bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of Sternoclavicular Joint Infections
Authors: Kendrick Aaron S. , Head Harold D. , Rehm Jason
Published: June 2020

Surgically managed infections of the sternoclavicular joint have rarely been reported, but general and thoracic surgeons may be consulted to manage such infections. Patients who have demonstrated resistance to antibiotic therapy or have infection extending beyond the joint capsule are best managed by surgical resection.
Morbidity and Mortality of the Confederate Generals during the American Civil War
Authors: Saclarides Theodore J.
Published: June 2020

During the American Civil War (1861–1865), 426 men were commissioned generals by Jefferson Davis and the Confederate Congress. Eighty (19%) died of battle wounds (versus 8% in the Union army) and 3 per cent died of disease.1 During the war, 211 (49%) were wounded; of these, each was wounded a mean 1.9 times. When noncombatants are excluded, 52 per cent sustained wounds. Of those who served in five or more major engagements, 62 per cent were wounded; of those who fought in more than 10, 71 per cent sustained wounds. Sixty-five per cent of battlefield deaths were immediate and 85 per cent were from gunshot wounds. Mortality did not vary by state of birth, age group, rank (brigadier, major, lieutenant, full), formal military education, or prewar profession. Professional soldiers fared no better or worse than prewar civilians appointed to the rank of general. Of those who survived the war, mean age at death was 68.0 years.
The Use of Seprafilm® in Pediatric Surgical Patients
Authors: Winfield Robert D. , Ang Darwin N. , Chen Mike K. , Kays David W. , Langham Max R. , Beierle Elizabeth A.
Published: June 2020

Hyaluronate carboxymethylcellulose (Seprafilm®; Genzyme Corp., Cambridge, MA) has been demonstrated to be safe and efficacious for the prevention of abdominal and pelvic adhesions; however, information is scarce regarding its use in children and adolescents. We wanted to characterize our experience with Seprafilm® in a pediatric surgical population. After Institutional Review Board approval, we searched our hospital and pediatric surgery database for cases in which Seprafilm® was used and retrospectively reviewed medical records for demographic and clinical information. Between July 2000 and October 2005, 18 patients had Seprafilm® placed. Patients ranged in age from 0.25 to 18 years. Seven patients had not undergone any previous operations. Of patients having undergone prior surgery, the most common preceding intervention was a Ladd's procedure. Seprafilm was applied in a variety of scenarios, the most frequently being adhesiolysis for bowel obstruction. No patient required reoperation for obstruction. Two patients underwent subsequent operations for unrelated reasons; one was noted to have no significant adhesions, but the other had extensive adhesions. No patient demonstrated signs or symptoms of small bowel obstruction, intraperitoneal abscess, or localized inflammatory reaction to Seprafilm®. Seprafilm® was successfully used in our pediatric surgical population without complications.
Handlebar Injuries in Children: Should We Raise the Bar of Suspicion?
Authors: Mezhir James J. , Glynn Loretto , Liu Donald C. , Statter Mindy B.
Published: June 2020

Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.
Chyloperitoneum after Blunt Abdominal Injury
Authors: Haan James M. , Montgomery Stephanie , Novosel Timothy J. , Stein Deborah M. , Scalea Thomas M.
Published: June 2020

The objective of this study was to evaluate incidence of chylous injury in blunt trauma using a retrospective chart review. We present two patients who sustained chyle duct injury after blunt trauma. The first patient is a pedestrian struck by car. Abdominal CT scan revealed duodenal thickening and a moderate amount of paraduodenal fluid, which prompted surgical exploration. At laparotomy, the patient was found to have a disruption of his lymphatics at the level of the inferior vena cava (IVC) without duodenal injury treated with hemoclips, fibrin sealant and elemental gastrojejunal feeds. The second patient was involved in a high speed motor vehicle collision (MVC) resulting in transection of the mesentery of the transverse colon. Disrupted lacteals were treated intra-operatively with hemoclips and fibrin sealant decreasing the lymph leak. In both cases, the leak completely resolved with use of tube feedings with medium chain triglycerides. On literature review, six prior patients with spontaneous chylous retroperitoneum were described undergoing similar operative management. Chylous leakage due to blunt trauma is a rare finding. Mechanism of injury includes hyperextension or flexion resulting in stretching and shearing of the tethered lymphatics. Open ligation or clipping of the injured ducts seems effective. Tube feeds with medium chain triglycerides may enhance efficacy of operative treatment.
Intraabdominal Hypertension in Patients with Septic Shock
Authors: Regueira Tomas , Hasbun Pablo , Rebolledo Rolando , Galindo Jose , Aguirre Marcia , Romero Carlos , Castillo Luis , Bugedo Guillermo , Hernandez Glenn
Published: June 2020

Intraabdominal hypertension (IAH) develops frequently in patients with septic shock. Even a moderate increase in intraabdominal pressure (IAP) in this setting could be associated with high lactate levels. The authors conducted a prospective, observational, nonrandomized control trial in the surgical intensive care unit of an academic tertiary center. Twenty-seven patients with septic shock (septic shock group), and 19 patients undergoing abdominal surgery with more than two risk factors for IAH (postoperative control group) were admitted consecutively to the intensive care unit. IAP was measured every 6 hours during the first 48 hours. IAH was diagnosed with two consecutive measurements greater than 20 mm Hg. The main outcome measures were prevalence of IAH in septic shock and control groups; and comparative lactate levels, norepinephrine requirements and organ dysfunctions in patients with and without IAH in both groups. Fifty-one per cent of patients with septic shock and 31 per cent of control patients developed IAH. Patients with septic shock with and without IAH were comparable in peak norepinephrine dose, sequential organ failure assessment score, and mortality. However, peak lactate levels were significantly higher in patients with septic shock and IAH compared with those without IAH (3.5 mmol/L versus 1.9 mmol/L, P < 0.04). There was a significant positive temporal correlation between IAP and lactate levels in patients with septic shock with IAH. Peak levels of both occurred early and decreased progressively over time. Control patients with and without IAH exhibited comparable peak lactate levels. Intraabdominal hypertension is very common in septic shock and appears to be related to high lactate levels, which diminish as IAP decreases. Future studies should address the usefulness of IAP monitoring in patients with septic shock.
Gastroduodenal Artery as the Inflow Tract to Repair the Right Hepatic Artery in a Combined Vasculobiliary Injury after Laparoscopic Cholecystectomy
Authors: Khanmoradi Kamran , Defaria Werviston , Moore Ronald E. , Guarneri Ralph , Tzakis Andreas G.
Published: June 2020

The frequency and significance of right hepatic artery injury associated with bile duct injury after laparoscopic cholecystectomy is unknown. Many reports suggest that a concomitant arterial injury worsens the outcome and prognosis of the bile duct injury even after an initially successful biliary repair. The optimal management of this complicated injury is controversial. We report a surgical technique to repair the right hepatic artery injury in these cases. We believe this technique is useful for surgeons who opt to repair the arterial injury at the time of biliary reconstruction, especially if it is performed soon after the injury occurred, before permanent damage to the liver and biliary system is established. To the best of our knowledge, this technique was not reported in the literature previously.
Early Selective Angioembolization Improves Success of Nonoperative Management of Blunt Splenic Injury
Authors: Wu Shih-Chi , Chow Kuan-Chih , Lee Kun-Hua , Tung Cheng-Cheng , Yang Albert D. , Lo Chong-Jeh
Published: June 2020

The role of angioembolization in the management of patients with blunt spleen injury is still under debate. Our study examined the impact of splenic artery embolization (SAE) on the outcome of such patients. We reviewed 114 consecutive blunt abdominal trauma patients with isolated splenic injury over a period of 40 months, including 61 patients seen before (Group A) and 53 patients seen after (Group B) the adoption of SAE. Hemodynamically unstable patients underwent the abdominal exploration and stable patients were evaluated with CT scans of abdomen and pelvis. Patients underwent SAE based on the findings of CT scans, including contrast extravasation or large hemoperitoneum. For initially stable patients, there were no differences in nonoperative management success rate between Groups A and B in regards to injury severity score ≥16, age, or grades of splenic injury ≥3. In comparison, among patients with large hemo-peritoneum found by abdominal CT, Group B had significantly better nonoperative management success rates (P < 0.05). SAE was successful to control bleeding in 80 per cent of patients. Partial splenic infarction was noted in all patients after the procedure but it resolved by six months. By using criteria developed based on abdominal CT scans for angioembolization, we are able to improve nonoperative splenic salvage rate.
Primary Umbilical Adenocarcinoma: Case Report and Review of the Literature
Authors: Alver Olcay , Ersoy Yeliz E. , Dogusoy Gulen , Erguney Sabri
Published: June 2020

Primary adenocarcinoma arising at the umbilicus is a very rare condition. The umbilicus has been found to show a wide variety of tumors and is predisposed to metastases from visceral tumors because of its relationships and generous vascular and embryologic connections. Herein, we describe a case of a primary umbilical adenocarcinoma with short time survival related to local recurrence and multiple hepatic metastases 6 months after her surgical treatment.
Outcomes of Right and Left Colectomy at Academic Centers
Authors: Hinojosa Marcelo W. , Konyalian Viken R. , Murrell Zuri A. , Varela J. Esteban , Stamos Michael J. , Nguyen Ninh T.
Published: June 2020

Few studies have compared outcomes of right colectomy (RC) and left colectomy (LC) with respect to both benign and malignant disease. The objective of this study was to compare outcomes of RC versus LC for benign and malignant disease using a national administrative database of academic medical centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, data was obtained from the University HealthSystem Consortium Clinical Data Base for patients that underwent RC and LC for benign and malignant disease between 2002 and 2006. The main outcomes compared were demographics, length of hospital stay, observed to expected in-hospital mortality, complications, 30-day readmission, and mean cost. There were a total of 27,483 patients; 12,971 patients (47.2%) underwent RC. Compared with LC for benign disease, RC was associated with a shorter length of stay, lower overall complications, lower wound infections, lower 30-day readmissions, and lower cost. Compared with LC for malignant disease, RC was associated with lower overall complications, lower wound infections, and lower cost. In this analysis of academic centers, RC was associated with a lower length of stay, lower morbidity, and lower cost when compared with LC for benign and malignant disease.
Malignant Phyllodes Tumors: A Review of 752 Cases
Authors: Grabowski Julia , Salzstein Sidney L. , Sadler Georgia R. , Blair Sarah L.
Published: June 2020

Malignant phyllodes tumor (MPT) is a rare breast malignancy. Because of the scarcity of the disease, there are no evidence-based treatment or follow-up guidelines established. This study evaluated the survival of MPT patients to create recommendations for management. We identified 752 cases of malignant phyllodes tumors in the California Cancer Registry from the years 1988 to 2003. Relative survival was determined using Berkson-Gage life table analysis which was then compared with the relative survival of nonphyllodes breast cancer patients. For MPT patients, the relative annual survival at 1 year was 94 per cent and at 10 years was 99.6 per cent. Thus, after 10 years, these patients are no more likely to die than the general population. At 10 years, the relative cumulative survival of the MPT patients was 87.4 per cent, whereas the nonphyllodes breast cancer patients had only a 57.2 per cent relative cumulative survival. MPT patients with localized disease had a higher 10-year relative cumulative survival than those with regional disease (90.9% vs 61.5%, P < 0.001). MPT has a good prognosis, particularly in patients with localized disease. After 10 years, MPT patients have no increased mortality relative to the general population. Clinicians should plan these patients’ follow-up accordingly.
The Efficacy of MRI as an Adjuvant to Traditional Mammography
Authors: Bremner Amy K. , Recabaren James
Published: June 2020

The objective of our study is to assess the utility of breast Magnetic Resonance Imaging (MRI) when used for indications other than those published in peer-reviewed studies. A retrospective chart review was conducted of the records of 588 women who underwent both mammography and breast MRI. Patients excluded from the study were those who had breast MRI for accepted indications based on published peer-review studies. Included on the study were the remaining 122 patients. An evaluation was then made in each case as to whether the MRI finding caused a change in the patient's management. In this review, subject age ranged from 27- to 85-years-old. The mean age of the sample was 54.5 years. Of the positive MRI results, 29 (27.7%) had additional findings. There were 25 (20.3%) subjects with a treatment change and 97 (79.5%) without. In conclusion, breast MRI affected the clinical management in 25 (20.3%) of 122 patients. The majority of the 25 patients have invasive ductal carcinoma, followed by ductal carcinoma in situ. We believe this is a significant percentage positively affected by the additional use of breast MRI. We suggest that indications for the use of breast MRI in addition to traditional breast imaging should include all patients with invasive ductal carcinoma.
Primitive Stem Cells Residing in the Skeletal Muscle of Adult Pigs are Mobilized into the Peripheral Blood after Trauma
Authors: Stout Christopher L. , Ashley Dennis W. , Morgan Joseph H. , Long Gypsy F. , Collins Julie A. , Limnios Jason I. , Lochner Frank , Mccommon George , Hixson Douglas , Black Asa C. , Young Henry E.
Published: June 2020

This study was designed to determine if trauma causes the release of adult-derived blastomere-like stem cells (BLSCs) from skeletal muscle into the circulating blood of adult pigs. Experimental procedures followed the guidelines of Fort Valley State University's Institutional Animal Care and Utilization Committee. Pigs were traumatized by splenectomy followed by pancreatectomy. Blood samples and skeletal muscle biopsies were taken before and after trauma. Adult-derived BLSCs were isolated from skeletal muscle and blood samples following established procedures. Nontraumatized skeletal muscle contained approximately 277 million BLSCs per gram of muscle. After trauma, skeletal muscle contained approximately 2 million BLSCs per gram of muscle. Blood taken before trauma contained approximately 22 million BLSCs per milliliter, whereas approximately 512 million BLSCs per milliliter were present within the blood after trauma. Blood values were statistically significant with a P < 0.05. This report is the first demonstration that trauma causes the release of adult-derived BLSCs from skeletal muscle into blood. Further studies are required to elucidate the roles that adult-derived BLSCs play in the response to injury and in the healing process. Surgeons must take a role in this evolving field.
Morbid Obesity Impacts Mortality in Blunt Trauma
Authors: Christmas A. Britton , Reynolds Jennifer , Wilson Ashley K. , Franklin Glen A. , Miller Frank B. , Richardson J. David , Rodriguez Jorge L.
Published: June 2020

Twenty-six per cent of adults in the Unites States are obese and trauma remains a major cause of death. We assessed the impact of morbid obesity on mortality in patients with blunt trauma. We reviewed the records of patients with a body mass index 40 kg/m2 or greater injured by blunt trauma from 1993 to 2003 and compared them with a 4:1 control population with a normal body mass index and matched for sex and constellation of injuries. For comparison, patients were categorized by Injury Severity Score 9 or less or Injury Severity Score 10 or greater. Student t test and χ2 were used for statistical analysis. P < 0.05 was considered significant. One hundred seven morbidly obese patients were identified and compared with 458 control subjects with a normal body mass index and matched for sex and constellation of injuries. Although the morbidly obese patients were found to be significantly younger, those who incurred multiorgan injury experienced a significantly longer hospital length of stay and displayed a greater than fourfold increase in mortality when compared with the control subjects. Furthermore, the number of morbidly obese patients admitted over the 10-year period significantly increased by fourfold (0.4% to 1.5%). Over the last decade, there has been a significant increase in morbidly obese patients cared for in our trauma center. Although these patients were significantly younger with a similar Glasgow Coma Score as that of the control population, morbid obesity significantly increased mortality when the injury from blunt trauma transitioned from a single to a multiorgan injury.
Foreign Body Ingestion and Management: “I Swallowed a Crack Pipe”
Authors: Young Justin , Beech Derrick , Offodile Regina
Published: June 2020

There is a wide variety of objects that find their way into the human gastrointestinal tract, either accidentally or deliberately. In this case a crack pipe was ingested in its entirety. Despite the seemingly rare and random nature that this scenario presents, this patient's care serves to reinforce what should be done to successfully manage a patient with an ingested foreign body, as well as the important issues related to crack cocaine abuse.
Pancreatic Resection for Metastatic Renal Cell Carcinoma to the Pancreas
Authors: Karimi Kamran M.H. , Mcfadden David W.
Published: June 2020

Although extremely rare, for most primary malignancies, the presence of metastases to the pancreas is a harbinger of diffuse systemic involvement. Clear cell renal cell carcinoma (RCC) of the kidney differs in that respect. Metastatic deposits tend to be isolated and diffuse systemic involvement may be absent. An Institutional Review Board-approved retrospective review of three cases of histologically confirmed RCC metastases to the pancreas was performed. We present their preoperative workup, surgical treatment, histopathological findings, and postoperative course. Three patients, all women, underwent distal pancreatectomy and splenectomy. Mean time period between nephrectomy and findings of pancreatic metastasis was 11.6 years. One patient had a major complication with a pancreatic fistula. Two patients have developed extrapancreatic recurrences. Resection of RCC metastases to the pancreas may offer a survival advantage in a select group of patients. Development of metastatic deposits after a prolonged disease-free period may actually be a negative prognostic indicator, implying a rapid and uncontrollable change in tumor biology.
Management of Laparotomy Wound Dehiscence
Authors: Abbott Daniel E. , Dumanian Gregory A. , Halverson Amy L.
Published: June 2020

Many studies identify risk factors for dehiscence, but a paucity of data exist suggesting an optimal treatment strategy. This study examines repair of abdominal wound dehiscence, comparing closure and interposition of mesh. We conducted a retrospective review of 37 individuals who suffered a wound dehiscence after laparotomy. Outcomes of repairs with either primary closure or polyglactin mesh interposition were examined. Twenty-seven individuals underwent repair with primary closure. Twelve of these individuals suffered repeat wound dehiscence; 10 were treated with repeat fascial closure, 2 with polyglactin mesh interposition. Seven individuals initially underwent successful repair with polyglactin mesh interposition; all subsequently had their hernias repaired. Three patients had minor fascial separation managed nonoperatively. Primary closure is associated with a relatively high rate of recurrent wound dehiscence. Closure with polyglactin mesh interposition has a higher initial success rate, but necessitates additional surgeries for repair of the abdominal wall defect.
The Use of a Computed Tomography Scan to Rule Out Appendicitis in Women of Childbearing Age is as Accurate as Clinical Examination: A Prospective Randomized Trial
Authors: Lopez Peter P. , Cohn Stephen M. , Popkin Charles A. , Jackowski Julie , Michalek Joel E. ,   THE APPENDICITIS DIAGNOSTIC GROUP
Published: June 2020

Diagnosing appendicitis continues to be a difficult task for clinicians. The use of routine CT scan has been advocated to improve the accuracy of diagnosing appendicitis. When compared with the use of clinical examination alone, CT scan was not significantly different with regard to making the diagnosis of appendicitis in women of childbearing age. The use of computed tomography in making the diagnosis of appendicitis has become the current standard of practice in most emergency rooms. In women of childbearing age, with possible appendicitis, we prospectively compared clinical observation alone (OBS) to appendiceal CT scan with clinical observation (CT). Ninety women (OBS: 48, CT: 42) with questionable appendicitis and an Alvarado Score ranging from two to eight were prospectively randomized. A true positive study/exam resulted in a laparotomy that revealed a lesion requiring operation (confirmed by pathology). A true negative exam/study did not require operation. Hospital stay (OBS = 1.9 ± 1.6 vs CT = 1.3 ± 1.4 days) and charges (OBS = $9,459 ± 7,358 vs CT = $9,443 ± 8,773) were similar. The OBS group had an accuracy of 93 per cent, sensitivity of 100 per cent, and a specificity of 87.5 per cent. The CT group had an accuracy of 93 per cent, sensitivity of 89.5 per cent, and specificity of 95.6 per cent. Although this study is too small to statistically establish equivalence, the data suggest that a CT scan reliably identifies women who need an operation for appendicitis and seems to be as good as clinical examination.
Mesenteric Lipodystrophy of the Left Colon
Authors: Edwards Michael A. , Smith Maurice , Parker William , Gu Keni
Published: June 2020

Mesenteric lipodystrophy is a rare condition characterized by tumor-like expansion of the mesocolon. The etiology remains obscure, but autoimmunity, abdominal trauma, abdominal surgery, and ischemic injury have all been postulated. To our knowledge, there have been no previous reports of synchronous mesenteric lipodystrophy and angiodysplasia. Whether these are independent or associate entities remains unknown. We present the clinical, radiological, and pathological findings of such a case.
Thyroid Storm Induced by Blunt Thyroid Gland Trauma
Authors: Delikoukos Stylianos , Mantzos Fotios
Published: June 2020

Isolated thyroid gland injury due to blunt neck trauma is uncommon and rarely complicated by thyroid storm in patients without known hyperthyroidism. The aim of this study was to report our experience on blunt thyroid gland injury followed by massive gland hemorrhage, acute airway obstruction, and symptoms of thyroid storm. Among 231 patients with neck trauma, four patients appeared with isolated thyroid gland injury. In two of them, the diagnosis of simultaneous thyrotoxic crisis was made on the basis of clinical findings and confirmed on emergency laboratory tests. The diagnosis of thyroid gland injury was supposed by the history and physical examination and established after neck exploration. Therapy was directed at stabilizing the patients by correcting the hyperthyroid state, followed by operative treatment. Left lobectomy and total thyroidectomy were performed and, along with postoperative medical measures, led to uneventful recovery. This study demonstrates that thyroid gland injury due to blunt neck trauma, although uncommon, may result in potentially life-threatening thyroid storm due to rupture of acini and liberation of thyroid hormones into the bloodstream. This may occur in patients without known hyperthyroidism.
Excess Mortality, Length of Stay, and Costs Associated with Serious Hemorrhage among Trauma Patients: Findings from the National Trauma Data Bank®
Authors: Boulanger Luke , Joshi Ashish V. , Tortella Bartholomew J. , Menzin Joseph , Caloyeras John P. , Russell Mason W.
Published: June 2020

Trauma is a serious injury or shock to the body from violence or crash and is an important and growing global health risk. Using 2000 to 2004 data from a comprehensive trauma registry, we estimated the prevalence of serious blunt and penetrating trauma-related hemorrhage among patients admitted to U.S. trauma centers along with excess in-hospital mortality, length of hospital stay, and inpatient costs. There were 65,750 patients with blunt trauma and 12,992 patients with penetrating trauma included in our analyses. Of patients sustaining blunt trauma, 7.6 per cent had serious hemorrhage; 18.8 per cent of patients sustaining penetrating trauma had serious hemorrhage. In-hospital mortality rates were significantly ( P < 0.05) higher for patients with serious hemorrhage than for patients without (24.9 per cent versus 8.4 per cent for blunt; 23.4 per cent versus 4.2 per cent for penetrating). Patients with serious hemorrhage had adjusted mean excess lengths of stay of 0.4 days for blunt trauma and 2.7 days for penetrating trauma ( P < 0.05); adjusted excess costs were $296 per day for patients sustaining blunt trauma and $637 per day for patients sustaining penetrating trauma ( P < 0.05). In both blunt and penetrating trauma cases, serious hemorrhage is significantly associated with excess mortality, longer hospital stays, and higher costs.
Adaptation of Median Partial Sternotomy in Head and Neck Surgery
Authors: Shpitzer Thomas , Saute Milton , Gilat Hanna , Raveh Eyal , Koren Ilan , Shvero Jacob , Bahar Gideon , Feinmesser Raphael
Published: June 2020

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or “minimal” sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hürthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.
Rare Case of Castleman Disease Involving the Pancreas
Authors: Tunru-Dinh Vonny W. , Ghani Abdul , Tom Yuel D.
Published: June 2020

Castleman disease, also known as angiofollicular lymph node hyperplasia, is an uncommon tumor involving lymph node tissues. The most common location is in the thorax presenting as a mediastinal mass. In the abdomen, most of the lesions are located in the pelvis, mesentery, and retroperitoneum. Only nine other cases of Castleman disease involving the pancreas have been described. We report a case of Castleman disease (hyaline vascular type) presenting as a pancreatic mass and an enlarged spleen. A 23-year-old woman presented with a 2-month history of abdominal pain localized to the left upper quadrant. Ultrasound and CT demonstrated a large retrogastric pancreatic mass and an enlarged spleen. Distal pancreatectomy and splenectomy were performed. Histopathologic examination revealed a markedly enlarged lymph node showing germinal centers with hyalinization and prominent follicular dendritic cells meshwork surrounded by concentric layers of small lymphocytes. Within the interfollicular area were regions of increased vascularity. BCL2, CD20, and CD79a show expanded mantle zones with a concentric targetoid arrangement of small lymphocytes. This is a case of unicentric Castleman disease of the hyaline-vascular type, which presented with signs and symptoms of a primary pancreatic neoplasm.
Evaluation and Monitoring of the Clinical Pathway for Thyroidectomy
Authors: Soria-Aledo VÍCtor , Flores-Pastor Benito , Fe Candel-Arenas Mari , Carrillo-Alcaraz AndrÉS , Campillo-Soto ÁLvaro , Miguel-PerellÓ Joana , Carrasco Prats Milagros , Aguayo-Albasini JosÉ Luis
Published: June 2020

The aim of this study is to present the evaluation and monitoring of a clinical pathway for thyroidectomy 1 year after its implementation and after 4 years’ follow up. We compare the results of an evaluation and monitoring indicators series before and after the establishment of the clinical pathway for thyroidectomy in the Surgery Department of Morales Meseguer Hospital, a general university hospital in Murcia, Spain. Implementation of the clinical pathway led to a reduction in length of hospital stay for all the surgery patients (4.8 ± 2.1 and 3.6 ± 1.9 days before and after pathway implementation, respectively; P < 0.001). Implementation of the clinical pathway led to a reduction in cost in all the operated patients (3357 ± 966 and 2695 ± 970 US$ before and after implementing the clinical pathway, respectively; P < 0.001). Evolution of the mean hospital cost according to year of study shows a reduction from 2000 (3400 ± 1056 US$) to 2004 (2404 ± 666 US$) with a slight increase during 2005 (2721 ± 1335 US$) (P < 0.001). Implementation of the clinical pathway for thyroidectomy has successfully reduced clinical variation and therefore the length of hospital stay and mean cost of the process. In subsequent years, no such major improvements have been made with regard to hospital stay, although they are still clearly better than those before pathway implementation.
A Rare Cause of Primary Hepatic Neoplasm: Malignant Peripheral Nerve Sheath Tumor in the Age of Modern Liver Surgery
Authors: Iddings Douglas M. , Wright Byron E. , Bilchik Anton
Published: June 2020

Primary malignant peripheral nerve sheath tumor (MPNST) of the liver is rare. Histologic identification of spindle cells from a biopsy specimen and the potential clinical diagnoses are discussed. Potential metastatic and primary spindle cell lesions, as well as their impact on treatment decisions are considered. This was successfully treated with ablation assisted surgical resection and minimal blood loss.
Inguinal Canal Dilatation: A Novel Technique for the Repair of Failed Testicular Descent despite Hormonal Treatment
Authors: Shafik Ahmed , Shafik Ali A. , El Sibai Olfat , Shafik Ismail A.
Published: June 2020

Treatment of the undescended testicle (UT) after it failed to descend on hormonal therapy is surgical. Spermatic cord elongation may impair testicular function, particularly in cases in which cord integuments or veins have to be divided to provide an extra cord length. A factor that might impede testicular descent is presence of a narrowed or obliterated inguinal canal. We investigated the hypothesis that dilatation of a narrowed or obliterated inguinal canal might assist spontaneous testicular descent. Twenty-six boys (age 3.6 ± 0.8 years) with unilateral UT and failed hormonal treatment, whose UT was located at deep inguinal ring, were included in the study. Through an inguinal incision, the inguinal canal was dilated, spermatic cord adhesions divided, hernial sac, if present, excised, and skin closed. Testicular descent into the scrotum occurred in 22 patients within 4.2 ± 1.3 months. The remaining four patients were reoperated on by Fowler-Stephens orchiopexy after 14 months. A technique is presented for the treatment of the UT after failure to respond to hormonal treatment. It consisted of clearing the testicular pathway of any adhesions and dilating the narrowed inguinal canal. The technique is simple, easy, and does not interfere with the testicle or spermatic cord.
Gastric Adenocarcinoma Arising from Fundic Gland Polyps in a Patient with Familial Adenomatous Polyposis Syndrome
Authors: Garrean Sean , Hering Justin , Saied Abdul , Jani Jigna , Espat N. Joseph
Published: June 2020

Familial adenomatous polyposis (FAP) is a rare hereditary syndrome characterized by multiple colorectal polyps and early development of colorectal cancer. Although FAP uniformly involves the large bowel, it may also produce lesions in the stomach and upper intestinal tract. Fundic gland polyps are the most common gastric lesion in FAP. In the general population, these polyps are considered benign and have no malignant potential. However, in FAP patients, fundic gland polyps have been occasionally recognized as precursor lesions from which invasive cancer may develop. Herein, we present a case of gastric adenocarcinoma arising from fundic gland polyps in an FAP patient. We also review reported cases of gastric cancer in FAP and FAP variant patients in an effort to better understand the pathology, clinical course, and optimal screening and treatment strategies for this disease manifestation.
Laparoscopic Spigelian Hernia Repair: The Scroll Technique
Authors: Saber Alan A. , Elgamal Mohamed H. , Rao Arun J. , Osmer Robert L. , Itawi Ed A.
Published: June 2020

Spigelian hernia is a rare clinical entity. It has a subtle clinical presentation with vague abdominal pain that may warrant laparoscopy. Even though laparoscopic ventral hernia repair is increasingly popular, laparoscopic repair of spigelian hernia has not been adequately studied. Eight patients who underwent laparoscopic spigelian hernia repair are presented herein, along with a description of our simple technique for mesh placement. In addition, literature review of laparoscopic repair of spigelian hernia is also presented. Our case series included six females and two males; two patients presented acutely whereas the others presented with chronic pain. Laparoscopic repair was successfully performed in all of our patients with a mean operative time of 92.5 minutes. There were no postoperative complications or recurrence with a mean follow up of 36 months. Our scroll technique for laparoscopic repair is simple and feasible. It minimizes intra-corporeal mesh manipulation, facilitates mesh fixation to the anterior abdominal wall, and maintains a precise orientation of the mesh in relation to the defect.
Recurrent Pure Mucinous Carcinoma of the Breast with Mediastinal Great Vessel Invasion: HER-2/neu Confers Aggressiveness
Authors: Adair Jamie D. , Harvey Kyle P. , Mahmood Ali , Caralis James , Gordon William , Yanish Gregory
Published: June 2020

Mucinous carcinoma of the breast, also known as colloid carcinoma, is a less common variant of breast cancer constituting less than five per cent of breast cancers. We report the case of a 42-year-old premenopausal female who presented with a palpable chest wall recurrence 4 years after simple mastectomy, axillary node dissection, and TRAM flap reconstruction for pure mucinous carcinoma. The recurrent neoplasm was a pure mucinous carcinoma and was found to be invading the mediastinum into the great vessels. The tumor was estrogen receptor positive, progesterone receptor negative, and HER-2/neu positive, which is an unusual finding for mucinous carcinoma. The fact that this tumor demonstrated HER-2/neu positivity may explain the uncharacteristic aggressive nature of this normally indolent type of breast tumor. To our knowledge, this is the first reported case of any mucinous breast cancer invading the mediastinal great vessels and its subsequent en-bloc resection.
Is Upper Extremity Deep Venous Thrombosis Underdiagnosed in Trauma Patients?
Authors: Spaniolas Konstantinos , Velmahos George C. , Wicky Stephan , Nussbaumer Karen , Petrovick Laurie , Gervasini Alice , Demoya Marc , Alam Hasan B.
Published: June 2020

It has been suggested that upper extremity deep venous thrombosis (UEDVT) is as common and dangerous as lower extremity deep venous thrombosis. Pulmonary embolism (PE) is often found with no evidence of associated lower extremity deep venous thrombosis and could have originated from UEDVT. Routine screening is well accepted for lower extremity deep venous thrombosis but not for UEDVT. We hypothesized that UEDVT in trauma is frequent but undetected; therefore, routine screening of trauma patients at risk will increase the UEDVT rate and decrease the PE rate due to early diagnosis and treatment. We evaluated the incidence of UEDVT and PE over 6 months before (Group BEFORE) and 6 months after (Group AFTER) implementing a policy of screening patients at high risk for deep venous thrombosis with Duplex ultrasonography. Group BEFORE was evaluated retrospectively and group AFTER prospectively. There were 1110 BEFORE and 911 AFTER patients. The two groups were similar. Of the AFTER patients, 86 met predetermined screening criteria and were evaluated routinely by a total of 130 Duplex exams. One patient in each group developed UEDVT (0.09% vs 0.11%, P = 1.00). The brachial vein was involved in both patients. Six BEFORE (0.54%) and 1 AFTER (0.11%) patients developed PE ( P = 0.137). The single AFTER patient with PE was not screened for UEDVT because he had no high-risk criteria. UEDVT is an uncommon event with unclear significance in trauma. Aggressive screening did not result in a higher rate of UEDVT diagnosis, nor an opportunity to prevent PE.
A Cautionary Tale: Anaphylaxis to Isosulfan Blue Dye after 12 Years and 3339 Cases of Lymphatic Mapping
Authors: Kaufman Gabriel , Guth Amber A. , Pachter H. Leon , Roses Daniel F.
Published: June 2020

Sentinel node biopsy has become the standard method for lymphatic staging in early-stage breast cancer and melanomas. The most commonly used technique uses both a radioactive tracer as well as blue dye, usually isosulfan blue. In this report, we discuss two episodes of anaphylaxis to isosulfan blue during lymphatic mapping, occurring 12 years and 3339 lymphatic mapping cases after adoption of the technique, and discuss management issues raised by these events.
Hyperglycemia and Infections in Pediatric Trauma Patients
Authors: Tuggle David W. , Kuhn M. Ann , Jones Susan K. , Garza Jennifer J. , Skinner Sean
Published: June 2020

Hyperglycemia has been associated with poor outcome in children with head injuries and burns. However, there has not been a correlation noted between hyperglycemia and infections in severely injured children. The trauma registry of a Level I trauma center was queried for injured children <13 years admitted between July 1, 1999 and August 31, 2003. The records of severely injured children [Injury Severity Score (ISS) > 15] were examined for survival, age, weight, ISS, infection, length of stay (LOS), and maximum glucose levels within the first 24 hours of injury (D1G). Statistical analysis was performed using a t test, Fisher's exact test, a Mann-Whitney Rank Sum test, or Kendall's Tau where appropriate. Eight hundred and eighty eight children under 13 years of age were admitted. One hundred and nine had an ISS > 15, and 57 survived to discharge with measured D1G. Patients excluded were those who died in less than 72 hours or had an LOS less than 72 hours. The survivors were divided into high glucose (≥130 mg/dL; n = 48) and normal glucose (<130 mg/dL; n = 9). There was no difference between the groups with respect to age, weight, incidence of head injury, and ISS. An elevated D1G correlated with an increased risk of infection (P = 0.05) and an increased LOS (P = 0.01). These data suggest that severely injured children are often hyperglycemic in the first 24 hours after injury. Hyperglycemia in this study population correlated with an increased incidence of infection and increased length of stay. This suggests that strict control of hyperglycemia in injured children may be beneficial.
Post-Laparoscopic Cholecystectomy Pain: Effects of Intraperitoneal Local Anesthetics on Pain Control–A Randomized Prospective Double-Blinded Placebo-Controlled Trial
Authors: Ahmed Bestoun H. , Ahmed Aryan , Tan Dongfeng , Awad Ziad T. , Al-Aali Ali Yousef , Kilkenny John , Orlando Frank A. , Al-Chalabi Abbas , Crass Richard , Alrawi Sadir J.
Published: June 2020

Postoperative pain after laparoscopic cholecystectomy (LC) is generally less than open cholecystectomy; however, the postoperative shoulder and abdominal pain experienced by patients still causes preventable distress. Intraperitoneal irrigation of the diaphragmatic surface and gallbladder fossa using normal saline, bupivacaine, or lignocaine may effectively control visceral abdominal pain after an LC. Two hundred patients with similar demographics undergoing elective LC were randomized to one of four groups of 50 patients each, including Group A placebo control, Group B with isotonic saline irrigation, Group C with bupivacaine irrigation, and Group D with lignocaine irrigation. All patients received preperitoneal abdominal wall infiltration with 0.25 per cent bupivacaine to control parietal (somatic) abdominal pain. The visual analogue and verbal rating pain scores at 0, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded in a prospective double-blind fashion at four points during the first 24 postoperative hours. Analgesia requirements, vital signs, blood glucose, and incidence of nausea and vomiting were also recorded. Patients in each group demonstrated a significant difference in visual analogue and verbal rating pain scores and analgesic consumption when compared with controls. Lignocaine controlled pain significantly better than saline or bupivacaine. Bowel function recovery was similar in all patients, and there were no significant complications. We conclude that intraperitoneal irrigation with either saline, bupivacaine, or lignocaine can significantly reduce visceral abdominal pain after LC. Lignocaine was the most efficacious local anesthetic in this trial and has a high safety profile when used at recommended doses.
Primary Colonic Lymphoma
Authors: Gonzalez QuintÍN H. , Heslin Martin J. , DÁVila-Cervantes Andrea , Alvarez-Tostado Javier , De Los Monteros Antonio Espinosa , Shore Gregg , Vickers Selwyn M.
Published: June 2020

Surgical resection of primary colonic lymphoma can be an important therapeutic tool. We performed a nonrandomized retrospective descriptive study at the University hospital tertiary care center. From January 1990 to June 2002, a total of 15 patients with primary colonic lymphoma were identified from the tumor registry at University of Alabama at Birmingham and retrospectively reviewed under Institutional Review Board approved protocol. Demographic data, clinical features, treatment method (surgery and/or chemotherapy), recurrence rate, and survival were analyzed. The results are presented as mean ± standard deviation or median and range. Differences in survival were evaluated by the log-rank test and the interval of disease-free survival was calculated using the Kaplan-Meier method. A P value of <0.05 was considered statistically significant. Main outcome measures included surgical results, morbidity, mortality, and recurrence rate. Mean age was 51.5 years (standard deviation 16.4), 33 per cent were male and 67 per cent were female. Presenting symptoms were diarrhea (53.5%), lower gastrointestinal bleeding (13.3%), and nausea and vomiting (46.7%) secondary to low-grade obstruction. Concomitant colorectal disease was present in one patient with ulcerative colitis. Preoperative diagnosis of lymphoma was made in 13 patients (87%) with colonoscopy and biopsy. CT scan was performed in all patients; and none had radiographic evidence of systemic extension. Only one patient had a history of lymphoproliferative disease and exposure to radiation. The most common disease location was the cecum (60%), followed by the right colon (27%), and the sigmoid colon (13%). The mean lactic dehydrogenase (LDH) value was 214.9 u/L (range 129–309). Thirty-three per cent of the patients had an LDH value that was above the upper normal limit. LDH returned to normal after treatment in all patients. Operations performed consisted of right hemicolectomy (13), total proctocolectomy with ileal J J-pouch (1), and sigmoid colectomy (1). Eighty-seven per cent had negative margins at the time of operation. Twelve patients received postoperative chemotherapy (80%). According to the clinical classification of primary non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (Lugano, 1993) all patients corresponded to stage IE. Mean hospital stay was 6.4 days (range 3–26). There was no surgical mortality and the morbidity rate was 20 per cent (3 patients). One patient had a systemic recurrence (7%) approximately 4 months after surgical resection. Mean follow-up was 31 months (median 2–73). Surgical resection of localized, primary colonic lymphoma provides excellent local disease control and should be considered a primary treatment option. The role of chemotherapy remains controversial depending on the grade, stage, and extension of residual disease.