bluuebunny/crossref_metadata_2025 huggingface dataset:
Laparoscopic Ultrasonic Epithelial Ablation of the Lower Esophagus after Nissen Fundoplication in a Porcine Model: Assessment of Tissue Damage and Healing Process
Authors: Tsai Peter I. , Bremner Ross M. , Mason Rodney J. , Nigro John J. , Chandrasoma Para , Peters Jeff H. , Bremner Cedric G. , Demeester Tom R.
Published: November 2022

A substantial population of patients with Barrett's esophagus has undergone antireflux surgery but still requires annual surveillance endoscopy. These patients would benefit from a definitive ablation of the Barrett's mucosa, which would remove the malignant potential of this disease. This study evaluates the efficacy of applying ultrasonic energy to remove the epithelium of the lower esophagus in a porcine model with prior Nissen fundoplication. Four Yakutan minipigs underwent laparoscopic Nissen fundoplication. After 2 weeks they underwent transgastric Cavitron ultrasonic surgical aspirator (CUSA; Valleylab, Boulder, CO) ablation of the lower esophageal epithelium. Healing of the mucosa was assessed by endoscopy at 2 weeks and pathological examination at 4 weeks after ablation. All pigs underwent successful laparoscopic Nissen fundoplication. Complete lower esophageal epithelial ablation was accomplished through the fundoplication in three animals. One pig developed a bezoar that prohibited ablation. At 2 weeks endoscopy showed patchy squamous epithelial regeneration, which was confirmed histologically. Esophageal specimens at 4 weeks showed complete regeneration of squamous epithelium with a partially healed small ulcer in one animal. No stricture formation was seen. We conclude that the CUSA technique can completely ablate Barrett's mucosa in the setting of a prior antireflux procedure. Healing with squamous mucosal regeneration is rapid and complete.
Surgical Diverticulitis: Treatment Options
Authors: Maggard Melinda A. , Chandler Charles F. , Schmit Paul J. , Bennion Robert S. , Hines O Joe , Thompson Jesse E.
Published: November 2022

Acute diverticulitis requiring surgical intervention has conventionally been treated by resection with colostomy or delayed resection with primary anastomosis at a second admission. Our objective was to determine the outcome for treatment of diverticulitis with resection and primary anastomosis during the same hospitalization. We conducted a retrospective review of patients (n = 74) undergoing surgery for diverticulitis. Groups included: 1) resection with primary anastomosis (n = 33), 2) resection with colostomy followed by a takedown colostomy (n = 32), and 3) delayed resection with primary anastomosis at a second admission (n = 9). Despite local perforation primary anastomosis was often performed unless patients were clinically unstable or had fecal contamination. The operation was urgent in five (15%) patients in Group 1 as compared with 26 patients (88%) in Group 2. Serious intra-abdominal complications occurred in two patients (6%) in Group 1 as compared with nine patients (28%) in Group 2 and one patient (11%) in Group 3. Postoperative abscesses occurred in two patients in Group 1, five patients in Group 2, and one patient in Group 3. We have shown that resection with primary anastomosis for acute diverticulitis—even in selected patients requiring urgent operation—can be safely performed during the same hospital admission with a low complication rate.
Reoperative Coronary Bypass Surgery Using Normothermic Cardiopulmonary Bypass: Comparison with First-Time Procedures
Authors: Ott Richard A. , Steedman Robert , Eugene John , Dajee Amrit , Ott Wendy , Tanner Teresa
Published: November 2022

Redo coronary artery bypass grafting (CABG) is characterized by increased patient risk compared with first-time CABG. The reason for higher risk is not completely understood but it is logically related to inadequate myocardial preservation evidenced by the higher incidence of postoperative low-output syndrome. We compared normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia in both first-time and redo CABGs to determine whether this single approach is appropriate for both instances. Five hundred seventeen consecutive CABG patients were retrospectively reviewed. Four hundred fifty-four first-time CABG procedures were compared with 44 redo procedures. All aspects of the operation were identical including myocardial preservation. Retrospective univariant analysis of both groups followed. Three clinical features distinguished first-time versus redo CABG. These were previous percutaneous transluminal coronary angioplasty (first-time 19% vs redo 71%; P < 0.001), preoperative intra-aortic balloon pump (first-time 38% vs redo 71%; P < 0.001), and Parsonnet risk score (first-time 11.7 ± 8.2 vs redo 19.2 ± 8.8; P < 0.001). Operative mortality for redo CABG was higher than in first-time procedures (3.4% vs 6.4%; P = not significant), although small sample size limited statistical significance. The length of stay was statistically longer in redo patients (8.7 ± 10.8 vs 6.0 ± 5.1 days; P < 0.01) and is related to a higher Parsonnet score, increased postoperative pneumonia, and failed percutaneous transluminal coronary angioplasty before redo CABG. We conclude that redo CABG is a different operation from first-time procedures and requires enhanced myocardial preservation. Normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia does not appear to achieve this goal.
Solid and Papillary Epithelial Neoplasms of the Pancreas: Aggressive Resection for Cure
Authors: Yoon Diana Y. , Hines Oscar J. , Bilchik Anton J. , Lewin Klaus , Cortina Galen , Reber Howard A.
Published: November 2022

Solid and papillary epithelial neoplasms of the pancreas (SPENP) are extremely rare and usually affect young women. We retrospectively reviewed our experience with pancreatic neoplasms from 1986 to the present and identified nine patients with SPENP. All nine patients were female with a mean age of 32 years (range 16–66). All patients presented with gastrointestinal complaints including pain, mass, dyspepsia, or bloating and were subsequently diagnosed with a tumor of the pancreas by CT scan. All patients underwent surgical resection. Two patients had tumors located in the head of the pancreas and underwent a pancreaticoduodenectomy. The remainder had tumors located in the tail of the pancreas and underwent distal pancreatectomy. Pathology demonstrated solid and papillary or solid and cystic pseudopapillary neoplasm of the pancreas. Three tumors were positive for both vimentin and α-1 antitrypsin on immunohistochemical studies, and three were positive for neuron-specific enolase. All nine patients underwent curative resection and are alive without any evidence of recurrence with a mean follow-up of 5.4 years. SPENP is considered to be a low-grade malignancy with an excellent prognosis. Prompt diagnosis and surgical resection can result in cure.
Use of Oncoscint Scan to Assess Resectability of Hepatic Metastases from Colorectal Cancer
Authors: Su Wendy T. , Brachman Michael , O'Connell Theodore X.
Published: November 2022

Patients with limited hepatic metastases from colorectal cancer can potentially be cured by resection. A number of patients deemed resectable by standard imaging procedures are found to have extrahepatic disease at laparotomy and are thus unresectable. A test capable of identifying these patients would assist in better patient selection. OncoScint (Cytogen Corp, Princeton, NJ) scan targets colorectal cancer by interacting with a tumor-associated glycoprotein. Can OncoScint scan be used to reliably identify patients with extrahepatic disease preoperatively? Between February 1996 and August 1998 eight patients with colorectal metastases to the liver were enrolled prospectively. All patients received preoperative OncoScint scan (indium-111) and underwent laparotomy. The laparotomy findings were correlated with the results of OncoScint scan. In four of eight patients (50%) OncoScint scan showed no extrahepatic disease. This was confirmed at laparotomy. All of these patients underwent hepatic resection. One of eight patients (12.5%) had OncoScint findings suggestive of extrahepatic disease pathologically confirmed during laparotomy. Three of eight patients (37.5%) had OncoScint findings of extrahepatic disease not confirmed by laparotomy. All three patients underwent hepatic resection. One of the three patients is still disease free for more than 48 months after hepatic resection. If OncoScint scan had been used to determine resectability this patient with false positive scan would have been denied a potentially curative operation. Because of the unacceptably high false positive rate the study was terminated after eight patients. Because of its high false positive rate (37.5%) OncoScint scan is not a reliable test for the assessment of extrahepatic disease. Other tests need to be developed to accurately stage extrahepatic disease with an acceptably low false positive rate to prevent exclusion of patients who can potentially be cured.
Radiofrequency Ablation of a Stereotactically Localized Nonpalpable Breast Carcinoma
Authors: Elliott Robert L. , Rice Pamela B. , Suits Joe A. , Ostrowe Alan J. , Head Jonathan F.
Published: November 2022

A nonpalpable breast lesion was detected in a 71-year-old woman who had returned for her annual mammogram. Stereotactic core needle biopsy revealed an infiltrating ductal carcinoma. The patient agreed to stereotactic localization and radiofrequency ablation of the lesion followed after 4 weeks by open surgical biopsy. The breast lesion was localized and the radiofrequency ablation performed under local anesthesia in the outpatient/office setting. The lesion was ablated for a total of 20 minutes at a sustained mean temperature of 75°C. After a 30-second cooldown the peripheral temperature of the four peripheral thermocouples ranged from 58°C to 70°C. A surgical clip was placed at the site of the ablated lesion. The postprocedure course was uneventful and the patient proceeded to open biopsy 4 weeks later. The open biopsy specimen, a left segmental mastectomy, underwent specimen radiography, which confirmed the surgical clip in the center of the lesion. There was extensive central necrosis and hemorrhage surrounded by fat necrosis. There was no definite viable residual tumor and the margins were clear. This is the first case in a clinical protocol designed to determine the efficacy of stereotactic localization and radiofrequency ablation of nonpalpable breast lesions. Additional ablations will be required to define the procedure but the results from this initial patient suggest that this is a promising minimally invasive curative approach for nonpalpable breast lesions.
Angiographic Selective Methylene Blue Staining of an Occult Small-Bowel Arteriovenous Malformation
Authors: Schechter Steven , Deorchis Douglas , Bass James , Marcoux David A.
Published: November 2022

This case report details a technique to intraoperatively define a segment of small bowel containing a bleeding arteriovenous malformation allowing definitive surgery. A patient with an arteriovenous malformation of the small intestine underwent angiographic localization using a highly selective microcatheter and intraoperative methylene blue dye allowing a specific segment of intestine to be resected. Angiographic identification and intraoperative location of small intestine arteriovenous malformations can allow the surgeon to more accurately define the affected segment allowing the surgery to be specific and successful.
The Benefit of Using Two Techniques for Sentinel Lymph Node Mapping in Breast Cancer
Authors: Sardi Armando , Spiegler Ethan , Colandrea Jean , Frishberg David , Singh Hardeep , Regan Patricia , Totoonchie Adil , Merchant Deepak , Hochuli Stephen , Setya Viney , Singer John A.
Published: November 2022

Sentinel lymph node (SLN) mapping has revolutionized the way we stage breast cancer. A blue dye technique (BD) and the use of a radiotracer with the assistance of a gamma-detecting probe (GDP) have been used for the identification of the sentinel nodes. Some groups have suggested that only one technique is necessary. The reported false negative rates have been 0 to 12 per cent and success rates as low as 65 per cent. We have prospectively evaluated these techniques and have used both for the identification of the SLN. Ten surgeons participated in this study. From April 1998 through May 1999, 58 patients underwent SLN mapping followed by an axillary lymph node dissection. After the injection of 0.3 to 1.96 mCi of filtered sulfur colloid diluted to 4 mL all patients had preoperative lymphoscintigraphy. Five minutes before surgery 3 to 5 mL of isosulfan blue was injected around the tumor or tumor bed. Even though preoperative lymphoscintigraphy identified an SLN in 35 patients (63%) successful intraoperative detection of an SLN was possible using both techniques in 53 patients (91%). The SLN was detected by the BD and the GDP in 37 (65%) and 45 (80%) respectively. Nineteen patients (33%) were positive for metastatic disease in the axilla. Twenty-two (19%) of 113 SLNs removed were positive for disease. All cases of metastatic disease in the axilla were detected by the mapping technique. False negative rate was 0 per cent. In 11 patients the only positive node was the sentinel node (58%). Furthermore six (32%) patients were upstaged by the use of immunostains for cytokeratin. Twenty-two positive SLNs were detected in the 19 patients. The positive lymph node was identified only by BD in four patients (21%), only by GDP in six patients (31%), and by both techniques in nine patients (47%). We conclude that if only one technique had been used the false negative rate could have been as high as 32 per cent. Both techniques must be used to obtain a low false negative rate and high yield in the identification of the SLN.
Infection in Penetrating Abdominal Trauma: Risk Factors and Preventive Antibiotics
Authors: Fabian Timothy C.
Published: November 2022

Infection remains the greatest risk for victims of penetrating abdominal injury with major infections occurring in 10 to 15 per cent. Attributable mortality is approximately 30 per cent of those who develop major abdominal infections. In addition to this morbidity infection adds approximately $43,000.00 of hospital charges per infected patients. This article addresses two significant areas: risk factors and antibiotic utilization. The most important risk factor is the presence of hollow viscus injury; colonic wounding carries the highest incidence of infection relative to intra-abdominal organs injured. Pancreatic and liver injuries significantly increase infection risk when combined with hollow viscus wounds. The degree of injury as measured by the volume of hemorrhage and the presence of shock as well as the anatomic degree of injury likewise correlates with the incidence of septic morbidity. Antibiotic utilization is addressed by the three issues of antibiotic agents of choice, duration of administration, and optimal dosing. Regimens of choice should include anaerobic coverage. Twenty-four hours of antibiotic administration is satisfactory with currently available agents. Evidence-based medicine analyses from the Eastern Association for the Surgery of Trauma have addressed those two issues. There are few data on optimal dosing. Increased volumes of distribution and rates of excretion have been demonstrated in trauma patients. This would suggest that higher-than-normal doses should be used. Laboratory studies would support such an approach. However, significant clinical research is desirable to address issues of concentration-dependent bacterial killing and time-dependent killing. Those pharmo-dynamic considerations are variable among antibiotic classes.
Giant Retroperitoneal Sarcoma: A Case Report and Review of the Management of Retroperitoneal Sarcomas
Authors: Bradley John C. , Caplan Richard
Published: November 2022

A 42-year-old man presented with lower abdominal pain and a vague abdominal mass. He underwent resection of a well-differentiated liposarcoma arising from his retroperitoneum measuring 50 cm and weighing 11.7 kg (25.8 lb). This is the second largest retroperitoneal soft-tissue sarcoma (RSTS) that has been reported. Over the last 15 years 1123 patients with RSTS in 25 series have been reported with a mean tumor size of 15.7 cm. RSTS represents 0.10 to 0.15 per cent of all malignancies but 45 per cent of all retroperitoneal tumors. Diagnosis and treatment of RSTS can be extremely challenging for a general surgeon. Symptoms are nonspecific and may occur only after the tumor is very large. Abdominal discomfort is the presenting complaint in 60 to 70 per cent of patients and palpable mass in 70 to 80 per cent. Treatment of RSTS remains surgical. Multiple trials of chemotherapy and radiation therapy show no survival benefit. The only successful treatment of this tumor is complete excision; 51.4 per cent of tumors can be completely excised, and 50.2 per cent of these excisions include adjacent organs. Long-term prognosis without complete excision is grim with average 5- and 10-year survival rates of 16.7 and 8.0 per cent. With aggressive surgical therapy survival is increased to 58.0 and 39.6 per cent.
Ultrasound is Not a Useful Screening Tool for Acute Acalculous Cholecystitis in Critically Ill Trauma Patients
Authors: Puc Matthew M. , Tran Hoang S. , Wry Philip W. , Ross Steven E.
Published: November 2022

Acute acalculous cholecystitis remains a diagnostic challenge in critically ill trauma patients. Laboratory studies are nonspecific and associated injuries or mental status changes may mask clinical signs and symptoms. We conducted a retrospective study to assess the utility of ultrasound in the diagnosis of acute acalculous cholecystitis. We hypothesized that ultrasound is inadequate as a screening tool for acute acalculous cholecystitis. The abdominal ultrasounds of all patients undergoing evaluation for acute acalculous cholecystitis in a 40-month period at our Level I trauma center were reviewed. Thickened gallbladder wall, pericholecystic fluid and emphysematous gallbladder were considered positive sonographic criteria. Sludge, cholelithiasis, and hydrops were considered suggestive. Patients who did not undergo cholecystectomy had their gallbladders evaluated either during subsequent laparotomy or at autopsy or they were discharged from the hospital without need for intervention. Sixty-two patients were included. Twenty-one patients underwent cholecystectomy for presumed acute acalculous cholecystitis. The data revealed a sensitivity of 30 per cent (6/20) and a specificity of 93 per cent (39/42) for ultrasound evaluation. Twenty patients had subsequent hepatobiliary scans [hepato-iminodiacetic acid (HIDA)] with a sensitivity of 100 per cent (12/12) and specificity of 88 per cent (7/8). Our data do not support ultrasound as a reliable routine screening tool for acute acalculous cholecystitis. Despite its convenience as a bedside procedure ultrasound has insufficient sensitivity to justify its use and a more sensitive diagnostic tool should be used.
Routine Chest Radiograph is not Indicated after Open Tracheostomy: A Multicenter Perspective
Authors: Tyroch Alan H. , Kaups Krista , Lorenzo Manuel , Schreiber Martin , Solis Diego
Published: November 2022

Obtaining a chest radiograph (CXR) after open tracheostomy has been standard practice for many surgeons. We hypothesized that routine CXR after uncomplicated open tracheostomy is unnecessary. A prospective multicenter protocol was carried out on adult surgical patients undergoing uncomplicated tracheostomy. CXR was not routinely ordered in the immediate postoperative period but was obtained only for clinical indications. Preoperative and subsequent postoperative CXRs were reviewed for evidence of complications. Twenty-two surgeons at four institutions performed 151 tracheostomies. Posttracheostomy CXR was not diagnostic in four patients with potential tracheostomy-related complications (i.e., tachypnea, tachycardia, desaturation, and elevated peak airway pressure). In the 147 patients without clinical indications for CXR subsequent CXR revealed no significant new findings. In this era of cost containment the need for CXR after tracheostomy must be questioned. Routine CXR is not indicated or cost effective after uncomplicated open tracheostomy in adults.
Laparoscopically Assisted Hemicolectomy for Crohn's Disease: Are we Still Getting Better?
Authors: Hamel Christian T. , Pikarsky Alon J. , Wexner Steven D.
Published: November 2022

The most common indications for laparoscopic surgery in Crohn's disease include ileocolic resection and right hemicolectomy. The aim of this study was to compare the results of right hemicolectomy in an early phase versus a later phase. Between August 1992 and October 1998 all patients who underwent laparoscopic surgery for ileocolic resection and right hemicolectomy were divided into chronological groups: Group I = August 1992 to January 1996 and Group II = February 1996 to October 1998. Statistical analysis was performed using the Mann-Whitney test, Student t test, or Fisher's exact test. We identified 41 patients; 16 patients [eight females and eight males with an average age of 37.1 (range 20–59) years] were in Group I and 25 [16 females and nine males with an average age of 41.9 (range 15–74) years] were in Group II [ P = not significant (NS)]. Overall there were five (12%) intraoperative complications reported: two (12%) in Group I and three (12%) in Group II ( P = NS). Mean operative time was 149 (range 90–260) minutes in Group I versus 158 (range 100–285) minutes in Group II ( P = NS). Mean length of hospital stay was 7.4 (range 4–18) days in Group I and 6.6 (range 3–20) days in Group II ( P = NS). Four patients (25%) in Group I and seven (28%) in Group II had their procedures converted to laparotomy ( P = NS). In Group I four (25%) patients had surgery-related postoperative complications, one of which was wound related. One patient has an anastomotic leak whereas two had prolonged postoperative ileus. In Group II six (24%) patients had surgery-related complications, two of which were wound related, three were cases of prolonged postoperative ileus, and one was an anastomotic leak ( P = NS between Groups I and II). Perhaps as a result of the relative technical ease of right-sided resections or the nature of the disease the expected decrease in morbidity and conversion rate over time could not be shown.
Daedalus Revisited: A Call for Redesign of the Bougie Esophageal Dilator
Authors: Sumanis Jacqueline , Kennedy Colleen , Biddle Chuck , Fallacaro Michael D.
Published: November 2022

We report a case of a patient undergoing gastric bypass in which an improperly introduced bougie dilator resulted in esophageal perforation and we examine the matter using a human-factors approach. The Institute of Medicine's widely distributed 1999 report estimated that up to 98,000 Americans die each year as a result of preventable errors with the operating room being a particularly error-prone environment. The report suggests that the majority of errors are not the result of poor provider performance but instead are the result of inherent systems-based problems. Perforation can be associated with significant negative outcome; modifying factors include experience, appreciating anatomical details, and cognizance of mechanisms of perforation. Human-factors research reveals that 1) humans are prone to err and 2) the majority of errors are not the result of personal inadequacy but instead are the product of defects in the design of health care environmental systems in which that work occurs. Here during a highly complex surgical procedure a simple preventable human error occurred, one often associated with significant negative outcome. We suggest a simple solution in line with a human-factors approach that might prevent future occurrences.
Obesity: Is there an Increase in Perioperative Complications in those Undergoing Elective Colon and Rectal Resection for Carcinoma?
Authors: Blee Thomas H. , Belzer G. Eric , Lambert Pamela J.
Published: November 2022

The hypothesis of this study was that obese and overweight patients undergoing elective resection for colon and rectal cancer have longer operative times, increased intraoperative blood loss, and more postoperative complications compared with normal-weight individuals. Our study cohorts included all patients undergoing elective first-time colon resection for proven colorectal carcinoma. Patients undergoing resection for recurrent disease or for emergent indications such as obstruction, perforation, or hemorrhage and those who underwent an additional surgical procedure at the time of colon resection were excluded from analysis. We conducted a retrospective chart review of all patients undergoing resection for colorectal carcinoma during a 30-month period. One hundred fifty-three consecutive patients were identified. Body Mass Index was calculated for each patient. Each patient was labeled as normal, overweight, or obese on the basis of World Health Organization criteria. Estimated intraoperative blood loss, duration of surgery, and postoperative complications were recorded for each patient. Comparisons of continuous variables were made using one- or two-way analysis of variance testing. Comparisons of discrete variables were made with chi-square testing. Level of confidence was defined as P < 0.05. Forty-eight normal, 54 overweight, and 51 obese patients were identified. The type of colon resection, age range, and premorbid conditions were well matched between groups. There was no statistical difference in intraoperative blood loss between groups. The operative times were statistically longer in obese and overweight groups compared with the normal group. No statistical differences existed in postoperative complications between groups. We conclude that obese and overweight patients undergoing resection for colorectal carcinoma when compared with normal-weight patients have similar intraoperative blood loss and postoperative complications but longer operative times.
Spontaneous Infarction of a Parathyroid Adenoma: Two Case Reports and Review of the Literature
Authors: Lucas David G. , Lockett Mark A. , Cole David J.
Published: November 2022

The spontaneous infarction of a parathyroid adenoma is an uncommon event, although it has been previously described. Patients may present symptomatically or experience resolution of their hyperparathyroidism. As such the appropriate clinical management of these patients remains unclear. We present two cases of spontaneous infarction of parathyroid adenomas. The first presented with neck pain and dysphagia and experienced at least temporary resolution of her hyperparathyroidism. The second patient experienced a fall in his parathyroid hormone and calcium levels before neck exploration. Inf arcted parathyroid adenoma was diagnosed on pathologic evaluation of the surgical specimen. Inflammation surrounding the infarcted adenoma provided for a technically difficult operation. Although resolution of hyperparathyroidism has been described postinfarction, a regeneration of the parathyroid adenoma may occur. Therefore neck exploration and parathyroidectomy should still be considered. We propose a period of observation after diagnosis of spontaneous parathyroid adenoma infarction to avoid these acute inflammatory changes that have been described.
Percutaneous Removal of Spilled Gallstones in a Subhepatic Abscess
Authors: Albrecht Roxie M. , Eghtestad Bijan , Gibel Lawrence , Locken Julie , Champlin Anna
Published: November 2022

Abscess formation from spilled gallstones after laparoscopic cholecystectomy is infrequent. However, if an abscess does form and contains the spilled stones simple percutaneous drainage will not resolve the dilemma of a recurrent abscess. Open drainage has previously been recommended to remove the retained stones and decrease recurrent abscess formation. We report two cases in which the retained stones within an abscess were successfully removed using a percutaneous minimally invasive urological technique.
Complications from Radio frequency Ablation of Liver Metastases
Authors: Zagoria Ronald J. , Michael Y.M. , Shen Perry , Levine Edward A.
Published: November 2022

The objective of this study is to evaluate complications from radiofrequency ablation of liver metastases. Eighty-one liver tumors in 38 consecutive patients were treated with radiofrequency ablation. All patients had one to six metastases treated in a single session. Eight patients underwent radiofrequency ablation intraoperatively after laparotomy and the remaining 30 patients were treated percutaneously with CT or ultrasound guidance. A total of 43 radiofrequency ablation procedures were studied. There was one (2%) mortality related to a hepatic abscess development 8 days after the procedure. One patient (3%) required a blood transfusion. Three patients (8%) developed severe upper abdominal or pleuritic chest pain that persisted several days after the procedure. We conclude that radiofrequency ablation of liver metastases is associated with a low rate of serious complications (two of 38; 5%). Complications requiring treatment usually develop several days after the procedure.
Gynecomastia: Complications of the Subcutaneous Mastectomy
Authors: Steele Cpt Scott R. , Martin Maj Matthew J. , Place Ltc Ronald J.
Published: November 2022

Gynecomastia is a benign enlargement of the male breast secondary to gland proliferation. Subcutaneous mastectomy is performed for symptomatic patients and in those desiring cosmetic changes. The aim of this study was to assess the risk factors and complications associated with the operation. We retrospectively examined the records of all patients undergoing a subcutaneous mastectomy for gynecomastia. Ninety-one patients were identified. We conducted telephone interviews with 52 patients and performed 65 subcutaneous mastectomies on those 52 patients. Thirty of the 65 procedures (46%) developed complications. These included sensory changes, pain, seromas, scarring, breast asymmetry, hematomas, and wound infection. No preoperative risk factors were significant for postoperative complications. Eighteen of 22 cases with drains placed intraoperatively developed complications as compared with 12 of 43 cases without drains ( P = 2.6 x 10–7). Specimens removed from the patients who had drains placed were significantly larger than those from patients who did not have drains placed ( P = 1.5 x 10–5). However, specimen size was not an independent risk factor for development of a complication ( P = 0.14). We found a relatively high complication rate in subcutaneous mastectomy for gynecomastia. Most complications are minor with no long-term effect. Drain placement was the only risk factor associated with postoperative complications.
Factors Affecting the Outcome of Patients with Splenic Trauma
Authors: Carlin Arthur M. , Tyburski James G. , Wilson Robert F. , Steffes Christopher
Published: November 2022

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17½-year period (1980–1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements ≤6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.
Burns with Multiple Trauma
Authors: Brandt Christopher P. , Yowler Charles J. , Fratianne Richard B.
Published: November 2022

The purpose of this study was to determine the incidence, mechanisms, and outcomes of management in patients with multisystem trauma and associated burn injury. A retrospective review was performed of patients admitted with combined burns and trauma from 1990 through 1999. Mechanism of injury, extent of burns, associated injuries, Injury Severity Score (ISS), and patient outcomes were identified. There were 2,845 burn and 19,418 trauma admissions. Fifty-six patients (2.0% and 0.29% respectively) had combined burns and trauma. Mean ISS was 21.7 and average percentage total body surface area was 16.2. Associated injuries included fractures in 32, complex soft-tissue injury in 20, head injury in 11, and abdominal trauma in seven. Mechanism of injury was industrial in 19, motor vehicle accident in 16, house fire in 13, high voltage in six, and other in three. Skin grafting was required in 33 of 56 patients (59%). Six of 56 patients died. Mean ISS was 19.0 in survivors compared with 46.2 in nonsurvivors. The combination of burns with multiple system trauma is uncommon. Fractures are the most frequent associated injury, and the majority of patients will require skin grafting in their burn treatment. Outcomes with appropriate management are favorable and are primarily dependent on the degree of associated trauma.
The Clinical Presentation and Operative Management of Nodular and Diffuse Substernal Thyroid Disease
Authors: Hedayati Nasim , McHenry Christopher R.
Published: November 2022

Patients with substernal thyroid disease, defined by the presence of enlarged thyroid tissue below the plane of the thoracic inlet, were identified from a prospective database maintained for patients who have undergone thyroidectomy at our institution since 1990. Substernal thyroid disease was present in 116 (30%) of 381 patients, anterior mediastinal in 109 (94%), and posterior mediastinal in seven (6%). Indications for surgery included compressive symptoms in 75 (65%) patients, an abnormal fine-needle biopsy in 45 (39%), progressive thyroid enlargement in 41 (35%), thyrotoxicosis in 11 (10%), and superior vena cava syndrome in two (1.7%). A median sternotomy and thoracotomy were performed in one patient each for a primary intrathoracic goiter. In all other patients thyroidectomy was accomplished through a cervical incision. Parathyroid autotransplantation was performed in 41 (37%) patients with retrosternal disease compared with 57 (22%) with disease confined to the neck ( P < 0.01). Twenty-five patients (22%) had malignancy; four of these had unresectable disease. Postoperative complications included transient hypocalcemia (n = 46), transient hoarseness (n = 7), recurrent laryngeal nerve injury (n = 1), and wound infection (n = 1). One patient died from aspiration pneumonia. In summary, substernal thyroid disease is typically present in the anterior mediastinum and with rare exceptions can be resected through a cervical incision. Parathyroid devascularization is more common with resection of a substernal goiter and autotransplantation can prevent permanent hypoparathyroidism.
Primary Hyperaldosteronism in the Era of Laparoscopic Adrenalectomy
Authors: Rossi Heather , Kim Anthony , Prinz Richard A.
Published: November 2022

Laparoscopic adrenalectomy has been recommended as the standard method for removing an aldosteronoma. To assess our surgical experience with primary hyperaldosteronism in the era of laparoscopic adrenalectomy a 6-year retrospective review of 30 consecutive patients was done. The 20 men and 10 women ranged in age from 35 to 78 with a mean of 51.2 years. All patients were hypertensive and hypokalemic with a mean serum potassium of 2.9 ± 0.32 (standard deviation) mmol/L. Serum aldosterone was elevated in 28 of 30 (94%) patients and normal in the remaining two. Serum renin was suppressed in all patients. CT correctly localized the tumor in all 30 patients. Twenty-eight patients had histologically documented adenomas and two had associated cortical hyperplasia on pathology. Mean adenoma size was 2.0 ± 1.12 cm. Twenty-four patients underwent left laparoscopic adrenalectomies, whereas right laparoscopic adrenalectomies were performed in five. One was converted to an open left adrenalectomy. Mean operative time was 183 minutes. The mean hospital stay for laparoscopic adrenalectomy was 2.2 days.

The patients were followed from one to 63 months (mean 26.1 months). Twenty-nine of 30 (95%) patients were rendered normokalemic. The remaining patient takes a potassium-wasting diuretic. Persistent hypertension was present in 10 of 30 (33%) patients. Blood pressure in nine of 10 patients was controlled with less medical therapy. The other patient's blood pressure remained difficult to control despite multiple medications. Duration of hypertension before surgery was a significant risk factor for persistent hypertension ( P < 0.05). Gender ( P < 0.05) and age ( P < 0.05) at the time of surgery were not statistically significant predicators for persistent hypertension. There were two reported trocar site hernias. We conclude that primary hyperaldosteronism due to aldosterone-producing tumors can be diagnosed and accurately localized with preoperative measurements of serum aldosterone, renin, and CT scanning. Laparoscopic adrenalectomy is safe and effective for the treatment of primary hyperaldosteronism with minimal associated morbidity and a short hospital stay. Hypokalemia may be cured by surgical treatment, although persistent hypertension still occurs. Duration of hypertension before surgery is a risk factor for persistent hypertension whereas age and sex are not.
Prognostic Factors Associated with Resectable Carcinoma of the Esophagus
Authors: Christein John D. , Hollinger Edward F. , Millikan Keith W.
Published: November 2022

A retrospective review of esophagectomy for esophageal carcinoma between 1982 and 1999 was performed. Two hundred twenty-two patients (mean age 61.7 years) underwent esophagectomy: 128 transhiatal, 74 Ivor Lewis, and 20 abdominal. Most tumors were adenocarcinoma (65%); the majority were in the lower third or cardia (78%). Excluding operative mortality the one-, 3–, and 5-year survival rates were 67, 39, and 31 per cent (median survival, 16.3 months) respectively. The hospital mortality rate was 6.8 per cent. Through univariate analysis race other than white, history of weight loss, poor or moderate differentiation ( P = 0.05), full-thickness invasion ( P = 0.02), positive lymph nodes ( P < 0.01), Ivor Lewis esophagectomy ( P = 0.02), intraoperative blood transfusion ( P = 0. 01), and tumor location in the upper or middle third in node-positive patients ( P = 0.02) were associated with a poorer survival. Adjuvant therapy improved survival for patients with positive lymph nodes ( P < 0.01). In multivariate analysis positive lymph nodes, tumor location, intraoperative blood transfusion, and adjuvant therapy were independent predictors of survival. To optimize survival esophagectomy for esophageal carcinoma should be performed without blood transfusion, and node-positive patients should receive multimodal therapy.
Outcome Analysis of Pancreaticoduodenectomy at a Community Hospital
Authors: Afsari Alan , Zhandoug Zhou , Young Shun , Ferguson Lorenzo , Silapaswan Sumet , Mittal Vijay
Published: November 2022

There is an ongoing debate about the proposed regionalization of pancreaticoduodenectomies. The purpose of our study is to demonstrate that good outcomes can be achieved in a well-managed low-volume community hospital. We retrospectively analyzed pathologic findings, morbidity, mortality, and one-year survival in 32 patients who underwent pancreaticoduodenectomy at Providence Hospital over a 10-year period and compared these results with data collected at Johns Hopkins, and the Mayo Clinic. The patients had a mean age of 68.5 ± 2.96 years; 56.3 per cent were female and 71.9 per cent were white. Overall in our series 90.6 per cent of specimens were found to be malignant, which is statistically higher than the 68 per cent at Johns Hopkins ( P = 0.013) and not significantly different from Mayo Clinic (76%). The 30-day mortality rate at Providence Hospital was 3.1 per cent, which is not statistically different from Johns Hopkins (1.3%) and Mayo Clinic (3.6%). One-year survival rate at Providence Hospital was 59.4 per cent, which is significantly different from 79 per cent at Johns Hopkins ( P = 0.016). The one-year survival rate at Providence Hospital is higher than an approximately 50 per cent average reported nationally. The postoperative complication rate was 62.5 per cent; the most common complication was delayed early gastric emptying (28.1%). A statistical difference in morbidity exists between Providence Hospital and Johns Hopkins ( P = 0.027) but not between Providence Hospital and Mayo Clinic (46%). The higher rate of malignant disease treated in the population at Providence Hospital may contribute to a higher complication rate and lower one-year survival rate than the reported rates at Johns Hopkins because of the poorer health of cancer patients. However, statistical analysis of mortality rates for pancreaticoduodenectomy at Providence Hospital show no difference from mortality rates at Johns Hopkins and Mayo Clinic. Therefore in low-volume community hospitals pancreaticoduodenectomy can be performed safely as evidenced by a comparable low mortality rate and a high one-year survival rate.
Fast Track Video-Assisted Thoracic Surgery
Authors: Preventza Ourania , Hui Han Ze , Hramiec John
Published: November 2022

Video-assisted thoracic surgery (VATS) has been advocated as one of the primary diagnostic modalities for suspicious pulmonary nodules and diffuse interstitial lung disease. The aim of our study was to evaluate the cost and safety of VATS lung wedge resection(s) as an “overnight” hospital admission. We retrospectively reviewed all 37 charts of patients who underwent VATS wedge resections for these indications from August 1999 to April 2001. There was a slight female predominance with mean age of 56.8 years (range 33–88). Eighteen patients had interstitial disease and 19 patients had pulmonary nodules. The duration of chest tube drainage was one day in the majority (92%). Length of hospital admission was overnight in 70 per cent whereas 22 per cent remained two days. This latter group from the earlier period of the trial had characteristics identical to those of an overnight stay. This creates a potential overnight stay in 87 per cent. Five complications occurred in three patients, which extended the length of stay. No mortality was reported. The overall hospital charges for the overnight-stay VATS were nearly half the charges for the open thoracotomy counterpart. Diagnostic VATS wedge biopsy is a cost effective and safe procedure allowing an overnight hospital stay in the majority of cases.
Emergency Thoracotomy: Appropriate Use in the Resuscitation of Trauma Patients
Authors: Grove Christopher A. , Lemmon Gary , Anderson Gary , Mccarthy Mary
Published: November 2022

The objective of this study was to evaluate the use of emergency thoracotomy in our institution in an effort to determine whether this procedure is both beneficial and cost effective in blunt and/or penetrating trauma. We conducted a retrospective review of charts and coroner's reports. Our setting was a Level I trauma center in a tertiary-care facility. We examined the cases of trauma patients presenting to the trauma center over a 2-year period. Of 2490 patients who presented to the emergency department over the study period 41 underwent early thoracotomy. Twelve of these were excluded from the study because their cases were not truly emergent. Of the remaining 29 ten were admitted for penetrating injuries and 19 for blunt injuries. The average Injury Severity Scores for penetrating and blunt injuries were 30 and 40 respectively. There were four blunt trauma patients who died in the emergency department, 15 went to the operating room, and five who survived to go to the intensive care unit. All blunt trauma patients requiring emergency thoracotomy died within 9 days of presentation. Of the ten penetrating wound patients two died in the emergency department, four died in the operating room, and four went to the intensive care unit after surgery. One of the four patients who went to the intensive care unit died approximately 6 days after injury. The other three patients survived and are now living normal productive lives. All survivors of penetrating trauma who required emergency thoracotomy had their procedure performed in the operating room. Overall survival rates for penetrating and blunt trauma were 30 and 0 per cent respectively. Pericardial tamponade was found in 50 per cent of the penetrating trauma patients (two of the three survivors) and four of 19 of the blunt trauma patients. This reinforces the importance of a prompt pericardiotomy upon opening the chest. At our institution the algorithm for emergency thoracotomy is liberal and is not cost effective for blunt trauma. We need to re-evaluate our decision-making process concerning the use of emergency thoracotomy especially in the blunt trauma patient. The review also shows the importance of pericardiotomy when performing an emergency thoracotomy.
Urban Trauma Centers: Not Quite Dead Yet
Authors: Patton Joe H. , Woodward Ann M.
Published: November 2022

With decreasing violent crime and an increase in the use of nonoperative management techniques the viability of urban trauma centers has come into question. In addition the workload and productivity for surgeons at such centers may be threatened. The current study examines the changing characteristics of patients admitted to an urban Level I trauma center over a 5-year period and examines factors that may affect trauma surgeon utilization. We reviewed all trauma registry admissions from January 1995 through December 1999. Data were collected regarding patient demographics, mechanism of injury, diagnostic workup, injury character and severity, operative procedures, intensive care unit (ICU) length of stay (LOS), hospital LOS, and patient disposition. Admissions declined 23 per cent over the 5-year period. Fewer patients were admitted to general practice units whereas more patients required ICU admission. Over the study period both mean patient age and mean Injury Severity Score increased significantly. Gunshot wound admissions declined by 45 per cent, but the percentage of those admitted who required operation rose 17 per cent. Number of operations for trauma performed by general surgeons was unchanged over time. Hospital LOS declined over time, and ICU LOS was unchanged. Although trauma center admissions—particularly those due to violent crime—are on the decline the operative productivity of trauma surgeons has remained unchanged. Patients admitted to the hospital are older and more severely injured; they undeniably require a higher level of care and service coordination. Urban trauma centers remain viable and are in fact more efficient in caring for sicker patients.