bluuebunny/crossref_metadata_2025 huggingface dataset:
Lymph Node Size Alone is Not an Accurate Predictor of Metastases in Rectal Cancer: A Node-for-Node Comparative Study of Specimens and Histology
Authors: Kono Yoshihiko , Togashi Kazutomo , Utano Kenichi , Horie Hisanaga , Miyakura Yasuyuki , Fukushima Noriyoshi , Lefor Alan T. , Yasuda Yoshikazu
Published: June 2020

Although size criteria have been proposed to identify lymph node metastases in patients with rectal cancer, size may not be an accurate predictor. Specimens from consecutive rectal cancer patients who underwent curative-intent radical surgery were examined. The long and short axes of lymph nodes were measured on the glass slides using micrometer calipers. The pathologic diagnosis was used as the reference. The diagnostic accuracy of metastatic status according to lymph node size was evaluated. Overall, 1283 lymph nodes from 78 patients were reviewed. The metastatic rate correlates with the length of both the long and short axes. However, metastases were present even in 1-mm lymph nodes, and the metastatic rate exceeds 5 per cent in lymph nodes measuring 3 mm along both axes. Cutoff values of ≥4 mm and ≥3 mm for the long and short axes result in a sensitivity of 76 per cent and 79 per cent, and a specificity of 36 per cent and 33 per cent, respectively, for each axis. Size criteria alone do not accurately predict the N-stage of rectal cancer. Diminutive lymph nodes, which are not seen on imaging studies, can contain metastatic disease.
Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury
Authors: Lee Yann-Leei L. , Simmons Jon D. , Gillespie Mark N. , Alvarez Diego F. , Gonzalez Richard P. , Brevard Sidney B. , Frotan Mohammad A. , Schneider Andrew M. , Richards William O.
Published: June 2020

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.
An Innovative Approach for Decreasing Fall Trauma Admissions from Geriatric Living Facilities: Preliminary Investigation
Authors: Evans Tracy , Gross Brian , Rittenhouse Katelyn , Harnish Carissa , Vellucci Ashley , Bupp Katherine , Horst Michael , Miller Jo Ann , Baier Ron , Chandler Roxanne , Rogers Frederick B.
Published: June 2020

Geriatric living facilities have been associated with a high rate of falls. We sought to develop an innovative intervention approach targeting geriatric living facilities that would reduce geriatric fall admissions to our Level II trauma center. In 2011, a Trauma Prevention Taskforce visited 5 of 28 local geriatric living facilities to present a fall prevention protocol composed of three sections: fall education, risk factor identification, and fall prevention strategies. To determine the impact of the intervention, the trauma registry was queried for all geriatric fall admissions attributed to patients living at local geriatric living facilities. The fall admission rate (total fall admissions/total beds) of the pre-intervention period (2010–2011) was compared with that of the postintervention period (2012–2013) at the 5 intervention and 23 control facilities. A P value < 0.05 was considered statistically significant. From 2010 to 2013, there were 487 fall admissions attributed to local geriatric living facilities (intervention: 179 fall admissions; control: 308 fall admissions). The unadjusted fall rate decreased at intervention facilities from 8.9 fall admissions/bed pre-intervention to 8.1 fall admissions/bed postintervention, whereas fall admission rates increased at control sites from 5.9 to 7.7 fall admissions/bed during the same period [control/intervention odds ratio (OR), 95% confidence interval (CI) = 1.32, 1.05–1.67; period OR, 95%CI = 1.55,1.18–2.04, P = 0.002; interaction of control/intervention group and period OR 95% CI = 0.68, 0.46–1.00, P = 0.047]. An aggressive intervention program targeting high-risk geriatric living facilities resulted in a statistically significant decrease in geriatric fall admissions to our Level II trauma center.
Using a Checklist to Improve Family Communication in Trauma Care
Authors: Dennis Bradley M. , Nolan Tracy L. , Brown Cecil E. , Vogel Robert L. , Flowers Kristin A. , Ashley Dennis W. , Nakayama Don K.
Published: June 2020

Modern concepts of patient-centered care emphasize effective communication with patients and families, an essential requirement in acute trauma settings. We hypothesized that using a checklist to guide the initial family conversation would improve the family's perception of the interaction. Institutional Review Board–approved, prospective pre/post study involving families of trauma patients admitted to our Level I trauma center for >24 hours. In the control group, families received information according to existing practices. In the study group, residents gave patient information to a first-degree family member using a checklist that guided the interaction. The checklist included a physician introduction, patient condition, list of known injuries, admission unit or intensive care unit, any consultants involved, plans for additional studies or operations, and opportunity for family to ask questions. An 11-item survey was administered 24 to 48 hours after admission to each group that evaluated the trauma team's communication in the areas of physician introduction, patient condition, ongoing treatment, and family perception of the interaction. Responses were on a Likert scale and analyzed using the Wilcoxon-Mann-Whitney test. There were 130 patients in each group. The study group had significantly ( P < 0.05) better responses in 8 of 11 items surveyed: physician spoke to family, physician introduction, understanding of their relative's injuries, admitting unit, consultants involved, urgent surgical procedures required, ongoing diagnostic studies, and understanding of the treatment plan. In conclusion, using a checklist improves the perception of the initial communication between the trauma team and family members of trauma patients, especially their understanding of the treatment plan.
Thromboelastography Does Not Detect Preinjury Antiplatelet Therapy in Acute Trauma Patients
Authors: Daley Mitchell J. , Trust Marc D. , Peterson Evan J. , Luftman Kevin , Miller Andrew H. , Ali Sadia , Clark Adam , Aydelotte Jayson D. , Coopwood Thomas B. , Brown Carlos V.R.
Published: June 2020

Thromboelastography (TEG) with platelet mapping has been proposed as an assay to detect the presence of antiplatelet agents (APA), yet no study has evaluated TEG markers of platelet dysfunction in acute trauma patients stratified by the use of preinjury APA. We hypothesized that patients on preinjury APA would demonstrate prolonged TEG markers of platelet dysfunction compared with those not on preinjury APA. This retrospective review evaluated all trauma patients admitted to a Level I trauma center from February 2011 to April 2013 who received a TEG within the first 24 hours of admission. Patients were classified as receiving preinjury APA or no APA if their documented medications included either aspirin or adenosine diphosphate (ADP) antagonists, including clopidogrel, prasugrel, and ticagrelor. A total of 129 patients were included (APA, n = 35; no APA n = 94) in the study. The time from admission to the first TEG was similar (APA 175 ± 289 minutes versus no APA 216 ± 321 minutes, P = 0.5). There was no significant difference in TEG markers of platelet dysfunction, including per cent ADP inhibition (APA 61.7 ± 25.8% versus no APA 62.3 ± 28.8%; P = 0.91) or per cent arachidonic acid inhibition (APA 58.2 ± 31% versus no APA 53.8 ± 34%; P = 0.54). Both groups had similar proportion of severe platelet dysfunction, defined as ADP inhibition greater than 70 per cent (APA 40% versus no APA 40%; P = 0.8) and arachidonic acid inhibition greater than 70 per cent (APA 40% versus no APA 39%; P = 0.89). In conclusion, platelet dysfunction after major trauma is common. Therefore, TEG alone should not be used to evaluate for the presence of APA due to apparent lack of specificity.
Results of Carotid Endarterectomy Using Bovine Pericardium Patch Closure, with a Review of Pertinent Literature
Authors: Olsen Stephen B. , Mcquinn William C. , Feliciano Philip
Published: June 2020

Patch closure after carotid endarterectomy lowers risk of recurrent stenosis and perioperative neurologic events. Although vein patches have theoretic benefits, few differences between vein and nonautologous patches have been noted. Bovine pericardium has been increasingly used in carotid surgery over the last 15 years, with favorable reports. This study reviews a large carotid surgery series using this patch. Data were gathered on 464 consecutive carotid operations using the bovine pericardium patch; all complications were analyzed and pertinent literature review was performed. Of 464 procedures, 218 (47%) were performed for symptomatic disease. Total peri-operative ipsilateral stroke rate was 0.65 per cent. A low rate of postoperative bleeding was noted. Recurrence of >70 per cent stenosis was 1.6 per cent at follow-up of 26 months in 410 patients. Handling was subjectively described as excellent. Literature review comprising 3239 carotid operations revealed low risks of stroke, bleeding requiring intervention, or high rates of recurrent stenosis. Bovine pericardium patch angioplasty has low perioperative and late complications and good handling characteristics, making it an acceptable choice for use in carotid surgery.
Laparoscopic-assisted Ventral Hernia Repair: Primary Fascial Repair with Polyester Mesh versus Polyester Mesh Alone
Authors: Karipineni Farah , Joshi Priya , Parsikia Afshin , Dhir Teena , Joshi Amit R.T.
Published: June 2020

Laparoscopic-assisted ventral hernia repair (LAVHR) with mesh is well established as the preferred technique for hernia repair. We sought to determine whether primary fascial closure and/or overlap of the mesh reduced recurrence and/or complications. We conducted a retrospective review on 57 LAVHR patients using polyester composite mesh between August 2010 and July 2013. They were divided into mesh-only (nonclosure) and primary fascial closure with mesh (closure) groups. Patient demographics, prior surgical history, mesh overlap, complications, and recurrence rates were compared. Thirty-nine (68%) of 57 patients were in the closure group and 18 (32%) in the nonclosure group. Mean defect sizes were 15.5 and 22.5 cm2, respectively. Participants were followed for a mean of 1.3 years [standard deviation (SD) = 0.7]. Recurrence rates were 2/39 (5.1%) in the closure group and 1/18 (5.6%) in the nonclosure group ( P = 0.947). There were no major postoperative complications in the nonclosure group. The closure group experienced four (10.3%) complications. This was not a statistically significant difference ( P = 0.159). The median mesh-to-hernia ratio for all repairs was 15.2 (surface area) and 3.9 (diameter). Median length of stay was 14.5 hours (1.7–99.3) for patients with nonclosure and 11.9 hours (6.9–90.3 hours) for patients with closure ( P = 0.625). In conclusion, this is one of the largest series of LAVHR exclusively using polyester dual-sided mesh. Our recurrence rate was about 5 per cent. Significant mesh overlap is needed to achieve such low recurrence rates. Primary closure of hernias seems less important than adequate mesh overlap in preventing recurrence after LAVHR.
Financial Benefits of a Hepatopancreaticobiliary Program
Authors: Rosemurgy Alexander S. , Ryan Carrie E. , Klein Richard L. , Wood Thomas W. , Co Franka , Ross Sharona B.
Published: June 2020

Financial implications of developing a hepatopancreaticobiliary (HPB) center have not been considered. We undertook this study to determine hospital income associated with a new HPB center and to gauge the opportunity cost associated with such a center. Operations included were based on the HPB fellowship curriculum and the six most commonly undertaken general surgery operations. The income with “core” HPB operations (n = 93) and the six most frequently undertaken general surgery operations (n = 583) at one hospital from June 2012 to June 2013 were determined. Patients were not screened based on the ability to pay. Data are reported as mean ± standard deviation. Per operation, hospital income with HPB operations and general surgery operations were $15,583.20 ± $45,909.41 and $5,162.22 ± $33,679.10 ( P < 0.005), respectively. Accordingly, net incomes of $1,449,238.04 (n = 93) and $3,009,572.78 (n = 583) were observed. Although general surgery operations are ubiquitous, HPB centers are uncommonly pursued at most hospitals, in part due to the patient volumes necessary to meet the expertise required. A “core” HPB operation produces triple the net income of a general surgery operation. Accordingly, significant financial benefit is achievable with the development of an HPB center when adequate volume is realized.
Duodenal Neuroendocrine Tumors: Location Matters!
Authors: Sheikh Mohd Raashid , Osman Houssam , Cheek Susannah , Hunter Shanee , Jeyarajah Dhiresh Rohan
Published: June 2020

Duodenal neuroendocrine tumors (NETs) are rare. Historically, when feasible a less aggressive surgical approach is considered. The aim of this study was to identify factors associated with prognosis and the necessity for more aggressive surgical procedures. All patients who underwent surgery for duodenal NETs between September 2005 and June 2014 were identified retrospectively. Data collected included clinical presentation, operative findings, and histopathological data. Eighteen patients underwent surgical management for duodenal NETs. Two patients underwent transduodenal excision (11%), two patients had partial duodenal resection (11%), two patients had antrectomy including 1st part of duodenum (D1) resection (33%), and eight underwent pancreaticoduodenectomy [PD (44%)]. On analysis, 2nd part of duodenum (D2) location was the most common site of duodenal NETs (n = 9, 50%). The odds of having a PD were 10 times higher when the lesion was in D2 location. The odds of having a positive lymph node are nine times higher when the lesion is in D2 region. The odds of having a positive lymph node are three times higher when lesion is greater than T1. D2 location of NETs is associated with higher odds of lymph node positivity and need for more extensive procedures like PD.
High-Volume Hospitals with High-Volume and Low-Volume Surgeons: Is There a “Field Effect” for Pancreaticoduodenectomy?
Authors: Wood Thomas W. , Ross Sharona B. , Bowman Ty A. , Smart Amanda , Ryan Carrie E. , Sadowitz Benjamin , Downs Darrell , Rosemurgy Alexander S.
Published: June 2020

Since the Leapfrog Group established hospital volume criteria for pancreaticoduodenectomy (PD), the importance of surgeon volume versus hospital volume in obtaining superior outcomes has been debated. This study was undertaken to determine whether low-volume surgeons attain the same outcomes after PD as high-volume surgeons at high-volume hospitals. PDs undertaken from 2010 to 2012 were obtained from the Florida Agency for Health Care Administration. High-volume hospitals were identified. Surgeon volumes within were determined; postoperative length of stay (LOS), in-hospital mortality, discharge status, and hospital charges were examined relative to surgeon volume. Six high-volume hospitals were identified. Each hospital had at least one surgeon undertaking ≥ 12 PDs per year and at least one surgeon undertaking < 12 PDs per year. Within these six hospitals, there were 10 “high-volume” surgeons undertaking 714 PDs over the three-year period (average of 24 PDs per surgeon per year), and 33 “low-volume” surgeons undertaking 225 PDs over the three-year period (average of two PDs per surgeon per year). For all surgeons, the frequency with which surgeons undertook PD did not predict LOS, in-hospital mortality, discharge status, or hospital charges. At the six high-volume hospitals examined from 2010 to 2012, low-volume surgeons undertaking PD did not have different patient outcomes from their high-volume counterparts with respect to patient LOS, in-hospital mortality, patient discharge status, or hospital charges. Although the discussion of volume for complex operations has shifted toward surgeon volume, hospital volume must remain part of the discussion as there seems to be a hospital “field effect.”
Draining T-Tube Jejunostomy: A Technique to Get Out of Trouble
Authors: Serrano Oscar K. , Solsky Ian , Sandoval Eduardo , Berlin Arnold , Bellemare Sarah
Published: June 2020

A perforated viscus in the postpancreaticoduodenectomy setting is a rare phenomenon and a devastating complication. In this situation, adherence to damage-control principles demands minimizing the operative intervention while addressing the intestinal perforation as a way to mitigate the injurious effects on a complex gastrointestinal reconstruction. Herein, we describe our intraoperative decision-making with an unconventional approach in the management of a perforated viscus in the postpancreaticoduodenectomy setting using a draining T-tube jejunostomy. Our patient recovered remarkably well from this and was discharged from the hospital in six days with a controlled draining T-tube jejunostomy, which was subsequently removed on postoperative day 35. Our case illustrates an important option when dealing with a perforated viscus in the complex gastrointestinal surgery patient that has minimal morbidity, adequate source control, and the potential for an excellent clinical outcome. As surgical care continues to be delivered in a specialty-driven manner, a draining T-tube jejunostomy presents the ideal technique to get out of trouble for the general surgeon practicing in the community who may not be as experienced with complex gastrointestinal surgery.
NSQIP Analysis: Increased Immediate Reconstruction in the Treatment of Breast Cancer
Authors: Sabino Jennifer , Lucas Donald J. , Shriver Craig D. , Vertrees Amy E. , Valerio Ian L. , Singh Devinder P.
Published: June 2020

Immediate reconstruction after the surgical treatment of breast cancer has increased in the last decade. The purpose of this study is to use the National Surgical Quality Improvement Program database to analyze long-term trends in breast reconstruction. Women who underwent mastectomy for invasive or in situ breast cancer or prophylaxis between 2005 and 2011 were selected from the National Surgical Quality Improvement Program database. Trends and predictors for reconstruction were explored. In 44,410 women identified, immediate reconstruction increased from 30.0 to 39.6 per cent from 2005 to 2011 ( P < 0.001). This trend persisted after adjustment for patient characteristics using multivariate logistic regression [odds ratio (OR) 1.09/year, 95% confidence interval (CI) 1.07–1.10]. Reconstruction type was 77.9 per cent implant, 13.3 per cent pedicle flap, 5.5 per cent free flap, and 3.3 per cent other. Pedicle flaps decreased from 27.1 to 9.2 per cent ( P < 0.001), implant-based reconstruction increased from 66.3 to 81.3 per cent ( P < 0.001), and free flaps remained stable between 4 and 7 per cent. Independent predictors for reconstruction were young age (stepwise decrease in OR from 1 to 0.02 by decade as age increased from 40 to 80, all P < 0.001), carcinoma in situ (OR 1.51, 95% CI 1.42–1.61), prophylaxis (OR 1.89, 95% CI 1.63–2.19), bilateral resection (OR 2.55, 95% CI 2.42–2.69), and non-Hispanic white race (OR 0.67 for other races, 95% CI 0.64–0.70). Immediate breast reconstruction has steadily increased since 2005 with an associated rise in implant-based reconstruction. Based on these trends, discussion with a reconstructive surgeon should be an early part of the newly diagnosed breast cancer patient's treatment algorithm.
Impact of Beta-Blockers on Nonhead Injured Trauma Patients
Authors: Hendrick Leah E. , Schroeppel Thomas J. , Sharpe John P. , Alsbrook Diana , Magnotti Louis J. , Weinberg Jordan A. , Johnson Benjamin P. , Lewis Richard H. , Clement L. Paige , Croce Martin A. , Fabian Timothy C.
Published: June 2020

Catecholamine surge after traumatic injury may lead to dysautonomia with increased morbidity. Small retrospective studies have shown potential benefit of beta-blockers (BB) in trauma patients with and without traumatic brain injury (TBI). This study evaluates a large multiply injured cohort without TBI that received BB. Patients were identified from the trauma registry from January 1, 2003 to December 31, 2011. Patients who received >1 dose of BB were compared to controls. Patients with TBI, length of stay (LOS) < 2 days, and prehospital BB were excluded. Outcomes were mortality, intensive care unit (ICU) LOS, and LOS. Stepwise multivariable regression was used to identify variables significantly associated with mortality. During the study period, 19,151 eligible patients were admitted. The mean age was 39 years. Most were male (74%) and most sustained blunt mechanism (75%). A total of 1854 (11%) patients received BB. BB patients had longer LOS (16 vs 6 days), ICU LOS (7 vs 1 days), and higher mortality (2.8 vs 0.5%) (all P < 0.001). Multivariable regression demonstrated no benefit to BB after adjusting for potential confounding characteristics [odds ratio (OR) 0.952; confidence interval (CI) 0.620–1.461]. In conclusion, in this largest study to date, patients receiving BB were older, more severely injured, and had a higher mortality. Unlike TBI patients, multivariable regression showed no benefit from BB in this population.
Can Abdominal Wall Reconstruction be Safely Performed without Drains?
Authors: Ramshaw Bruce , Dean Jonathan , Forman Brandie , Heidel Eric , Gamenthaler Andrew , Fabian Michael
Published: June 2020

The use of closed suction drains in the abdominal wall is a common practice in abdominal wall reconstruction (AWR) operations. Drains can be a conduit for bacteria and can cause pain and discomfort for patients after surgery. A single hernia program has implemented the principles of clinical quality improvement in an attempt to improve outcomes for hernia patients. An attempt at a process improvement was implemented to eliminate the use of drains in AWR by adapting the technique. A total of 102 patients undergoing AWR were included between 8/11 and 9/15 (49 months). Compared with the group before the attempt at eliminating the use of abdominal wall drains (8/11–9/13), the group of patients after the implementation of the attempted process improvement (9/13–9/15) had less wound and pulmonary complications, a shorter hospital stay, less time in the postanesthesia care unit, and less opioid use in the postanesthesia care unit as well as for the entire hospital stay. In this group of AWR patients, an attempt at process improvement that eliminated the use of drains led to improved outcomes. Abdominal wall drains may be able to be safely eliminated with appropriate technique adaptation for AWR.
Perioperative Statin Treatment: Can it Decrease Postsurgical Cardiac Event Risk in Noncardiac Surgery?
Authors: Spivey Matthew G. , Atwood Jon , Fogel Sandy L.
Published: June 2020

Cardiac events are an important cause of postsurgical morbidity and mortality. Statin drugs have been studied as potentially risk-modifying agents in perioperative medicine. They have been shown to confer a protective benefit in cardiac surgery, but the evidence available in noncardiac surgery patient populations remains less conclusive. We hypothesized that perioperative statin treatment would be associated with lower incidence of postsurgical cardiac events (PSCEs) after major noncardiac surgery. A retrospective cohort study included 21,637 major noncardiac surgeries. Statin treatment was the exposure of interest and PSCE was the primary outcome measure. Data collection included patient age, body mass index, smoking status, diabetic status, cardiac event history, statin treatment history, and PSCE diagnoses. Perioperative statin treatment occurred in 4176 cases (19.3%). PSCEs occurred in 50 cases (0.23%), 29 in the untreated control group (0.17%) and 21 in the statin treatment group (0.50%). Relative risk in the untreated group was 0.3303 (95% confidence interval = 0.1886, 0.5786). This implied that statin-treated patients had higher risk than the untreated group. However, a logistic regression model that accounted for observed cardiac disease risk factors showed statin treatment not to be a significant predictor of PSCE in this sample. Analysis repeated in high-risk subsets of the cohort yielded similar results. A propensity score matching method that minimized differences between study groups also failed to demonstrate a significant association between statin treatment and PSCE risk. Our study did not demonstrate a significant association between perioperative statin treatment and PSCEs after major noncardiac surgery.
Factors Associated with Persistently Positive Margin Status after Breast-Conserving Surgery in Women with Breast Cancer: An Analysis of the National Cancer Database
Authors: Hanna Jonathan , Lannin Donald , Killelea Brigid , Horowitz Nina , Chagpar Anees B.
Published: June 2020

Margin status after definitive breast-conserving surgery (BCS) is a key predictor of local tumor recurrence. This study utilized the National Cancer Database, which captures 70 per cent of all cancer cases nationally, to determine factors associated with persistently positive margins status post-BCS. From 1998 to 2010, there were 1,170,284 patients with stage 0 to 3 breast cancer who underwent BCS. After final definitive surgery, 7.3 per cent of patients had positive margins. On bivariate analysis, persistently positive margin status post-BCS was correlated with patient age, race, ethnicity, comorbidities, facility type and location, tumor size, grade, presence of invasive disease, lymph node positivity, as well as receipt of neoadjuvant chemotherapy and adjuvant radiation therapy ( P < 0.001). On multivariate analysis, patients who were black, with multiple comorbidities, living in a Pacific state, who had larger, high-grade, node-positive invasive tumors, who did not receive neoadjuvant chemotherapy, and who did not receive adjuvant radiation therapy were more likely to have persistently positive margins ( P < 0.05). Although the goal of BCS is the attainment of negative margins, 7.3 per cent of patients have persistently positive margins after definitive surgery. These patients tend to have more aggressive disease and greater comorbidities, and are less likely to receive adjuvant radiation therapy.
Appendicitis in Diabetics: Predictors of Complications and Their Incidence
Authors: Bach Lindsay , Donovan Andrew , Loggins Whitney , Thompson Stephanie , Richmond Bryan
Published: June 2020

Appendicitis is the most common surgical emergency encountered by the general surgeon. Literature has demonstrated that diabetics may manifest atypical signs of infection, often clouding the diagnostic picture. We conducted a 3-year retrospective analysis of adults with appendicitis to determine differences in presentation, diagnosis, treatment, and outcomes for diabetic versus nondiabetic patients. Demographics, symptoms, imaging, procedure(s), complications, and length of stay (LOS) were obtained via chart review. Factors were compared between patients with and without diabetes using chi-squared test, t test, or Mann-Whitney U test (significance at P ≤ 0.05). Multivariate regression analysis identified variables predicting longer LOS or perforation at diagnosis. Overall, 339 patients met inclusion criteria [303 were nondiabetic (ND), 36 were diabetic (D)]. On univariate analysis, diabetics were more likely to have other comorbid illnesses: obesity ( P < 0.001), chronic kidney disease ( P = 0.003), hypertension ( P < 0.001), coronary artery disease ( P < 0.001), peripheral vascular disease (PVD, P = 0.31), and chronic obstructive pulmonary disease ( P = 0.002). Diabetics presented with lower white blood cell counts (mean 14.2 ND, 11.9 D, P = 0.02), and were more likely to present with perforation (18.5% ND, 38.9% D, P = 0.008). LOS was longer in diabetics (1.0 day for ND, 3.0 day for D, P < 0.001). Complications were more frequent in diabetics (19.4% D vs 8.6% ND), which trended toward but failed to reach significance ( P = 0.066). On multivariate analysis, however, old age was the only characteristic associated with perforation [odds ratio: 1.05 (1.02–1.06), P < 0.001], whereas diabetes, chronic obstructive pulmonary disease, and older age predicted longer LOS ( P ≤ 0.001). Diabetics present a more complicated clinical picture having significantly more comorbidities and a trend toward postoperative complications necessitating a higher index of suspicion to detection complications. Further study is needed to evaluate the optimal diagnostic and management approach in this challenging population.
Fetus in Fetu—A Case Report with a Variant Host Anastomosis
Authors: Tran Michael N. , Landin Mackenzie D. , Blackwood Brian P. , Shah Ami N.
Published: June 2020

Fetus in fetu is a rare congenital condition where a vertebrate fetus is found within the body of its host twin. It features a monozygotic parasitic twin attached via a vascular anastomosis to its host circulation. This report describes an instance of fetus in fetu with a variant presentation of its vascular pedicle to its host via the inferior epigastric vasculature.
Malignancy Rate, Number Needed to Treat, and Positive Predictive Value for Breast MRI
Authors: Kennedy John S. , Robbins Patrick A.
Published: June 2020

Breast MRI is being used more frequently for advanced screening for breast cancer. Patients may be at increased risk, or are symptomatic, with nonsuspicious mammograms. There is little data regarding the likelihood of a recommendation for biopsy, or for detecting a malignancy, in this population. We intended to determine the malignancy rate, number needed to treat, and positive predictive value for patients receiving adjunctive MRI at our institution. A retrospective review of all breast MRIs from 2008 to 2010 was done. Patients with any prior diagnosis of breast cancer, or BRCA+ were excluded. There were 324 patients. Most common reasons for ordering the breast MRI included: abnormal test result 130 (44%), palpable mass 74 (23%), family history 58 (18%), breast pain 47 (15%), and nipple discharge 45 (14%). Breast Imaging-Reporting and Data System score (BIRADS) was 1 or 2 in 36 per cent, 4 or 5 in 18 per cent, 3 in 26 per cent, 0 in 10 per cent, and not given in 9 per cent. Biopsy was recommended in 77 (24%), with biopsy actually performed in 57 (18%). Of the eight cancers identified, four (1.2%) were ductal carcinoma in situ (DCIS) and four (1.2%) were invasive cancer, yielding a true-positive rate of 2.5 per cent. Number needed to treat was 40. Positive predictive value was 14 per cent with a false-positive rate of 86 per cent. In this group of generally higher risk women, typically prescreened with mammography, 1.2 per cent had an invasive cancer, and another 1.2 per cent had DCIS. Those who undergo biopsy are 6.1 times more likely to have benign pathology. The efficacy of adjunctive breast MRI could be improved through refinements in indication, test interpretation, or alternative screening strategies.
Development of Electronic Medical Record-Based “Rounds Report” Results in Improved Resident Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour Violations
Authors: Ham Phillip B. , Anderton Toby , Gallaher Ryan , Hyrman Mike , Simmerman Erika , Ramanathan Annamalai , Fallaw David , Holsten Steven , Howell Charles Gordon
Published: June 2020

Surgeons frequently report frustration and loss of efficiency with electronic medical record (EMR) systems. Together, surgery residents and a programmer at Augusta University created a rounds report (RR) summarizing 24 hours of vitals, intake/output, labs, and other values for each inpatient that were previously transcribed by hand. The objective of this study was to evaluate the RR's effect on surgery residents. Surgery residents were queried to assess the RR's impact. Outcome measures were time spent preparing for rounds, direct patient care time, educational activity time, rates of incorrect/incomplete data on rounds, and rate of duty hour violations. Hospital wide, 17,200 RRs were generated in the 1-month study. Twenty-three surgery residents participated. Time spent preparing for rounds decreased per floor patient (15.6 ± 3.0 vs 6.0 ± 1.2, P < 0.0001) and per intensive care unit patient (19.9 ± 2.9 vs 7.5 ± 1.2 P < 0.0001). The work day spent in direct patient care increased from 45.1 ± 5.6 to 54.0 ± 5.7 per cent ( P = 0.0044). Educational activity time increased from 35.2 ± 5.4 to 54.7 ± 7.1 minutes per resident per day ( P = 0.0004). Reported duty hour violations decreased 58 per cent ( P < 0.0001). American Board of Surgery in Training exam scores trended up, and estimates of departmental annual financial savings range from $66,598 to $273,141 per year. Significant improvements occur with surgeon designed EMR tools like the RR. Hospitals and EMR companies should pair interested surgeons with health information technology developers to facilitate EMR enhancements. Improvements like RRs can have broad ranging, multidisciplinary impact and should be standard in all EMRs used for inpatient care at academic medical centers.
Pain Assessment and Control in the Injured Elderly
Authors: Ko Ara , Harada Megan Y. , Smith Eric J.T. , Scheipe Michael , Alban Rodrigo F. , Melo Nicolas , Margulies Daniel R. , Ley Eric J.
Published: June 2020

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.
Dysphagia after Cardiac Operations is Associated with Increased Length of Stay and Costs
Authors: Nguyen Son , Zhu Allen , Toppen William , Ashfaq Adeel , Davis Jessica , Shemin Richard , Mendelsohn Abie H. , Benharash Peyman
Published: June 2020

Although the true incidence of postoperative dysphagia after cardiac surgery is unknown, it has been reported to occur in 3 to 21.6 per cent of patients. Historically, dysphagia has been associated with increased surgical complications and prolonged hospital stay. This study aimed to evaluate the costs and outcomes associated with dysphagia after cardiac surgery. Patients undergoing nonemergent, nontransplant cardiac operations between June 2013 and June 2014 were eligible for inclusion. Independent predictors of cost were identified through a multivariate linear regression model. Of the 354 patients (35% female) included for analysis, 56 (16%) were diagnosed with postoperative dysphagia. On univariate analysis, patients with dysphagia had increased intensive care unit and total hospital lengths of stay (11.8 vs 5.2 days, P < 0.001 and 18.2 vs 9.7 days, P < 0.001, respectively), and a 57 ± 15 per cent increase in cost of care ( P < 0.001). Dysphagia was not associated with higher rates of in-hospital mortality (3.6% vs 3.0%, P = 0.83). On multivariate linear regression, the development of dysphagia was independently associated with a 45.1 per cent increase in total hospital costs [95% confidence interval (31% and 59%), P < 0.001]. Dysphagia is an independent and major contributor to health care costs after cardiac operations, suggesting that postoperative dysphagia represents a highly suitable target for quality improvement and cost containment efforts.
A Durable Laparoscopic Technique for the Repair of Large Paraesophageal Hernias
Authors: Reynolds Jessica L. , Zehetner Joerg , Bildzukewicz Nikolai , Katkhouda Namir , Lipham John C.
Published: June 2020

Laparoscopic repair of large paraesophageal hernias has been challenging due to high recurrence rates with primary repair and complications associated with the use of nonabsorbable mesh to reinforce the hiatus. The aim of our study was to evaluate the recurrence rate over time and mesh-related complications using an absorbable polyglactin mesh secured with Bioglue to reinforce the hiatus after laparoscopic repair of large paraesophageal hernias. There were 190 patients who met inclusion criteria from June 2006 to June 2014. Follow-up was routinely performed at 1-year intervals, including endoscopy and/or video esophagram, and the gastroesophageal reflux disease health-related quality of life questionnaire. Mean follow-up was 21 months (3–88). There were no incidences of mesh erosion. Recurrence was detected in 17 patients (15.3%), with a median time to recurrence of 23 months (8–67). Recurrence rate was estimated with the Kaplan-Meier method to be 2.9 ± 1.6 per cent, 11.6 ± 3.7 per cent, 22.4 ± 5.6 per cent, 25.1 ± 6.0 per cent, and 29.5 ± 7.9 per cent at 12, 24, 36, 48, and 60 months, respectively. The mean gastroesophageal reflux disease health-related quality of life was 2 in patients both with and without recurrence. Laparoscopic intrathoracic stomach repair using absorbable polyglactin mesh and Bioglue for crural reinforcement is effective, safe, and durable. The rate of recurrence plateaus over time with the majority of recurrences being small to moderate asymptomatic hernias.
Outcomes of Nipple-Sparing Mastectomy: Role of Anatomic Measurements
Authors: Pairawan Seyed S. , Cody Derek , Kim Hahns , Hughes M. Katherine , Solomon Naveenraj , Senthil Maheswari , Garberoglio Carlos , Lum Sharon
Published: June 2020

Nipple-sparing mastectomy (NSM) offers improved cosmesis for women undergoing mastectomy; however, there is increased risk for complications with this technique. We sought to determine if standard anatomic measurements could be used to predict complications of NSM. We performed a retrospective review of NSM for which anthropometric measurements of sternal notch to nipple distance, base width, and inframammary fold to nipple distance were available, and compared outcomes by anatomic measurements. We identified 102 cases of NSM with measurements available for study performed in 55 patients. Areola necrosis was associated with base width of greater than 15 cm (42.9% vs 10.9%, P = 0.02), infections were more likely with inframammary fold to nipple distance of more than 10 cm (29.2% vs 10.3%, P = 0.02), hematomas were more likely with sternal notch to nipple distance more than 30 cm (22.2% vs 4.3%, P = 0.03), and delayed wound healing was more likely with sternal notch to nipple distance of more than 25 cm (10.3% vs 1.6%, P = 0.03). There were no significant differences in nipple necrosis, skin flap necrosis, wound care requirements, or operative intervention based on anatomic measurement. Standard anatomic measurements are inconsistent predictors of outcome from NSM and should not be used alone to exclude attempts at NSM.
Do Antiplatelet and Anticoagulation Agents Matter after Repair of Traumatic Arterial Injuries?
Authors: Wang Eugene , Inaba Kenji , Cho Jayun , Byerly Saskya , Rowe Vincent , Benjamin Elizabeth , Lam Lydia , Demetriades Demetrios
Published: June 2020

Thrombosis is a devastating complication after repair of traumatic vascular injury. Although thrombosis rates have been described, the value of anticoagulation in preventing postrepair thrombosis is unknown. We hypothesize that postoperative anticoagulation reduces thrombosis rates. A total of 1524 consecutive patients with traumatic arterial injuries from January 2005 to June 2015 were identified, and 381 patients underwent the following repair types: direct suture of vessel wall, primary anastomosis, extra-anatomic reconstruction, tissue and synthetic interposition reconstruction. Twenty six patients received postoperative heparin at therapeutic levels, and 29 patients received postoperative aspirin for five consecutive days. The heparin and aspirin groups were matched with patients without postoperative anticoagulation by the following variables: anatomic arterial injury, type of vascular repair, and age. These groups were then compared using the following outcome measures: mortality, thrombosis of repaired vessel, amputation, hemorrhage, cerebral vascular accident, and extremity compartment syndrome. The demographics between the heparin, aspirin, and respectively matched groups were not statistically different. There was no statistically significant difference in the rate of thrombosis, bleeding, compartment syndrome, cerebral vascular accident, limb amputation, or mortality. Although there was no increase in bleeding complications with the use of heparin or aspirin, there was also no impact on the rate of thrombosis.
Complications of Diverting Ileostomy after Low Anterior Resection for Rectal Carcinoma
Authors: Maroney Sean , De Paz Carlos Chavez , Duldulao Marjunphilip , Kim Tracey , Reeves Mark E. , Kazanjian Kevork K. , Solomon Naveenraj , Garberoglio Carlos
Published: June 2020

There have been few studies directly comparing the postoperative complications in patients with a diverting ileostomy to patients who were not diverted after low anterior resection (LAR) for rectal carcinoma. This study is a retrospective chart review of all rectal carcinoma patients (99) who underwent a LAR from January 2009 to December 2014 at Loma Linda University Medical Center and Veterans Affairs Loma Linda Healthcare System. A majority of patients were diverted (58% vs 42%). The diverted patients were more likely to have a low tumor location ( P < 0.01), preoperative chemoradiation ( P < 0.01), and more intraoperative blood loss ( P < 0.01). Our study shows a statistically significant higher overall complication rate among patients receiving a diverting ileostomy in the six months after LAR (61% vs 38%, P = 0.02). The difference is due to a higher rate of readmission (27% vs 14%) and acute kidney injury (14% vs 5%) in patients with a diverting ileostomy. It also shows that there is a higher rate of unplanned reoperation (11% vs 6%) due to anastomotic leak (17% vs 5%) in nondiverted patients. Further studies are needed to refine the specific indications to maximize the benefit of diverting ileostomy after LAR for rectal carcinoma.
A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients
Authors: Brown Carlos V. R. , Rix Kevin , Klein Amanda L. , Ford Brent , Teixeira Pedro G. R. , Aydelotte Jayson , Coopwood Ben , Ali Sadia
Published: June 2020

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.
Resection of Gastrointestinal Metastases in Stage IV Melanoma: Correlation with Outcomes
Authors: Prabhakaran Sangeetha , Fulp William J. , Gonzalez Ricardo J. , Sondak Vernon K. , Kudchadkar Ragini R. , Gibney Geoffrey T. , Weber Jeffrey S. , Zager Jonathan S.
Published: June 2020

The prognosis of patients with gastrointestinal (GI) melanoma metastases is poor. Surgery renders select patients disease free and/or palliates symptoms. We reviewed our single-institution experience of resection with GI melanoma metastases. A retrospective review was performed on patients who underwent surgery for GI melanoma metastases from 2007 to 2013. Fifty-four patients were identified and separated based on completeness of resection into curative 13 (24%) and palliative 41 (75.9%) groups. Thiry-six (63.2%) were symptomatic preoperatively with bleeding and/or obstruction/pain with 91.7 per cent achieving objective symptom relief. Thirty-day operative mortality was 0 per cent. The most common complication was wound infection (n = 5); major complications like anastomotic leak (n = 1) were uncommon. With a median follow-up of 9.5 months (range 0.2–75.8), median overall survival was not reached (curative) versus 9.53 months (palliative group). Median recurrence-free and progression-free survival after resection were 18.89 and 1.97 months in the curative versus palliative groups, respectively. On multivariate analysis, resection to no clinical evidence of disease (P = 0.012) and presence of single metastases (P = 0.031) were associated with improved overall survival. Surgery for GI metastases from melanoma provides symptomatic relief without major morbidity. Fewer metastases and curative resection were associated with improved survival.