. Infrequently, unilateral recurrent nerve palsy has been reported in patients with substernal goiter. We report a case of bilateral recurrent nerve palsy associated with multinodular substernal goiter in an 89-year-old female who presented in respiratory distress.
Winner of the Best Paper Award from the Gold Medal Forum: Clinical Characteristics and Antibiotic Utilization in Surgical Patients with Clostridium difficile-Associated Diarrhea
Authors: Crabtree Traves D. , Pelletier Shawn J. , Gleason Thomas G. , Pruett Timothy L. , Sawyer Robert G.
Published: November 2022

Clostridium difficile-associated diarrhea (CDAD) remains a significant problem in surgical patients. To address this, we prospectively studied all episodes of treated CDAD in surgical inpatients at the University of Virginia hospital from December 1996 through March 1998. CDAD accounted for 3.2 per cent (32) of 1000 total infections. Compared with a randomly selected control group with other nosocomial infections, patients with CDAD had a longer period from the time of admission to diagnosis of infection (19 ± 4 versus 9 ± 1; P = 0.01), were more likely to be female (66% versus 37%; P = 0.009), and had a higher overall crude mortality (31% versus 11%; P = 0.01), although there were no deaths directly attributable to CDAD. Ciprofloxacin (19%) and cefoxitin (16%) were the most common individual antibiotics prescribed before the diagnosis of CDAD. The average time from completion of antibiotic therapy to diagnosis of CDAD was 7 ± 2 days (range, 0-58). Sixteen per cent (5 of 32) developed CDAD after administration of prophylactic perioperative antibiotics only. The high crude mortality rate associated with CDAD suggests that this may be a significant predictor of poor outcome among infected surgical patients. Antibiotics used commonly but not classically associated with CDAD frequently precipitate this infection. Finally, the use of prophylactic antibiotics is not without risk, as demonstrated by the significant percentage of CDAD occurring after routine administration of these agents.
Surgical Experience with Hepatic Colorectal Metastasis
Authors: Bradley Anne L. , Chapman William C. , Wright J. Kelly , Marsh John W. , Geevarghese Sunil , Blair K. Taylor , Pinson C. Wright
Published: November 2022

The outcome of 134 patients undergoing hepatic resection for colorectal metastasis was studied. Current follow-up was available in 98 per cent of patients, for more than 5 years in 58 patients, and totaling 360 patient-years. Patients (52% male) had an average age of 62 ± 1 years (standard error of the mean). Time lapse between the primary colon surgery and hepatic resection was a median of 16 months and a mean of 19 ± 1 months. Thirty-two (24%) were operated on within 6 months for both their primary tumor and hepatic metastasis. Intensive care unit and total hospital length of stay were a median of 1 and 7 days, respectively. Pathology reports demonstrated that on average there were 2.0 ± 0.1 lesions, with the largest lesion measuring 4.4 ± 0.2 cm. In 72 per cent of patients, the lesions were found in one lobe only. CEA was elevated in 83 per cent of patients preoperatively and was 60 ± 11 ng/mL before and 4.0 ± 0.5 ng/mL after hepatic resection. Patient survival was 81 per cent at 1 year, 50 per cent at 3 years, 36 per cent at 5 years, and 23 per cent at 10 years. Actual 5- and 10-year survival was 22 of 58 (38%) patients and 4 of 21 (19%) patients respectively. Disease-free survival was 58 per cent at 1 year, 27 per cent at 3 years, 16 per cent at 5 years, and 12 per cent at 7 years. Survival was much better for one to four lesions than for five or more lesions (P < 0.01). Several other potential risk factors did not affect survival, including whether the patient received chemotherapy after hepatic resection. There were 36 (43%) patients who recurred with hepatic involvement only, 27 (32%) including hepatic involvement and 21 (25%) with nonhepatic involvement only. There were 15 patients who went on to receive repeat hepatic resections, with a 5-year survival of 74 per cent and disease-free survival of 58 per cent. Hepatic resection provides the best outcome of any form of therapy for selected patients with isolated hepatic metastasis.
Combined Blunt Cardiac and Pericardial Rupture: Review of the Literature and Report of a New Diagnostic Algorithm
Authors: May Addison K. , Patterson Mark A. , Rue Loring W. , Schiller Henry J. , Rotondo Michael F. , Schwab C. William
Published: November 2022

The spectrum of blunt cardiac injury varies from the asymptomatic cardiac concussion to the immediately fatal cardiac rupture. Although the majority of victims sustaining blunt cardiac rupture die before receiving medical attention, some survive to evaluation. The diagnosis of cardiac rupture, if established, typically results from the signs and symptoms of pericardial tamponade. However, some patients may have remarkably few signs and symptoms suggestive of cardiac injury and represent a significant diagnostic challenge. We provide two cases of cardiac rupture in which the diagnosis was delayed by the presence of an associated pericardial tear with decompression into the mediastinum and pleural space. In neither of the cases did existing institutional algorithms for blunt cardiac injury assist in establishing the diagnosis before the acute demise of the patient. The presence of a coexisting pericardial injury in these patients with blunt cardiac rupture obscured the diagnosis, leading to the deaths of these patients. A discussion of these two cases and review of the literature is provided with recommendations for diagnostic algorithms in patients sustaining blunt thoracic trauma with possible cardiac and pericardial injury.
Organ Injury Scaling System Can be Used to Predict Length of Stay in Patients with Penetrating Neck Injuries
Authors: Atta Hussein M.
Published: November 2022

Predicting probability of survival of trauma patients has received greater attention than predicting other trauma outcomes such as length of stay. Most trauma scoring systems depend on the anatomic description of injuries of the Abbreviated Injury Score (AIS). The recently introduced Organ Injury Scale (OIS) was developed to give more precise and comprehensive anatomic description of injuries. Unlike the AIS, it also avoids including immediate injury sequelae, such as the amount of hemorrhage. This retrospective study was performed to assess the degree of association between the sum of grades of penetrating neck injuries using the OIS and the length of hospital stay. There were 31 males and 7 females, with ages ranging from 13 to 65 years and a mean of 31 years. The length of hospital stay ranged between 1 and 34 days, with a mean of 7.0 ± 6.5 days. There were 32 vascular, 7 esophageal, and 7 tracheal injuries. The sum of the OIS grades correlates significantly with the length of hospital stay (r = 0.78; P < 0.005). This study suggests that the OIS system can be used to predict the length of hospital stay. It proposes also that the OIS replaces similar anatomic components of the AlS-based scoring systems.
Antiperistaltic Roux-en-Y Biliary-Enteric Bypass after Bile Duct Injury: A Technical Error in Reconstruction
Authors: Zorn George L. , Wright J. Kelly , Pinson C. Wright , Debelak Jacob P. , Chapman William C.
Published: November 2022

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.
Laparoscopic Transcystic Management of Choledocholithiasis
Authors: Hyser Matthew J. , Chaudhry Vivek , Byrne Mitchel P.
Published: November 2022

Our objective was to review our community hospital experience with laparoscopic management of choledocholithiasis from 1991 to 1997. We performed a retrospective review of all case records of patients with choledocholithiasis managed surgically at St. Francis Hospital during the study period. Data regarding the history, presentation, investigations, operative details, and follow-up were recorded. Procedures were performed by multiple attending surgeons supervising surgical residents. All common bile duct explorations (CBDEs) were performed by a transcystic approach and followed routine cholangiography. In most cases, cystic duct dilatation over a guide wire was followed by transcystic CBDE with choledochoscopy. Stone extraction was accomplished through a combination of flushing, basket manipulation, fragmentation, retrieval, or advancement of stones through the ampulla. Data were analyzed using SPSS computer software, and P < 0.05 was considered statistically significant. During the period of study there were 1053 laparoscopic cholecystectomies with and without cholangiography and 100 total CBDE performed. Of these, 54/100 had an attempt at laparoscopic CBDE. There were 39 females and 15 males, with a median age of 52 years (range 14–88). Presentation included acute cholecystitis or biliary colic (63%), gallstone pancreatitis (20%), and jaundice or cholangitis (17%). Successful laparoscopic stone removal was achieved in 36 of 54 (67%) cases. Eighteen of the remainder (33%) were converted to an open procedure. Size, number, position of stones, technical difficulties in accessing the common bile duct, and patient factors contributed to open conversion. The rate of successful laparoscopic CBDE improved for each individual surgeon from an average of 22 per cent in the first half of the study period (1991–1994) to 87 per cent in the second half (1995–1997). There was no operative mortality. Significant morbidity in the laparoscopic group included one retained stone and two cases of postoperative pancreatitis. There were three false negative preoperative endoscopic retrograde cholangiopancreatography examinations. Multivariate analysis showed that experience of the individual surgeon was the only significant factor predicting successful laparoscopic CBDE. Low initial success rate in the early phase of the study period improved dramatically to reach an overall success rate of 87 per cent in the second half. Laparoscopic management of common bile duct stones is possible in a community setting with a high success rate and minimal morbidity. It precludes excessive use of endoscopic retrograde cholangiopancreatography with its own set of complications but is associated with a significant learning curve. It is currently our preferred therapeutic approach for choledocholithiasis discovered pre- or intraoperatively.
Prognostic Factors Associated with Resectable Adenocarcinoma of the Head of the Pancreas
Authors: Millikan Keith W. , Deziel Daniel J. , Silverstein Jonathan C. , Kanjo Tadge M. , Christein John D. , Doolas Alexander , Prinz Richard A.
Published: November 2022

A retrospective study of patients with surgically resectable adenocarcinoma of the pancreatic head was undertaken to determine which prognostic factors are independently associated with improved survival. Thirty-four men and 41 women (mean age, 61.9 years) had resection for adenocarcinoma of the pancreatic head between 1980 and 1997 at Rush-Presbyterian-St. Luke's Medical Center. Surgical resections included 15 total pancreatectomies, 43 pyloric-preserving procedures, and 17 standard Whipple procedures. Thirty-six patients received adjuvant radiation and/or chemotherapy. Overall median survival was 13 months, with a 5-year survival of 17 per cent. Thirty-day surgical mortality was 1.3 per cent. Significant factors that negatively influenced survival using univariate Kaplan-Meier analysis were: positive resection margin (P = 0.01), intraoperative blood transfusion (P = 0.01), and lymph node metastases (P = 0.01). Presenting signs and symptoms, patient demographics, operative procedure, tumor size, histologic differentiation, and adjuvant therapy did not have a significant impact on survival. Using multivariate Cox regression analysis, the only significant independent factors improving survival were the absence of intraoperative blood transfusion (P = 0.02) and a negative resection margin (P = 0.04). Performing pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas with negative microscopic margins of resection and without intraoperative transfusion significantly improves survival.
Local Excision and Chemoradiation for Low Rectal T1 and T2 Cancers Is an Effective Treatment
Authors: Voyer T. E. Le , Hoffman J. P. , Cooper H. , Ross E. , Sigurdson E. , Eisenberg B.
Published: November 2022

Lesions located in the distal third of the rectum are usually treated with abdominoperineal resection or a low anterior resection with a coloanal anastomosis. However, in a select group of patients with favorable histology and a low probability of lymphatic spread, sphincter-sparing procedures will afford long-term disease-free survival and cure without the need for extensive, complicated surgery. We performed a 10-year retrospective review, including pathologic examination of specimens by a single pathologist, in an attempt to identify factors associated with a decreased disease-free survival. Thirty-five patients (median age, 71 years; range, 48–88) with low rectal carcinomas were treated with full-thickness disc excision (with or without chemoradiation), with curative intent Median follow-up was 46 months (range, 8–120). There were 15 T1, 16 T2, and 4 T3 lesions. Tumors with poor histologic factors or greater than T1 received adjuvant radiation (with or without 5-fluorouracil). Four patients developed a local failure at a median of 21.5 months (range, 9–30) and were salvaged with abdominoperineal resection. The 5-year cancer-specific survival was 91 per cent. Negative margins approached statistical significance (P < 0.07) in influencing local control. We conclude that, when combined with chemoradiation for lesions deeper than submucosa or with adverse histologic factors, local resection of rectal cancer is an effective treatment in selected patients.
Same Hospitalization Resection for Acute Diverticulitis
Authors: Wasvary Harry , Turfah Fuad , Kadro Omar , Beauregard William
Published: November 2022

We reviewed our experience with same hospitalization resection in the treatment of acute diverticulitis (AD) and compared outcomes with patients admitted for elective resection. From January 1987 through December 1996, 20 patients (Group 1) were admitted with AD and were operated on during the same hospital admission. During that same time period, 22 patients (Group 2) were admitted for elective resection and found to have an abscess intraoperatively. Thirty patients had elective resection with no abscess found (Group 3), and 10 patients were found to have a fistula to adjacent structures during elective resection (Group 4). Demographics and type of procedure done were similar in all groups. Fifteen patients (75%) in Group 1 had an abscess; eight were pericolic, and seven were pelvic. In contrast, all Group 2 abscesses were pericolic (P < 0.001). There was no mortality or major morbidity in any group. Patients in Groups 1 and 4 had higher fluid requirements (not significant), estimated blood loss (P < 0.01), and longer operative times (P < 0.05) when compared with the other groups. Postoperative and total hospital stay was significantly longer in Group 1. We conclude that hospitalized patients with AD who meet indications for surgery can be operated on during the same hospitalization without an increase in morbidity, compared with those patients discharged and later readmitted for elective resection.
Is Resuscitation after Traumatic Suicide Attempt a Futile Effort? A Five-Year Review at a Level I Trauma Center
Authors: Cusick Therese E. , Chang Frederic C. , Woodson Teresa L. , Helmer Stephen D.
Published: November 2022

A retrospective analysis of all traumatic suicide attempts at a Level I regional trauma center between 1990 and 1994 was performed. Data were obtained from the trauma registry, charts, computer data, and telephone interviews. Age, gender, mechanism of injury, and prior mental status were noted. Repeat suicide attempts/ideation, postinjury employment status, and subsequent deaths were recorded. Nontraumatic attempts and successful suicides not transported to the hospital were excluded. Ninety-one patients (71 males and 20 females) with attempted suicide were identified. Average patient age was 33.6 years. Method of attempted suicide and deaths by that method were: firearms (n = 55 attempts/36 deaths), sharp instrumentation (n = 22 attempts/0 deaths), and others. Mortality by firearms and all other mechanisms were 65.0 per cent and 8.3 per cent, respectively. Fifty-two patients survived to be discharged from the hospital. Follow-up data were available for 38 patients with a mean follow-up interval of 53.6 months. Three subsequent deaths were confirmed. The mortality from the index attempt was 42.9 per cent. Mortality by firearms was significantly higher than by all other mechanisms. Patients with chronic mental illness had a significantly higher incidence of subsequent suicide attempts/ideation and unemployment. Confirmed mortality at follow-up was only eight per cent (mean, 53.6 months), and all were patients with chronic mental illness.
The Hemodynamic Effects of Local Anesthetic Injection into the Carotid Body during Carotid Endarterectomy
Authors: Fardo Dean J. , Hankins W. Tracy , Houskamp William , Robson Larry
Published: November 2022

Hemodynamic changes consisting of hypertension, hypotension, or bradycardia are commonly seen in patients undergoing carotid endarterectomy. It is a potentially serious clinical problem that may increase mortality rates or incidence of neurologic deficits. The frequency of hemodynamic alterations has been believed to be related to the proximity of the carotid sinus baroreceptor to the endarterectomized region. Consequently, intraoperative or postoperative injection of local anesthetics into the carotid body have been recommended to help offset this compensatory mechanism. However, its effectiveness has not been thoroughly studied. We examined this situation with a prospective, randomized, double-blind clinical study consisting of 99 patients. Xylocaine (short-acting anesthetic), bupivacaine (long-acting anesthetic), or saline (control) was injected into the carotid body intraoperatively. Intraoperative and postoperative hemodynamic changes were then closely monitored and evaluated. We were unable to detect a significant difference in hypotension, hypertension, or bradycardia either during or after surgery. Therefore, on the basis of this study, routine use of local anesthetic injection into the carotid body cannot be recommended.
Endoscopic Ultrasound for Diagnosis and Staging of Pancreatic Tumors
Authors: Harrison Jacqueline L. , Millikan Keith W. , Prinz Richard A. , Zaidi Syed
Published: November 2022

Endoscopic ultrasound (EUS) is proving to be a useful tool for evaluation of clinically suspected pancreatic masses unsatisfactorily evaluated by other means of imaging. We reviewed the records of 19 patients who had CT and EUS performed for clinically suspected pancreatic masses. Each patient had subsequent surgical exploration. Nineteen patients (11 females and 8 males) presenting with symptoms (11 with obstructive jaundice, 6 with abdominal pain and weight loss) or incidental CT findings suspicious for pancreatic carcinoma underwent EUS for further pancreatic evaluation. All of these patients had exploratory laparotomies, with 13 pancreaticoduodenectomies, 3 distal pancreatectomies and splenectomies, 1 bypass procedure, 1 open pancreatic and hepatic biopsy showing metastatic disease, and 1 open exploration with negative fine-needle aspiration biopsy. EUS correctly identified pancreatic neoplasms in 17 of 19 cases, with two false positives. The tumors included 15 adenocarcinomas, 1 microcystic adenoma, and 1 lymphoma. Node status was correctly predicted in 9 of 12 specimens. Nine of 12 tumors had accurate tumor staging by EUS. Absence of vascular invasion was accurately predicted in 13 of 14 cases. Two patients had metastatic disease discovered at laparotomy. All 19 patients had preoperative abdominal CT scans, with six of these negative for pancreatic masses. EUS is more sensitive than CT in detecting pancreatic masses and is more accurate than CT in locally staging pancreatic tumors. This higher sensitivity is important because those patients with earlier stage tumors are the most likely to benefit from resection.