bluuebunny/crossref_metadata_2025 huggingface dataset:
Traditional Criteria for Observation of Splenic Trauma Should be Challenged
Authors: Gaunt W. Trevor , Mccarthy Mary C. , Lambert Carie S. , Anderson Gary L. , Barney Linda M. , Dunn Margaret M. , Lemmon Gary W. , Paul Doug B. , Peoples James B.
Published: November 2022

Age less than 55 years, normal Glasgow Coma Score (GCS), and absence of hypotension are traditional criteria for the selection of adult patients with blunt splenic trauma for observation. The objective of this study is to challenge these criteria. Two hundred twelve patients who presented with blunt splenic injury between 1992 and 1997 were identified from the Trauma Registry at our Level I trauma center. The patients were divided into three groups: 100 patients (47%) were observed, 108 (51%) underwent immediate splenorrhaphy or splenectomy, and 4 (2%) failed observation. The three groups were compared by participants’ ages, GCSs, and histories of hypotension. No statistical differences were noted between the successfully observed patients and those requiring immediate surgery with respect to these criteria. Of the 4 patients who failed observation, all were younger than 55 years, all had a GCS >12, and all were normotensive. Our findings suggest that traditional criteria used to select patients for splenic trauma observation are not absolute indicators and should be liberalized: patients can be successfully observed despite having criteria that, in the past, would have led to immediate operative intervention.
The Feasibility and Accuracy of the Sentinel Lymph Node Biopsy for Breast Carcinoma
Authors: Jaderborg Jana M. , Harrison Paul B. , Kiser John L. , Maynard Samuel L.
Published: November 2022

As the procedure of sentinel lymph node biopsy for breast cancer becomes more widely available, the practicality of it in the hands of general surgeons should be assessed. This is a study of the accuracy and use of this procedure. A prospective study was conducted at two university-affiliated teaching hospitals. Ninety-one patients with invasive breast cancer were enrolled in the study. Twelve patients were excluded from analysis. The remaining 79 patients were injected peritumorally with technetium-99m-labeled sulfur colloid and isosulfan vital blue dye. The sentinel lymph node was located and excised using a gamma probe, and the definitive breast cancer operation was completed, including an axillary dissection. Histology of the sentinel lymph node specimen was compared with that of the axilla. Sentinel lymph nodes were located in 64 (81.0%) of the 79 patients. Sentinel lymph nodes and axillary nodes were benign in 44 (68.8%) of the 64 patients; these patients could potentially have been spared the axillary dissection. Fourteen (21.9%) patients had metastatic cancer to the sentinel nodes only, and five (7.8%) patients had axillary metastasis beyond the sentinel lymph node. Among the 64 patients, there was one false negative. Sensitivity and specificity when a sentinel lymph node was found were 95.0 per cent and 100 per cent, respectively. The sentinel lymph node accurately predicted the axillary contents 98.4 per cent of the time. This study demonstrates that the sentinel lymph node can be identified and is reliable in predicting axillary node status. This study also shows that the procedure has a notable learning curve, but can be used by general surgeons with a commitment to the care of breast cancer patients.
Trends in Nosocomial Pneumonia in Surgical Patients as We Approach the 21st Century: A Prospective Analysis
Authors: Crabtree Traves D. , Gleason Thomas G. , Pruett Timothy L. , Sawyer Robert G.
Published: November 2022

To compare outcome and prognostic factors of pneumonia in surgical patients, we prospectively studied all episodes of nosocomial infection at all sites in 1997 on the surgical services at a single hospital. Pneumonia accounted for 74 of 287 episodes of infection. The crude mortality for pneumonia was 31.1 versus 12.2 per cent for all other infections (P < 0.001). Pneumonia patients had a higher severity of illness compared with those with infections at other sites (18.7 ± 0.8 vs 14.0 ± 0.5; P < 0.001). Crude mortality remained higher in pneumonia patients when compared with an infected control group matched for severity of illness and age (31% vs 15%; P = 0.02). Staphylococcus aureus (15%) was the most common isolate, followed by Pseudomonas aeruginosa (9%). Resistant Gram-positive cocci accounted for 7 per cent of all isolates but was associated with a 60 per cent mortality vs 28 per cent with other organisms (not significant; P = 0.1). The Acute Physiology and Chronic Health Evaluation (APACHE) II score for patients with resistant Gram-positive cocci was 22 ± 1 versus 18 ± 1 with other organisms (P = 0.03). Nonsurvivors of pneumonia were older (58 ± 2 vs 51 ± 3; P = 0.03), had a higher APACHE II score (23 ± 1 vs 17 ± 1; P < 0.001), and were diagnosed later in their hospital course (18 ± 4 days vs 11 ± 1; P = 0.05) compared with survivors. Pneumonia-associated mortality in surgical patients remains high compared with other infections even when correcting for differences in severity of illness. Although resistant Gram-positive cocci appear to be increasing in frequency, they may represent markers of severe illness rather than true pathogens. Increasing age, severity of illness, and length of stay before diagnosis were all associated with a worse prognosis.
Abdominal Closure Using Nonabsorbable Mesh after Massive Resuscitation Prevents Abdominal Compartment Syndrome and Gastrointestinal Fistula
Authors: Ciresi David L. , Cali Robert F. , Senagore Anthony J.
Published: November 2022

Patients who receive high-volume resuscitation after massive abdominopelvic trauma, or emergent repair of a ruptured abdominal aortic aneurysm (RAAA), are at a significant risk for postoperative abdominal compartment syndrome (ACS). Absorbable prosthetic closure of the abdominal wall has been recommended as a means of managing ACS. However, use of absorbable prosthetic has been associated with very high rates of intestinal fistula formation and ventral hernia formation. The purpose of this study was to retrospectively review our experience with the use of nonabsorbable prosthetic abdominal closures in patients with documented ACS or at high risk for ACS. All patients managed by this technique from July 1995 through July 1997 after repair of ruptured abdominal aortic aneurysm or massive abdominopelvic trauma were evaluated. A total of 18 patients were identified: 15 primary prosthetic placements (Gore-Tex™ patch, 12; Marlex™ mesh, 2; and silastic mesh, 1) and 3 delayed prosthetic placements for ACS (Gore-Tex™, 1 and Marlex™, 2). The mortality rate was 22 per cent (4 of 18) and resulted from multisystem organ failure (2 patients), cardiac arrest 1 hour postoperatively (1 patient), and severe closed head injury (1 patient). Secondary closure and prosthetic removal was possible in 16 of 18 patients, including the 2 patients who died of multisystem organ failure within the same hospitalization. Delayed abdominal closure at a subsequent admission was performed in two cases. This same patient developed an enterocutaneous fistula 2 months after discharge. Importantly, only 1 of 18 closed in this manner developed ACS requiring reoperation. The results indicate that use of a nonabsorbable prosthetic, particularly with Gore-Tex™, is efficacious in the prevention of postoperative ACS in high-risk patients, while it enhances the possibility for delayed abdominal closure and minimizes the risk of gastrointestinal fistulization associated with other techniques.
Supraclavicular Lymphadenopathy: The Spectrum of Pathology and Evaluation by Fine-Needle Aspiration Biopsy
Authors: Mchenry Christopher R. , Cooney Matthew M. , Slusarczyk Sandra J. , Khiyami Amer
Published: November 2022

Fine-needle aspiration biopsy (FNAB) has emerged as an important modality for the evaluation of supraclavicular lymphadenopathy. To determine the spectrum of pathology and the efficacy of FNAB, all patients with supraclavicular lymphadenopathy evaluated from 1990 to 1997 were analyzed for: 1) a prior history of malignancy; and 2) the side of the abnormal lymph node, FNAB result, and final pathologic diagnosis. FNAB was used to evaluate left- and right-sided supraclavicular lymphadenopathy in 33 and 19 patients, respectively. FNAB was malignant in 37 patients (71%), benign in 4 patients (8%), nondiagnostic in 6 patients (11%), and suspicious in 5 patients (10%). A prior history of malignancy was present in 30 patients and, of these, 23 (77%) had a malignant FNAB compared with 14 of 22 patients (64%) with no previous history of cancer (P > 0.05). Of the 37 patients with a malignant FNAB, 22 (59%) were from a left supraclavicular node. Abdominal and pelvic tumors uniformly metastasized to a left supraclavicular lymph node, whereas malignancies of the head and neck, thorax, breast, and skin and lymphoma showed no significant difference in laterality. There were no false positive or false negative FNAB results. In conclusion, the yield of FNAB is similar in patients with or without a history of malignancy, justifying the routine use of FNAB as the initial diagnostic test for evaluation of patients with supraclavicular lymphadenopathy. However, FNAB is not definitive in 21 per cent of patients with supraclavicular lymphadenopathy, emphasizing the importance of selective excisional biopsy.
Intraoperative Radio-Guided Identification of Parathyroid Adenomas with the Gamma Probe: Initial Experiences in a Community Hospital
Authors: Baskies Arnold M. , Mayer Paul , Holaday William J. , Cannon Anthony J. , Rosenbaum Daniel N. , Choi Hong Y. , Davis Linda V. , Tilton Cheryl M.
Published: November 2022

Previous radiological imaging studies for identification of parathyroid adenomas have generally been unreliable. Currently, preoperative administration of Tc-99m sestamibi improves detection of parathyroid adenomas. Combining preoperative administration of sestamibi radionuclide with the gamma probe intraoperatively can successfully identify the exact location of parathyroid adenomas in a community hospital setting and facilitate a safe and efficient operation. A team approach, including surgeon, radiologist, and technologist, is recommended to facilitate mastery of the learning curve.
A New Economic Benchmark for Surgical Treatment of Appendicitis
Authors: Firilas Anthony M. , Higginbotham Patti H. , Johnson Donna D. , Jackson Richard J. , Wagner Charles W. , Smith Samuel D.
Published: November 2022

Cost reduction in the management of common surgical diseases such as appendicitis has become paramount for the survival of children's hospitals. We designed a clinical pathway to treat appendicitis with the goal of reducing cost and hospital length of stay (LOS) while maintaining quality of care. From September 1995 through December 1996, patients with nonperforated appendicitis (NPApp) and perforated appendicitis with peritonitis (PApp) were enrolled into a clinical pathway. NPApp patients were discharged when tolerating a regular diet. PApp patients were discharged if the following criteria were met: temperature < 38.5° C for 24 hours, WBC < 14,000 on postoperative day 3, tolerating diet, and transition to oral analgesics accomplished. Hospital LOS and actual hospital costs in pathway patients were compared with those of historic controls. Patients with appendicitis from the Pediatric Health Information Systems (PHIS) database, a consortium of 20 children's hospitals in the United States, served as concurrent controls. Hospital LOS and hospital charges in PHIS NPApp and PApp patients from our institution were compared with national PHIS database patients. Mean LOS and hospital costs for both NPApp and PApp pathway patients were significantly decreased compared with historic controls (P < 0.05). Mean LOS and hospital charges in our institution's PHIS NPApp and PApp patients were also significantly decreased compared with the national PHIS database (P < 0.05). Innovative approaches such as these are necessary for the survival of children's hospitals in an increasingly cost competitive healthcare market.
Extended Subcostal Hinge Incision for Right Hepatic Lobectomy
Authors: Ahrendt Steven A. , Schlossberg Leon , Bulkley Gregory B.
Published: November 2022

The safe performance of a right hepatic lobectomy requires adequate exposure of the hepatic veins and of the suprahepatic vena cava. An extended subcostal or midline incision is commonly used to provide exposure for this operation. The technique for an extended subcostal incision that uses the natural hinge mechanism of the rib cage to provide exposure to the right upper quadrant is described. This approach provides adequate exposure during a difficult hepatectomy, avoiding the need for a thoracotomy or sternotomy.
Contribution of Endoscopic Retrograde Pancreatography in Management of Complications following Distal Pancreatic Trauma
Authors: Wind Philippe , Tiret Emmanuel , Cunningham Christopher , Frileux Pascal , Cugnenc Paul H. , Parc Rolland
Published: November 2022

Pancreatic trauma is associated with high morbidity and mortality. Treatment of this condition is controversial. This retrospective study aimed to evaluate the management of distal pancreatic trauma and its complications, assessing the role of endoscopic retrograde cholangiopancreatography (ERCP). The clinical course and surgical management of 38 patients with distal pancreatic trauma were analyzed in a university hospital in Paris, France. Twenty-five patients were referred after initial treatment elsewhere. As initial treatment, patients underwent external drainage (n = 25), pancreatic resection (n = 6), laparotomy alone (n = 5), and no surgery (n = 2). Nineteen patients with pancreatic duct injury and no pancreatic resection developed fistulae (n = 14) or pseudocysts (n = 5). Only four of these patients recovered without a subsequent pancreatic resection or internal drainage procedure. In the absence of duct injury, patients recovered without the need for pancreatic resection. ERCP was performed in 16 cases and provided critical information on duct status influencing surgical management. We conclude that the presence of pancreatic trauma duct injury is a major determinant of complications and outcome after pancreatic trauma. It is optimally managed by pancreatic resection. ERCP is valuable in providing a definitive diagnosis of duct injury, thereby directing treatment.
Penetrating Cardiac Trauma at an Urban Trauma Center: A 22-Year Perspective
Authors: Thourani Vinod H. , Feliciano David V. , Cooper William A. , Brady Kevin M. , Adams Andrew B. , Rozycki Grace S. , Symbas Panagiotis N.
Published: November 2022

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975–1985; 113 patients) and Period 2 (1986–1996; 79 patients) were by χ2 or Fisher's exact tests. Statistical significance was defined as P ≤ 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30–90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.
Splenic Flexure Volvulus in Association with Chilaiditi Syndrome: Report of a Case
Authors: Havenstrite Keith A. , Harris James A. , Rivera David E.
Published: November 2022

Hepatodiaphragmatic interposition of the intestine, or Chilaiditi syndrome, is uncommon and typically asymptomatic, but it can be associated with symptoms ranging from intermittent, mild abdominal pain to acute intestinal obstruction. Factors such as the interruption or absence of peritoneal attachments and redundant colon with a long mesentery predispose to both Chilaiditi syndrome and colonic volvulus. The presence of hepatodiaphragmatic interposition of the intestine requires no specific treatment in the absence of symptoms. Colonic volvulus in association with Chilaiditi syndrome is treated based on the location of the volvulus. Volvulus of the splenic flexure is typically treated with resection and primary anastomosis. We report only the third case of colonic volvulus in association with Chilaiditi syndrome and the first with volvulus of the splenic flexure.
Competency-Based Instruction to Improve the Surgical Resident Technique and Accuracy of the Trauma Ultrasound
Authors: Frezza Ermenegildo Eldo , Solis Ricardo L. , Silich Robert J. , Spence Richard K. , Martin Marcel
Published: November 2022

In a surgical trauma center, programs and workshops have improved the performance on focused abdominal sonogram for trauma (FAST). The purpose of this single-blind study was to prove that a cadaver laboratory competency-based instruction program may be an effective method of FAST training to acquire the skills that would be applied in the trauma room. The study was divided in two parts, laboratory and clinical. Nine surgical residents were divided into two groups: Group I performed the test only once, and Group II performed the training twice. A third “group” was the senior ultrasound technician, whose readings served as our “gold standard” with which to compare the resident readings (Group HI). Using cadavers, a 2-cm catheter was introduced into the peritoneal cavity. Sequential aliquots of normal saline were introduced into the abdominal cavity at 0–, 200–, 400–, 600–, and 1000-cc increments in each group tested. The residents were asked to describe their examinations for the presence or absence of fluid in the abdomen. The ultrasound examination was then performed with the cadaver in three different positions to study if there was any difference of fluid detection in varied positions. True positive, true negative, and accuracy were then calculated comparing the three different groups of test sonographers. In the second part of the study, the same residents were then followed in the trauma room, where they performed the FAST in the absence of the ultrasound technician during emergencies. As in the laboratory, the accuracy of their reading compared with that of the ultrasound technician was also evaluated. From 400 cc and upward, Group II began having an overall significantly superior accuracy than the first group and the technician in most quadrants examined. The trend was apparent for more accurate results in all quadrants and positions by all groups as the fluid was increased. Overall, group II was most superior in detection of intra-abdominal fluid in the cadaver. In the clinical scenario, the residents as a whole had similar accuracy (92% vs 96%) in reading FAST as the ultrasound technician. Our results suggest that surgical residents have the ability to detect fluid in the abdomen, there exists a fast learning curve, and the minimum detection level of fluid was between 200 and 400 cc in the peritoneal cavity in the laboratory. Surgical residents were able to detect intra-abdominal fluid in the trauma situation, as shown by the 92 per cent accuracy of the FAST in the emergency situation. We conclude that a cadaver laboratory training program is an important adjunct to improve the skills of the resident in performing and reading FAST.
Primary Resection and Anastomosis for Perforated Left Colon Lesions
Authors: Umbach Thomas W. , Dorazio Richard A.
Published: November 2022

The records of 33 patients with perforated left colon lesions over a 6-year period from 1992 to 1998 were examined retrospectively for clinical course and complications. All patients had a free perforation, feculent or purulent peritonitis, and/or a large inflammatory mass. All patients had primary resection and anastomosis without a protective colostomy or ileostomy. Indications included diverticulitis in 28 patients, obstructing colorectal carcinoma in 3, and iatrogenic perforations in 2. Complications occurred in 10 patients, including atelectasis in 1, urinary retention in 2, urinary tract infections in 2, wound infections in 3, line catheter sepsis in 1, and acute tubular necrosis in 1. There was one anastomotic dehiscence, which was successfully converted to a Hartmann procedure. Patients were discharged an average of 7 days after surgery. Two patients required surgery after discharge: one had a fascial dehiscence and the other an incisional ventral hernia. There was no mortality. Primary resection and anastomosis of selected perforated left colon lesions can be performed with a morbidity and mortality rate lower than that usually reported for the Hartmann procedure.
Iatrogenic Gallbladder Perforation during Laparoscopic Cholecystectomy: Etiology and Sequelae
Authors: Hui Thomas T. , Giurgiu Dan I. , Margulies Daniel R. , Takagi Sumito , Iida Atsushi , Phillips Edward H.
Published: November 2022

Iatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.
Unresectable Pancreatic Carcinoma: Correlating Length of Survival with Choice of Palliative Bypass
Authors: Di Fronzo L. Andrew , Cymerman Judith , Egrari Sepehr , O'connell Theodore X.
Published: November 2022

The preferred method of biliary bypass and the need for prophylactic gastroenterostomy in unresectable pancreatic carcinoma are dependent on the length of survival of the patient. From 1980 through 1996, 60 patients with biopsy-proven pancreatic cancer were found to be unresectable at exploration. The reasons for unresectability included major vascular involvement in 21 patients (35%), liver metastases in 16 (26.7%), celiac or portal lymph node metastases in 13 (21.7%), carcinomatosis in 5 (8.3%), and advanced age and/or comorbid medical condition in 4 patients (6.7%). One patient refused pancreaticoduodenectomy. Nine patients (15%) underwent Roux-en-Y choledochojejunostomy, and 51 (85%) underwent choledochoduodenostomy. Prophylactic gastroenterostomy was not performed routinely; however, in 9 patients (15%), gastrojejunostomy was performed for impending duodenal obstruction. Late biliary obstruction did not occur. Late gastric obstruction occurred in 6 of 51 patients (11.7%), at a median of 13.5 months after initial operation (range, 5–26 months). However, late gastric obstruction primarily occurred in 5 of 31 patients (16%) with locally advanced disease (major vessel involvement or lymph node metastases). The median survival was 12.0 months (range, 3.5–62 months) for patients with major vessel involvement, 11.5 months (range, 3–42 months) for patients with lymph node metastases, 4.5 months (range 0.5–24 months) for patients with liver metastases, 5.0 months (range, 4–7 months) for patients with carcinomatosis, and 9.0 months (range 2–27 months) for patients with significant comorbid medical illness and/or advanced age. Patients with liver metastases and carcinomatosis do not survive long enough to develop late obstruction. On the other hand, patients with locally advanced pancreatic carcinoma have a longer median survival and could be considered for prophylactic gastroenterostomy to avoid late gastric obstruction. Choledochoduodenostomy offers effective palliation for biliary obstruction.
Computed Tomography Scanning for the Diagnosis of Perforated Appendicitis
Authors: Oliak David , Sinow Robert , French Samuel , Udanl Vikram M. , Stamos Michael J.
Published: November 2022

The optimal initial treatment for perforated appendicitis may be nonoperative. For this reason it is important to be able to reliably distinguish between acute and perforated appendicitis. CT scanning has been shown to be highly accurate for the diagnosis of appendicitis, but it has not been specifically evaluated for perforated appendicitis. Our objective was to evaluate CT for the diagnosis of perforated appendicitis. Our study population comprised 84 patients who underwent appendectomy between 1993 and 1997 and who had CT scanning performed preoperatively. Medical records were reviewed retrospectively. CT scans were reviewed in a blinded fashion. CT findings were correlated with pathologic and clinical factors. Sixteen patients with acute appendicitis, 59 patients with gangrenous or perforated appendicitis, and 9 patients with normal appendices or other diagnoses were evaluated. For patients with pathologic documentation of appendicitis, CT findings that independently predict perforation or gangrene included abscess (P < 0.001), phlegmon (P < 0.001), extraluminal gas (P = 0.01), and terminal ileal wall thickening (P = 0.03). CT findings of an abscess, extraluminal gas, or phlegmon have a sensitivity of 92 per cent, specificity of 88 per cent, positive predictive value of 96 per cent, and negative predictive value of 74 per cent for perforated or gangrenous appendicitis. We conclude that CT can reliably distinguish between acute and perforated appendicitis.
Complex Repair for the Management of Duodenal Injuries
Authors: Velmahos George C. , Kamel Eman , Chan Linda S. , Hanpeter David , Asensio Juan A. , Murray James A. , Berne Thomas V. , Demetriades Demetrios
Published: November 2022

The management of duodenal injuries is a subject of ongoing debate. In this study we attempt to describe duodenum-related morbidity (DRM) after primary repair or complex repair (CR) and to identify risk factors for development of complications. The medical records of 145 consecutive patients admitted to Los Angeles County+University of Southern California Medical Center with duodenal injuries between January 1991 and December 1997 were reviewed. Fifty-four (37%) died within 24 hours of admission because of associated injuries. The remaining 91 were subjected to univariate and multivariate analysis. Of them, 66 (72.5%) developed complications and 3 (3%) died. CR was used in 32 (35%) patients and with increasing frequency as the grade of duodenal injury increased. DRM rate was overall low (9%) and not different between low-grade and high-grade duodenal injuries. This occurred despite a significant increase in Injury Severity Score and abdominal Abbreviated Injury Score in patients with more severe duodenal injuries. Patients with overall complications had higher Injury Severity Scores, higher abdominal Abbreviated Injury Scores, and more severe duodenal injuries. We conclude that duodenal injuries are frequently associated with other highly lethal injuries. Liberal use of CR in patients with more severe duodenal injuries prevents DRM.
Radiofrequency Ablation: A Novel Primary and Adjunctive Ablative Technique for Hepatic Malignancies
Authors: Rose D. Michael , Allegra David P. , Bostick Peter J. , Foshag Leland J. , Bilchik Anton J.
Published: November 2022

The majority of primary and metastatic tumors of the liver are not amenable to surgical resection at presentation. Radiofrequency ablation (RFA) is a new modality for local tumor destruction with minimal local and systemic complications. We prospectively reviewed the experience with RFA at a single institute as a primary or adjunctive ablative technique in the treatment of hepatic malignancies. Between November 1997 and December 1998, 30 patients with primary or metastatic hepatic lesions were treated with RFA at the John Wayne Cancer Institute and the Cancer Center at Century City Hospital. Pathology of the treated lesions included colorectal metastases (29 in 14 patients), neuroendocrine metastases (29 in 4 patients), noncolorectal metastases (29 in 9 patients), and hepatocellular carcinoma (6 in 3 patients). Twelve patients underwent RFA laparoscopically, 12 at celiotomy, and the remaining 6 patients had percutaneous ablation. RFA was the only procedure in 17 patients, whereas the remainder underwent a combination of RFA and other procedures including resection, cryosurgical ablation, and hepatic artery infusion pump placement. Median length of stay for all patients was 6 days (2 days for laparoscopic patients). A single complication of a delayed intrahepatic abscess was noted in this series (3%). There have been no deaths associated with RFA. At a median follow-up of 5 months, 16 patients remain disease free, and 10 are alive with disease. RFA is a safe and effective method of tumor ablation for hepatic malignancies. This technique can be performed laparoscopically, at celiotomy, or percutaneously and can be used as a primary technique or in conjunction with other interventional procedures.
Lung Cancer Found Unresectable at Thoracotomy: Reappraisal of an Old Problem
Authors: Michaelson Robert , Shaughnessey Elizabeth , Wagman Lawrence D. , Grannis Frederic W.
Published: November 2022

We review our experience with unresectable non-small cell lung cancer, after adoption of a more aggressive surgical approach, including mediastinal lymph node dissection. Cases with enlarged mediastinal lymph nodes (MLNs, cN2) that were predicted to be resectable were included. Our objective was to identify preoperative findings to prevent unnecessary thoracotomy. In 1988–1997, 192 patients had thoracotomy for non-small cell lung cancer. Fifteen cases (7.7%) were found unresectable at thoracotomy. CT scans demonstrated enlarged MLNs in 7 of 15 and enlarged hilar lymph nodes in 6 of 15 cases. The tumor abutted the hilum in 5 of 15, chest wall in 2 of 15, and mediastinal structures in 7 of 15 cases. Atelectasis was seen in 3 of 15 cases. During the same period, 63 patients with stage III disease, including 39 patients with enlarged MLNs, were resected. The unresectability rate for cN2 patients was 15.2 per cent. Five (33%) patients were physiologically unable to tolerate the required pneumonectomy [forced expiratory volume in 1 second, 1.65 liters (range, 1.15–2.07)]. There were three (20%) esophageal invasions, two (13.3%) mediastinal invasions, two (13.3%) aortic invasions, two (13.3%) metastases to the diaphragm, and one (6.6%) invasion of proximal pulmonary artery. Median survival was 4 months. Two-year actuarial survival was 8 per cent. We conclude that careful palpation and dissection were required to establish unresectability. Preliminary thoracoscopy would have prevented thoracotomy in two cases (13.3%) of diaphragmatic metastases but would not reliably establish unresectable invasion of mediastinal structures.
Minimal Debridement in the Treatment of Fournier's Gangrene
Authors: Frezza Ermenegildo Eldo , Atlas Ian
Published: November 2022

Scrotal and perineal gangrene of the male genitalia was first described by Founder in 1883. Treatment of the disease remains surgical despite the availability of modern antibiotics. Many authors advocate a wide debridement of all tissue superficial to the involved fascial layers. We have reviewed our experience of using wide and minimal debridement as the surgical technique of choice. In our retrospective study, nine patients were diagnosed and treated over a 2-year period for Fournier's gangrene. The mean age was 65 ± 28 years. Two patients were admitted from chronic care facilities, four were diabetic, and two had taken oral steroids. Five of the nine patients were treated with the technique of minimal tissue debridement. In brief, the scrotum was bivalved along the median raphe, each scrotal sac was drained, and the testicles were exteriorized. Orchiectomy was performed if the testicles were grossly necrotic. Penrose drains were inserted from each scrotal sac to the counterincision at the level of the internal rings. All of the tissue involved was irrigated with betadine and peroxide, after debridement of the necrotic tissue. Broad-spectrum antibiotics along with daily packing were continued for 4 to 6 weeks; at the end of that time the testicles were returned to the scrotum and the skin was loosely reapproximated. Three of the nine patients were treated with wide debridement of all the soft tissue including the fascia. One of the patients displayed gangrene of the entire abdominal wall; he was not a surgical candidate and died 3 days later. The four patients treated with minimal debridement all obtained successful treatment of their fasciitis. However, one died of complications related to a duodenal ulcer. The mean hospital stay was 45 ± 10 days. Two of the three patients treated with wide debridement required plastic reconstruction using a skin-muscle flap of the perineum. The remaining patient treated with wide debridement died of complications related to metastatic renal carcinoma. The mean hospital stay of this group was 62 ± 12 days. The specific flora included: Bacteroidis fragilis in 87 per cent, Peptostreptococcus and Streptococcus in 75 per cent, Clostridia group, Escherichia coli, Enterobacter and Pseudotnonas in 62 per cent, Klebsiella in 50 per cent, Staphylococcus in 37 per cent, and Proteus in 12 per cent of the patients. In the surgical management of Fournier's gangrene, wide drainage with minimal debridement resulted in similar morbidity and shorter hospital stay when compared with extensive debridement.
Managing Intractable Pain with an Intrathecal Catheter and Injection Port: Technique and Guidelines
Authors: Meenan Daniel , Lagares-Garcia Jorge A. , Kurek Stanley , Craig Dianna , Green James , Fritz William
Published: November 2022

The objective of our study was to describe an effective technique for the management of chronic intractable pain in patients with intermediate life expectancy or as a long-term screening device prior to implantable pump therapy. In the study, an InDura™ intraspinal catheter is connected to a BardPort™, which is accessed transdermally. We describe our surgical technique, recommended dosage calculations, cost comparison to an implantable infusion pump, and our experience with 13 cases. In our series of 13 patients, there was one seroma and one dural leak. There were no infections, and all were functioning well in the 12 cancer patients until their deaths. One case was converted to an implantable pump. There were no malfunctions or infections of the intrathecal infusion system in the 12 cancer patients. This intrathecal drug infusion system should be considered in the treatment armamentarium for chronic intractable pain and cancer pain.
Management Issues regarding Hepatic Adenomatosis
Authors: Yoshidome Hiroyuki , Mcmasters Kelly M. , Edwards Michael J.
Published: November 2022

Hepatic adenomatosis is a rare disease defined by multiple hepatic adenomas. There is controversy with regard to the optimal treatment for this disease because the potential for intraperitoneal hemorrhage or malignant transformation of the tumors is difficult to estimate. Furthermore, the technical difficulties of complete resection of all adenomas present unique operative challenges. We report experience with two patients and reviewed all reported cases from 1977. We define hepatic adenomatosis as five or more hepatic adenomas not associated with a medical history of glycogen storage disease, anabolic steroid use, or oral contraceptive use. The incidence of hepatic adenomatosis was preponderate among women [20 of 32 patients (63%)]. Thirteen of 32 patients (41%) had intratumoral bleeding, including four patients with intraperitoneal hemorrhage. Ten of 13 patients (77%) with intratumoral bleeding complained of abdominal pain; overall, 19 of 32 patients (59%) had abdominal pain. Twelve patients underwent hepatic resection, 6 patients underwent liver transplantation with no reported mortality, and 14 patients had no surgical treatment. Hepatocellular carcinoma was histologically confirmed in 2 of 32 patients (6%). Larger symptomatic adenomas exposed to liver surface have a bleeding propensity and should be surgically resected. Routine biopsy of other small nodules suspected as adenomas is recommended for definitive diagnosis.
Efficacy of Jejunogram after Jejunostomy Insertion
Authors: Puc Matthew M. , Tran Hoang , Goldstein Matthew , Tarnoff Michael , Goodman Martin , Slotman Gus J.
Published: November 2022

The era of managed care has spawned a national debate over the allocation of health care resources. We hypothesized that routine postjejunostomy jejunogram rarely provides additional clinical information or changes patient management and, therefore, is unwarranted. We retrospectively reviewed the charts of 128 consecutive patients undergoing feeding jejunostomy tube insertion between January 1995 and December 1996. All patients had postinsertion jejunograms. Eighty-five (66%) of the jejunograms were performed after operative insertion of the jejunostomy, and 43 (33%) were performed after percutaneous reinsertion of a previously placed jejunostomy. Data extracted from the charts include age, sex, indication for jejunogram, length of time prior jejunostomy was in place at time of reinsertion, and results of jejunogram. There were no patients (0%) with misplaced jejunostomy or extravasation of dye, as noted on jejunogram. There were no management changes implemented as a result of jejunogram readings (P < <0.05). The use of routine jejunogram after operative insertion or reinsertion of a prior jejunostomy that has become dislodged or occluded does not alter patient management, incurs unnecessary costs, and, therefore, is unwarranted.
The Role of Pancreaticoduodenectomy in the Treatment of Severe Chronic Pancreatitis
Authors: Vickers Selwyn M. , Chan Carlos , Heslin Martin J. , Bartolucci Alfred , Aldrete Joaquin S.
Published: November 2022

Chronic pancreatitis remains a debilitating disease with few definitive options for treatment. The purpose of this study was to evaluate the benefit of pancreaticoduodenectomy in the treatment of chronic pancreatitis. The results were evaluated by standard descriptive statistics. In a retrospective study, we reviewed the patients at a single institution undergoing pancreaticoduodenectomy between 1994 and 1997 for complications of chronic pancreatitis. Patients were evaluated for preoperative indication for surgery and perioperative morbidity and mortality, as well as long-term results. Thirty-two patients underwent pancreaticoduodenectomy for chronic pancreatitis; 56 per cent (18) underwent pylorus-preserving and 44 per cent (14) underwent classic pancreaticoduodenectomy. The mean age of these patients was 56 ± 14.7 years (range, 23–79). All patients underwent preoperative CT scan and endoscopic retrograde cholangiopancreatography. The preoperative indication for surgery in 81 per cent (26) of these patients was intractable pain in the setting of a nondilated pancreatic duct. The other 19 per cent were treated for biliary/pancreatic duct stricture and pancreatic head fibrosis (mass suspicious of malignancy). Fifty-three per cent of the patients had a history of previous abdominal surgery. There were no perioperative deaths. The mean postoperative stay was 12.2 ± 7.4 days. The postoperative morbidity rate was 31 per cent (10), consisting of 25 per cent with delayed gastric emptying, 3 per cent with pneumonia, and 3 per cent with wound infections. There was no occurrence of pancreatic fistulas. With a mean follow-up of 40 months (range, 10–52 months), 85 per cent reported a significant improvement in pain with 71 per cent being pain free and not requiring narcotics. Twenty per cent developed new-onset diabetes. The overall event survival rate at 5 years was 97 per cent. Thus, in a selected group of patients with severe chronic pancreatitis, resection of the head of the pancreas achieved relief of symptoms and was a safe and effective treatment for chronic pancreatitis.
Thoracoscopic Resection of Posterior Neurogenic Tumors
Authors: Hazelrigg Stephen R. , Boley Theresa M. , Krasna Mark J. , Landreneau Rodney J. , Yim Anthony P.
Published: November 2022

Video-assisted thoracic surgery (VATS) may be used for resection of posterior mediastinal tumors to avoid thoracotomy and shorten hospital stay. Between October 1990 and June 1998, 23 patients had VATS resection of posterior neurogenic tumors. The 14 females and 9 males ranged in age from 14 months to 70 years, with a median of 35 years. Operation time ranged from 30 to 120 minutes (median, 83), and intraoperative complications were limited to minor problems as well as conversion to thoracotomy to enhance complete tumor resection in four cases. Tumor pathology included nerve sheath origin (20) and autonomic ganglia (3). There was only one malignant schwannoma. Tumor size ranged from 0.7 to 13 cm in diameter. Median chest tube days was 1 day (range, 1–4), and hospital stay was 2 days (range, 1–9). Postoperative complications included transient paresthesia (three cases), ileus (two cases), pleural effusion (one case), and transient intercostal pain (one case). Posteripr neurogenic tumors may be resected safely using video-assisted techniques. Conversion to thoracotomy to enhance complete resection is both possible and encouraged. The use of VATS seems to decrease hospital stay and minimize postoperative complications. In posterior neurogenic tumors without tumor extension to the spinal canal, VATS has become our preferred method for resection.
The Continuing Challenge of Fournier's Gangrene in the 1990s
Authors: Olsofka John N. , Carrillo Eddy H. , Spain David A. , Polk Hiram C.
Published: November 2022

Fournier's disease is a potentially fatal acute, gangrenous infection of the scrotum, penis, or perineum associated with a synergistic bacterial infection of the subcutaneous fat and superficial fascia. Thrombosis of small subcutaneous arterioles with resultant ischemia contributes to the rapid extension of the infection. During a 12-year period, the clinical and operative records of 14 patients with Fournier's gangrene were analyzed. All patients were treated with broad spectrum antibiotics and serial surgical debridements. Nine patients had polymicrobial isolates from the initial wound culture; two patients had Group A Streptococcus species as the sole isolate. The etiology of the infection was identified in 12 patients. Five patients died for an overall mortality of 38 per cent. The mean age of survivors was 51 years compared with 75 years for nonsurvivors (P < 0.05). The last six patients in this series survived. The mean hospital stay was 29 days. Four patients (31%) had a prior history of diabetes; however, 11 patients (85%) had elevated serum glucose levels (>120 mg/dL) on admission. All patients were hypoalbuminemic on admission. Survivors had an average serum creatinine on admission of 1.28 mg/dL compared with 3.1 mg/dL for nonsurvivors. Although supportive care is required in these patients, the mainstay for treatment of Fournier's gangrene entails an aggressive approach with frequent and extensive soft tissue debridements to control the invasive nature of the infection with delayed wound coverage once the infection has been controlled. Elderly patients with evidence of renal dysfunction on admission have a poor prognosis despite aggressive therapy.
Air Travel following Traumatic Pneumothorax: When is it Safe?
Authors: Cheatham Michael L. , Safcsak Karen
Published: November 2022

The safety of air travel for patients sustaining a recent traumatic pneumothorax has long been a subject of debate. The Aerospace Medicine Association has suggested that patients should be able to fly 2 to 3 weeks after radiographic resolution of their pneumothorax. To validate these recommendations, a prospective study was performed. Twelve consecutive patients with recent traumatic pneumothorax expressing a desire to travel by commercial airline were evaluated. Ten patients waited at least 14 days after radiographic resolution of their pneumothorax before air travel (mean, 17.5 ± 4.9 days), and all were asymptomatic in-flight. One of two patients who flew earlier than 14 days developed respiratory distress in-flight, with symptoms suggestive of a recurrent pneumothorax. We conclude that commercial air travel appears to be safe 14 days following radiographic resolution of a traumatic pneumothorax.
Large Bowel Obstruction Due to Intrauterine Device: Associated Pelvic Inflammatory Disease
Authors: Antonelli Darrin , Kustrup John F.
Published: November 2022

Pelvic actinomycosis associated with the use of intrauterine contraceptive devices (IUDs) can mimic pelvic malignancy. Recognizing this rare, but not uncommon complication of IUD use can spare a patient from an extensive surgical procedure. If recognized preoperatively, a simple regimen of antibiotics can be curative; however, if symptomatic, a limited surgical procedure is warranted. We present the case of a 55-year-old woman with a slow, indolent course of partial large bowel obstruction and a history of IUD use for over 20 years. A preoperative CT scan revealed a frozen pelvis mimicking a pelvic malignancy. Exploratory laparotomy revealed a firm, indurated, fibrotic reaction in the pelvis involving the uterus, adnexa, and sigmoid colon. A diverting loop colostomy was performed, and pathology revealed sulfur granules from the extracted IUD that grew Actinomyces. The patient was treated with the appropriate antibiotics, and during the takedown of the colostomy 6 months later the pelvic inflammation was completely resolved. An extensive review of the literature involving actinomycotic abscesses associated with IUD use reveals a limited number of studies reported in the general surgical literature. It behooves the general surgeon to be aware of this unusual case so that the appropriate consultation and treatment can be performed with limited morbidity to the patient.