bluuebunny/crossref_metadata_2025 huggingface dataset:
Hartmann's Colostomy Reversal: Outcome of Patients Undergoing Surgery with the Intention of Eliminating Fecal Diversion
Authors: Boland Elena , Hsu Allen , Brand Marc I. , Saclarides Theodore J.
Published: June 2020

Reversal of a Hartmann's operation can be a morbid undertaking; successful restoration of intestinal continuity cannot be guaranteed. Between June 2001 and July 2006, 35 Hartmann's reversals were undertaken. There were 19 males (54%). Mean age was 54.7 years (range, 14–82 years). Twenty-one (60%) patients had their Hartmann's for diverticular disease, 7 (20%) for anorectal cancer, 4 (11%) for volvulus, and 3 for miscellaneous reasons. Mean length of stay was 7.7 days (range, 3–16 days); 23 per cent required intensive care for a mean 2.3 days (range, 1–4 days). Blood loss was 470 mL, and mean operative time was 4.28 hours (range, 1–8.3 hours). The mean time interval between the original operation and its reversal was 8.9 months (range, 1.4–55 months). Extensive lysis of adhesions was required in 69 per cent, 40 per cent experienced minor complications (urinary tract infections, ileus, and so on), and 38 per cent had major complications (myocardial infarction, leak, hernias, respiratory failure). There was one death (3%). The operation failed because of intraoperative circumstances in three patients (8%). Ten patients (26%) had stomas at the time of discharge of which 3 were intended to be permanent and 7 were temporary. Of the latter, 3 were successfully closed, 3 are awaiting closure, and 1 had complete anastomotic failure requiring permanent diversion. Total failure rate was 10.3 per cent; contributing factors included prior radiation and ultra-low anastomoses.
Prediction of Nonsentinel Lymph Node Involvement in Patients with a Positive Sentinel Lymph Node in Malignant Melanoma
Authors: Page Andrew J. , Carlson Grant W. , Delman Keith A. , Murray Douglas , Hestley Andrea , Cohen Cynthia
Published: June 2020

Completion lymph node dissection (CLND) is routinely performed after metastatic melanoma is detected at sentinel lymph node (SLN) biopsy. Nonsentinel lymph node (NSLN) involvement is found in less than one-third of the cases. Possible predictors of NSLN involvement are examined. A retrospective review of 70 patients with a positive SLN biopsy for melanoma and drainage to one lymphatic basin was performed. The size of metastatic deposits was defined as macrometastases (>2 mm), micrometastases (≤2 mm), a cluster of cells (10–30 grouped cells) in the subcapsular space or interfollicular zone, or isolated melanoma cells (1–20 or more individual cells) in sub-capsular sinuses. Tumor stage, ulceration, SLN tumor burden, mitoses, number of positive SLNs, and total number of lymph nodes removed were examined as predictors of NSLN involvement after CLND. Two additional models based on SLN tumor burden and the number of nodes biopsied were designed. Nineteen patients (24.3%) were found to have NSLN metastases after CLND. Tumor stage, ulceration, SLN tumor burden, mitoses, number of positive SLN, and number of lymph nodes removed were not statistically significant. Residual disease at CLND stratified by SLN tumor burden was: isolated melanoma cells, 0; cluster of cells, 8 (38.1%); ≤2 mm, 5 (20.8%); and >2 mm, 6 (27.3%). A comparison of the means for the models was not predictive of NSLN involvement. None of the risk factors or models examined could predict nonsentinel lymph node involvement with melanoma. The SLN sample and minimal SLN metastatic disease when defined as isolated clusters of cells warrant further study as a potential indicator against CLND after positive SLN.
Laparoscopic Ladd Procedure: A Minimally Invasive Approach to Malrotation without Midgut Volvulus
Authors: Draus John M. , Foley David S. , Bond Sheldon J.
Published: June 2020

The management of intestinal malrotation without midgut volvulus is controversial. Some advocate the Ladd procedure in all patients with malrotation, whereas others propose a more selective approach. We attempted the laparoscopic Ladd procedure on nine patients who were diagnosed with intestinal malrotation without volvulus. Patient records were retrospectively reviewed. Data were collected on patient presentation, operative procedure, hospital course, and outcome. The laparoscopic Ladd procedure was successfully completed in eight patients (aged 10 weeks to 25 years). One patient required conversion to an open procedure. Operative time averaged 111 minutes (range, 77–176 minutes). Hospital stay ranged from 3 to 5 days (average, 3.6 days). All patients were discharged home on a regular diet. There was one complication and no deaths. Eight patients had complete resolution of their symptoms. The laparoscopic Ladd procedure is a safe and effective procedure for infants, children, and adults who have intestinal malrotation without midgut volvulus. The operative times, hospital stay, and clinical outcomes were acceptable. We recommend that laparoscopic intervention be considered in patients with intestinal malrotation without volvulus. Intestinal malrotation occurs along a wide spectrum of anatomic variants and clinical presentations. The management of malrotation without midgut volvulus remains controversial. Most advocate performing the Ladd procedure on all patients found to have malrotation because there is no way to know which of these patients will develop catastrophic midgut volvulus. Some propose a more selective approach because of the morbidity associated with operative intervention. There have been a number of small series and case reports describing the use of laparoscopy to diagnose and correct malrotation. Proponents of this method point out its minimally invasiveness, patients’ quick recoveries, and successful outcomes. We describe our experience with the laparoscopic Ladd procedure and its long-term results.
Early Glucose Normalization Does Not Improve Outcome in the Critically Ill Trauma Population
Authors: Shin Susanna , Britt Rebecca C. , Reed Scott F. , Collins Jay , Weireter Leonard J. , Britt L.D.
Published: June 2020

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.
Idiopathic Granulomatous Mastitis: In Search of a Therapeutic Paradigm
Authors: Wilson Jason P. , Massoll Nicole , Marshall Julia , Foss Robin M. , Copeland Edward M. , Grobmyer Stephenr
Published: June 2020

Idiopathic granulomatous mastitis, also known as idiopathic granulomatous lobular mastitis, is a benign breast lesion that represents both a diagnostic and therapeutic dilemma. We report two cases of granulomatous mastitis recently evaluated and managed at our institution. To better understand this rare disease, we analyzed treatment outcomes in reported cases of granulomatous mastitis. One hundred sixteen cases were subsequently analyzed. Primary management strategies included observation (n = 9), steroids (n = 29), partial mastectomy (n = 75), and mastectomy (n = 3). Success rates with each treatment were observation, 56 per cent; steroids, 42 per cent; partial mastectomy, 79 per cent; and mastectomy, 100 per cent. Based on this analysis, we propose a clinically useful algorithm for both workup and management of these challenging cases.
Evolution of Fine Needle Aspiration Cytology in the Accurate Diagnosis of Pancreatic Neoplasms
Authors: Ho Joyce M. , Darcy Sean J. , Eysselein Viktor E. , Venegas Rose , French Samuel W. , Stabile Bruce E.
Published: June 2020

In the era of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), a minimally invasive, safe, and accurate cytologic examination of a variety of intra-abdominal neoplasms has become possible. To assess the efficacy of EUS-FNA for diagnosis of primary pancreatic tumors, a 10-year retrospective review of a consecutive series of patients diagnosed between 1996 and 2005 was undertaken. Comparisons were made between early (1996–2000) and late (2001–2005) periods regarding diagnostic modalities used and the concordance of EUS-FNA cytology with macroscopic tissue histology. Although macroscopic biopsy diagnostic yield did not change over time, yield from EUS-FNA increased from 40 per cent to 95 per cent ( P = 0.001). Because of improved accuracy of FNA cytology, only six per cent of tumors required additional macroscopic tissue histology in the late period versus 35 per cent in the early period ( P = 0.001). There was 100 per cent concordance between the cytologic and histologic diagnoses in the late period versus only 33 per cent in the early period ( P = 0.032). We conclude that 1) the frequency of pathologically diagnosed pancreatic tumors doubled over 10 years, 2) utilization of EUS-FNA significantly increased the accuracy of cytologic diagnosis, and 3) as a result, the need for macroscopic tissue biopsy for diagnosis of pancreatic neoplasms has been obviated.
Enhanced Touch Preps Improve the Ease of Interpretation of Intraoperative Breast Cancer Margins
Authors: Blair Sarah L. , Wang-Rodriguez Jessica , Cortes-Mateos Maria Jose , Messmer Davorka , Sandoval Sergio , Messmer Bradley , Trogler William , Kummel Andrew
Published: June 2020

Positive margins and the resulting multiple operations are a major problem for breast conservation therapy. Accurate assessment of intraoperative tumor margins can limit multiple re-excision procedures. Intraoperative touch preparations have been used in the past but can be difficult to interpret without an experienced cytopathologist. The objective of this study is to examine the reliability of enhanced intraoperative touch preps (EIOTP) compared with final pathologic margins. We prospectively performed EIOTP on 20 tumors in women undergoing breast conservation therapy. Six margins and the main tumor were touched onto poly-L-lysine coated slides. The slides were stained with anti MUC1 and anti-E-cadherin antibodies, and Hoechst nuclear stain. A parallel set of slides were stained with hematoxylin and eosin for comparison. The EIOTP results were compared with pathologic interpretation of paraffin embedded permanent sections. A total of 120 margins underwent EIOTP in 20 patients. We found a sensitivity equal to 80 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 99 per cent. EIOTP in conjunction with MUC-1 and E-cadherin by immunofluorescence is a sensitive and highly specific mechanism to identify cancer cells at breast tissue margins. The immunofluorescence stains may help the pathologist to identify cancer cells in fresh breast tissue and limit breast re-excisions in the future.
Can We Predict Unplanned Hospital Readmission after Colectomy for Ulcerative Colitis and Indeterminate Colitis?
Authors: Medress Zack , Fleshner Phillip R.
Published: June 2020

Unplanned readmission (UR) is considered to be an index of quality surgical care. We examined whether any perioperative factor was associated with UR after colectomy for ulcerative colitis (UC) or indeterminate colitis (IC). Patients undergoing a two-stage or three-stage ileal pouch-anal anastomosis were included. Patient, disease, and surgical factors were collected. UR occurring within 30 days of hospital discharge was assessed. The 202 study patients had a median age of 38 years. Median body mass index was 22. There were 130 (64%) UC patients and 72 (36%) IC patients. Indications for surgery were medically refractory disease (n = 176, 87%) and dysplasia/cancer (n = 26, 13%). Preoperative medical therapy included steroids alone in 25 patients and steroids combined with other immunomodulators in 151 patients. A two-stage and three-stage ileal pouch-anal anastomosis was used in 146 (72%) and 56 (28%) patients, respectively. Median white blood cell count before discharge was 8600 cells/mm3. Median length of stay after surgery was 7 days. Complications before discharge were observed in 28 patients (14%). Thirty-eight patients (19%) had a UR. No preoperative or surgical factor was associated with UR. Although UR occurs frequently (19%) after colectomy for UC or IC, it cannot be predicted.
Serious Lower Extremity Venous Injury Management with Ligation: Prospective Overview of 63 Patients
Authors: Kurtoglu Mehmet , Yanar Hakan , Taviloglu Korhan , Sivrikoz Emre , Plevin Rebecca , Aksoy Murat
Published: June 2020

Management of lower extremity venous trauma using repair or ligation has been an area of controversy during the past decades. However, in unstable patients or if primary repair is technically impossible as a result of extensive disruption of the vein, ligation is recommended. This study investigated the effects of venous ligation on major veins in the lower extremities when primary repair is impossible as a result of extensive laceration of the vein. Between January 2001 and April 2004, 63 patients with Grade III and IV venous injuries were observed prospectively. Compression ultrasonography was performed postoperatively on the fifth day, once before discharge, and at the 3-month visit to assess deep vein thrombosis (DVT) and the patency of arterial repair. If DVT was present, the patient was given an oral anticoagulant (warfarin Na) for 3 months (international normalized ratio, 2.0–3.0), and Class II compression stockings (Sigvaris-212, Ganzoni, Switzerland) were used for 1 year. Follow-up visits occurred at 1, 3, 6, and 12 months and at 6-month intervals thereafter. Combined arterial and venous injuries were present in 50 (79.4%) patients and pure venous injuries were present in 13 (20.6%) patients. DVT developed in 49 patients (77.7%; postoperative n = 37 [58.7%], late n = 12 [19%]). Three arterial restenoses (4.7%) and one pseudoaneurysm (1.6%) of the superficial femoral artery developed. Five early (prophylactic) and two late (compartment syndrome) fasciotomies were performed. Postoperative edema was seen in 56 (88.8%) patients and wound infection was seen in 19 patients (30.1%; n = 18 superficial, n = 1 deep). Two amputations (3.2%) were performed. One patient (1.7%) died as a result of irreversible shock. After a median of 18 months, 25 patients were classified with Clinical Etiology, Anatomy, Pathology classification: 10 legs C-0, seven legs C-2, and eight legs C-3. No severe postthrombophlebitic syndrome was observed. Early leg swelling after venous ligation was the most common morbidity. We observed no significant sequelae of chronic venous insufficiency, and venous ligation had no detrimental effect on associated arterial repair. In cases of DVT, anticoagulation with low-molecular-weight heparin and oral anticoagulants should begin immediately and continue for 3 months along with compression stocking support for 1 year.
How Accurately Can We Predict Forced Expiratory Volume in One Second after Major Pulmonary Resection?
Authors: Wang Tina , Tagayun Alvin , Bogardus Alicia , Qian Dajun , Tiep Brian , Horak David , Grannis Frederic W.
Published: June 2020

Standard formulas for predicting postoperative forced expiratory volume in 1 second (po-FEV1) do not consider bronchi obstructed by tumor or chronic obstructive pulmonary disease, e.g., Formula 1 [ppo-FEV1 = (pre-opFEV1) x (# segments remaining)/(# of total segments)] whereas Formula 2 [ppo-FEV1 = (pre-opFEV1) x (# segments remaining)/(# of total unobstructed segments)] does. A retrospective chart review was conducted to determine accuracy of predicting po-FEV1, at a comprehensive cancer center. Predicted po-FEV1 was calculated using different formulas and analyzed using regression analysis and Pearson correlation. We found good correlation between po-FEV1 and predicted po-FEV1 using Formulas 1 and 2. In patients with tumor airway obstruction or chronic obstructive pulmonary disease, predictive accuracy decreased for both formulas. Prediction of FEV1 in patients undergoing pulmonary resection was generally accurate, but major errors were observed in some cases; therefore, better predictive formulas are needed in patients with airway obstruction by tumor or chronic obstructive pulmonary disease.
Tissue Welding Forceps Usage in Superficial Parotidectomy: A Clinical Assessment
Authors: Michel Randall G. , Tsau Kang , Weinstock Bernard I.
Published: June 2020

Tissue welding forceps (TWF) have been used effectively in a number of surgical procedures including blood vessel harvesting and tonsillectomy. Our objective was to assess the safety and efficacy of TWF usage in superficial parotidectomy. We performed a retrospective review of 25 patients between November 2002 and July 2006 who underwent superficial parotidectomy using TWF. The inpatient and outpatient records were reviewed for diagnosis, operative times, estimated blood loss, and postoperative facial paresis. Only one of the 25 patients (4%) who underwent superficial parotidectomy using TWF had transient postoperative facial weakness and no procedure had blood loss of greater than 150 cc. This initial evaluation suggests that use of TWF is safe in superficial parotidectomy and may help reduce the development of postoperative facial paresis.
Leiomyosarcoma of the Anal Canal: Case Report and Review of the Literature
Authors: Thalheimer Liza , Richmond Bryan , Lohan Jay
Published: June 2020

A rare case of a leiomyosarcoma of the anal canal is presented. A 68-year-old male presented with painful defecation and rectal bleeding. Endorectal ultrasound revealed a mass invading both sphincters (T4 lesion), and extending 6 cm into the anal canal. Colonoscopy revealed an ulcerated area in the anal canal, of which biopsies revealed high-grade leiomyosarcoma–only the eighteenth such case at the time of this submission. The details of the case and teaching images are presented in detail, as is a comprehensive review of the relevant literature.
Perils of Rib Fractures
Authors: Sharma Om P. , Oswanski Michael F. , Jolly Shashank , Lauer Sherry K. , Dressel Rhonda , Stombaugh Heather A.
Published: June 2020

Rib fractures (RF) are noted in 4 to 12 per cent of trauma admissions. To define RF risks at a Level 1 trauma center, investigators conducted a 10-year (1995–2004) retrospective analysis of all trauma patients. Blunt chest trauma was seen in 13 per cent (1,475/11,533) of patients and RF in 808 patients (55% blunt chest trauma, 7% blunt trauma). RF were observed in 26 per cent of children (<18 years), 56 per cent of adults (18–64 years), and 65 per cent of elderly patients (≥65 years). RF were caused by motorcycle crashes (16%, 57/347), motor vehicle crashes (12%, 411/3493), pedestrian-auto collisions (8%, 31/404), and falls (5%, 227/5018). Mortality was 12 per cent (97/808; children 17%, 8/46; adults 9%, 46/522; elderly 18%, 43/240) and was linearly associated with a higher number of RF (5% 1–2 RF, 15% 3–5 RF, 34% ≥6 RF). Elderly patients had the highest mortality in each RF category. Patients with an injury severity score ≥15 had 20 per cent mortality versus 2.7 per cent with ISS <15 ( P < 0.0001). Increasing age and number of RF were inversely related to the percentage of patients discharged home. ISS, age, number of RF, and injury mechanism determine patients’ course and outcome. Patients with associated injuries, extremes of age, and ≥3 RF should be admitted for close observation.
Video-Assisted Transumbilical Meckel's Diverticulectomy in Children
Authors: Clark Jason M. , Koontz Curt S. , Smith Lisa A. , Kelley Joseph E.
Published: June 2020

The treatment of Meckel's diverticulum (MD) in children is resection. Some data exist for the use of laparoscopic resection. The Video-Assisted Transumbilical (VAT) single-trocar technique has been recently described for appendectomy. We also have used this technique for the resection of MD. The purpose of this study is to report our experience with laparoscopic-assisted resection of MD using both the three-trocar and the single-trocar techniques. The Institutional Review Board approved our retrospective chart review of all patients with the diagnosis of MD. Only the cases that were treated via laparoscopy were included. Technique of resection was at the discretion of the surgeon. Nine patients underwent laparoscopic resection of an MD from 2000 to 2005. Four patients underwent the three-trocar technique (LAP n = 4) and the remaining five underwent the video-assisted transumbilical single-trocar technique (VAT n = 5) procedure. Indications for surgery included gastrointestinal bleeding (VAT n = 3; LAP n = 2), malrotation (LAP n = 2), intussusception (VAT n = 1), and abdominal pain (VAT n = 1). All patients were male, and ages ranged from 7 months to 17 years for the VAT group and 8 months to 15 years for the LAP group. The average length of surgery for the LAP versus VAT was 128 minutes (94–170 minutes) and 81.4 minutes (42–96 minutes) respectively. Of the five patients undergoing LAP, two Ladd's procedures and three appendectomies were included during the same anesthesia. Only a single appendectomy procedure was performed during a VAT. The average time until full feeds with the LAP and VAT was 4.3 days (2–8 days) and 2.0 days (1–3 days) respectively. The overall length of stay with LAP versus VAT was 4.3 days (2–8 days) and 3.7 days (2–5 days). Only one case using the LAP method required conversion to an open laparotomy. Though no randomized trial for the removal of MD exists, our data suggest that the use of laparoscopy for removal of both symptomatic and asymptomatic MD is safe and effective. Additionally, the one trocar technique is feasible and may be beneficial in terms of fewer incisions and operative costs; however, more patients need to be studied.
Clinical Examination is Superior to Plain Films to Diagnose Pelvic Fractures Compared to CT
Authors: Duane TherÈSe M. , Dechert Tracey , Wolfe Luke G. , Brown Holly , Aboutanos Michel B. , Malhotra Ajai K. , Ivatury Rao R.
Published: June 2020

We prospectively compared clinical examination (CE) with plain films (PXR) and both tools with CT in patients sustaining blunt trauma. There were 1388 patients who had both PXR and CT of whom 168 (12.1%) were diagnosed with a fracture by CT. CE findings most predictive of fracture included age (OR, 1.025; CI, 1.011–1.039), hip pain (OR, 4.971; CI, 2.508–9.854), internal rotation of the leg (OR, 4.880; CI, 1.980–12.027), or tenderness to palpation over the sacrum (OR, 2.297; CI, 1.144–4.612), over the right or left hip (OR, 3.626; CI, 1.823–7.214), or diffusely throughout the pelvis (OR, 16.445; CI, 4.277–63.237). These factors were still predictive of pelvic fractures even in patients with a Glasgow Coma Scale score less than 13. There were 136 fractures identified by PXR all of which were identified by CE (sensitivity 100% [136 of 136], negative predictive value 100% [619 of 619]). There were six patients with negative clinical examinations and positive CTs (sensitivity 96.4% [162 of 168], negative predictive value 99.03% [613 of 619]), none of which were hemodynamically significant. The sensitivity for PXR compared with CT was 79.17 per cent (133 of 168) and the NPV was 97.2 per cent (1217 of 1252). CE is a reliable way to diagnose pelvic fractures and PXR is a poor screening tool for these injuries compared with CT. Because the majority of patients undergo CT after blunt trauma, routine screening radiographs should be eliminated.
Development of a Functional, Internet-Accessible Department of Surgery Outcomes Database
Authors: Newcomb William L. , Lincourt Amy E. , Gersin Keith , Kercher Kent , Iannitti David , Kuwada Tim , Lyons Cynthia , Sing Ronald F. , Hadzikadic Mirsad , Heniford B. Todd , Rucho Susan
Published: June 2020

The need for surgical outcomes data is increasing due to pressure from insurance companies, patients, and the need for surgeons to keep their own “report card”. Current data management systems are limited by inability to stratify outcomes based on patients, surgeons, and differences in surgical technique. Surgeons along with research and informatics personnel from an academic, hospital-based Department of Surgery and a state university's Department of Information Technology formed a partnership to develop a dynamic, internet-based, clinical data warehouse. A five-component model was used: data dictionary development, web application creation, participating center education and management, statistics applications, and data interpretation. A data dictionary was developed from a list of data elements to address needs of research, quality assurance, industry, and centers of excellence. A user-friendly web interface was developed with menu-driven check boxes, multiple electronic data entry points, direct downloads from hospital billing information, and web-based patient portals. Data were collected on a Health Insurance Portability and Accountability Act-compliant server with a secure firewall. Protected health information was de-identified. Data management strategies included automated auditing, on-site training, a trouble-shooting hotline, and Institutional Review Board oversight. Real-time, daily, monthly, and quarterly data reports were generated. Fifty-eight publications and 109 abstracts have been generated from the database during its development and implementation. Seven national academic departments now use the database to track patient outcomes. The development of a robust surgical outcomes database requires a combination of clinical, informatics, and research expertise. Benefits of surgeon involvement in outcomes research include: tracking individual performance, patient safety, surgical research, legal defense, and the ability to provide accurate information to patient and payers.
Mesh-Free Laparoscopic Spigelian Hernia Repair
Authors: Bittner James G. , Edwards Michael A. , Shah Malay B. , Macfadyen Bruce V. , Mellinger John D.
Published: June 2020

Varied Spigelian hernia mesh repair techniques have been described, although evidence suggests laparoscopy results in less morbidity and shorter hospitalization compared with open procedures. Laparoscopic suture repair of Spigelian hernias is rarely reported. Two patients with small Spigelian hernias (≤2 cm) were diagnosed and repaired laparoscopically using a transabdominal suture technique. Under laparoscopic guidance, a suture-passer was used to place two or three transfacial, interrupted 0 polypropylene sutures along the horizontal plane of the defect. Sutures were tied extracorporeally and closure was confirmed laparoscopically. These cases spurred a review of world literature (2001–2007) including clinical characteristics, operative techniques, and urgency of operations in Spigelian hernia patients. Data were compared using Fisher's exact test. One year postoperatively, the patients are without sequelae or recurrence. Literature review demonstrated most patients were females ( P < 0.001), ranged in age from 60 to 80 years ( P = 0.042), and presented with left-sided hernias ( P = 0.026). Open mesh repair (182/392 cases; 47%) was the most common technique; however, increasingly articles describe laparoscopic mesh repair. Mesh-free laparoscopic suture repair is feasible and safe. This novel uncomplicated approach to small Spigelian hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material.
All-Terrain Vehicle Trauma in the Elderly: An Analysis of a National Database
Authors: Deladisma Adeline M. , Parker William , Medeiros Regina , Hawkins Michael L.
Published: June 2020

The elderly are a growing proportion of all-terrain (ATV) drivers. The purpose of this study was to determine if the outcomes of geriatric ATV trauma victims are different from those of their younger counterparts and if age is an independent predictor of mortality. ATV trauma cases in the United States reported to the National Trauma Data Bank between 1989 and 2003 comprised the study population. A logistic regression model was constructed with mortality as the outcome and age as the primary covariate of interest. A total of 6308 ATV-related traumas were reported to the National Trauma Data Bank during the study period. Geriatric victims presented with significantly higher systolic blood pressure (138.6 ± 34.4 vs 131.4 ± 24.8, P < 0.001) and had a significantly longer length of stay (8.3 ± 11.4 vs 4.8 ± 8.8, P < 0.001) and greater number of intensive care unit days (3.1 ± 7.1 vs 1.3 ± 4.0, P < 0.001). In a multivariate model, age older than 60 years was associated with increased risk of mortality (OR, 6.96; 95% CI, 3.75–12.92). Age older than 60 years is an independent predictor of mortality among ATV trauma cases. Improved training on the use of ATVs in this population and better safety features are warranted.
Papillary Endothelial Hyperplasia of the Adrenal Gland: Report of a Case and Review of the Literature
Authors: Constantinou Constantinos , Sheldon David
Published: June 2020

Papillary endothelial hyperplasia (PEH) is a benign vascular proliferative process most frequently seen in the skin and integument, but may involve any of the visceral organs. It is a rare entity, with less than 30 cases of visceral PEH described in the literature. Adrenal papillary endothelial hyperplasia is an exceedingly rare process and is the basis of this review. A 66-year-old female was referred for evaluation of an asymptomatic 6 cm right adrenal mass. Computed tomography indicated that the lesion was solid and hypervascular. After appropriate workup, the patient underwent laparoscopic adrenalectomy. The pathologic analysis was consistent with adrenal PEH. The patient recovered without incident and is doing well at 1 year follow-up. A review of the world's literature on papillary endothelial hyperplasia (PEH), and in particular adrenal PEH, yields five previous reports of this entity, and no comprehensive review. A compilation of the now six patients with adrenal PEH reveals several common features: five of six patients were female and mean age was 64 years. The disease radiologically mimics adrenal cortical carcinoma mandating a surgical oncological technique. Pathologic differentiation from angiosarcoma can be a difficult task requiring evaluation by an experienced pathologist.
The Influence of Diabetes Mellitus in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study
Authors: Woods Scott E. , Eppley Chris , Engel Amy
Published: June 2020

This study was conducted to prospectively assess if there are any outcome differences between patients undergoing coronary artery bypass graft surgery with and without diabetes. This is an 11-year, prospective, hospitalization cohort study. Data were collected on 225 variables. A total of 8935 patients were available for our analysis (6023 nondiabetics, 319 diet-controlled diabetics, 1636 diabetics on oral medications, 957 insulin-controlled diabetics). Compared with nondiabetics, diet-treated diabetics possessed four significant comorbidities, diabetics treated with oral medications possessed 12 significant comorbidities, and insulin-treated diabetics possessed 13 significant comorbidities ( P < 0.05). There was no significant difference between diet-treated diabetics and nondiabetics for all outcomes. Diabetics treated with oral medications possessed a longer length of stay [relative risk (RR), 1.09; CI, 1.08–1.10], longer intensive care unit length of stay (RR, 1.56; CI, 1.12–2.00), and more intraoperative complications (RR, 1.42; CI, 1.12–1.66). Insulin-treated diabetics possessed more neurological complications (RR, 2.39; CI, 1.52–3.77), wound complications (RR, 2.42; CI, 1.19–4.95), and renal complications (RR, 2.43; CI, 1.70–3.49), longer length of stay (RR, 1.20; CI, 1.14–1.27), and longer intensive care unit length of stay (RR, 1.33; CI, 1.16–1.48). In diabetics undergoing coronary artery bypass graft surgery, as their diabetes progresses from diet treated with oral medications to insulin-dependent, this is associated with more comorbidities at surgical presentation and more morbidity after surgery.
Adding Insult to Injury: Neck Exploration for Penetrating Pediatric Neck Trauma
Authors: Vick Laura R. , Islam Saleem
Published: June 2020

Penetrating neck injuries are uncommon in children, and management involves mandatory exploration of the neck. This results in a number of unnecessary operations. Adult experience is moving towards selective exploration. A retrospective review was performed on all trauma patients presenting over the past 10 years. Pediatric patients with penetrating neck injury were selected and data were collected and analyzed. Out of a total of 19,363 trauma patients over the study period, we identified 39 children with 42 penetrating neck injuries. The average age was 13 years, and 56 per cent of cases were male. A large proportion (72%) was African-American. Over half of the injuries (63%) were from projectiles, including gun shot wounds (59%), which tended to be in the older children, whereas animal bites (5) were noted as a predominant cause in the younger ones. Six patients underwent exploration without any preoperative imaging due to penetration of the platysma, and four of these were nontherapeutic. Eighteen patients with platysma penetration underwent directed preoperative imaging, and 15 avoided operative exploration. CT scans were the most common imaging modality (68%). The median injury severity score was 11. The hospital length of stay was longer in the patients who underwent exploration. Mandatory exploration of the neck in children should not be performed unless clinically indicated. Preoperative imaging should be used liberally to limit nontherapeutic explorations, improve diagnostic accuracy, and reduce morbidity.
Early Thrombosis of the Superior Vena Cava in a Patient with a Central Venous Catheter and Carcinoma of the Ampulla of Vater
Authors: Cannon Robert , Shah Malay , Suydam Erin , Gucwa Angela , Bowden Talmadge , Holsten Steven B.
Published: June 2020

Superior vena cava syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology. Thrombosis of the vessel most often occurs in the setting of indwelling catheters or pacemakers. The diagnosis is suggested by the clinical manifestations of facial and upper extremity swelling, dyspnea, and cough. It is confirmed by CT scan showing the development of collateral flow around the lesion. In this report, we present a patient who developed superior vena cava thrombosis after undergoing a short period of central venous catheterization and a Whipple procedure for adenocarcinoma of the ampulla of Vater. The endothelial damage caused by the catheter, the low-flow state induced by the large fluid shifts during the operation, and the hypercoagulable state induced by malignancy fulfill Virchow's triad for venous thrombosis. To our knowledge, this is the first reported case of superior vena cava syndrome after the Whipple procedure with symptoms appearing after a shorter period of catheterization than previously reported in the adult literature.
An International Fellowship in Trauma Research and the Potential Benefits for Fellows, Sponsoring Institution, and the Global Trauma Community
Authors: Dubose Joseph J. , Teixeira Pedro G.R. , Recinos Gustavo , Barmparas Galinos , Ottochian Marcus , Inaba Kenji , Petrone Patrizio , Demetriades Demetrios
Published: June 2020

For over a decade, the Los Angeles County/University of Southern California Hospital has supported an international fellowship in trauma that provides research experience, education, and opportunity for clinical observation at a high-volume American College of Surgeons (ACS) designated Level I trauma center. We performed a descriptive study of the design, implementation, and results of an international fellowship in trauma and critical care. Fellows from 27 countries throughout the world have actively engaged in trauma research at Los Angeles County/University of Southern California Hospital. Our program involves intensive education and clinical observation components designed to facilitate dissemination of evidence-based trauma practices throughout the world by graduates. The majority of alumni responding to a survey returned to their countries of origin, remaining active in trauma care and research. Motivation for participation varied, but former fellows universally rated their experience highly and stated they would recommend the program to their colleagues. An international research fellowship in trauma and critical care provides foreign medical trainees opportunities for exposure to research and evidence-based practices at a high-volume trauma center. The program is designed to be beneficial to both the participating fellow and sponsoring institution; and is constructed to effectively promote improved trauma education and the dissemination of quality trauma practices internationally
Intraoperative Endoscopy and Leaks after Laparoscopic Roux-en-Y Gastric Bypass
Authors: Alaedeen Diya , Madan Atul K. , Ro Charles Y. , Khan Khurram A. , Martinez Jose M. , Tichansky David S.
Published: June 2020

Postoperative leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) are a source of morbidity and mortality. Any intervention that would decrease leak rates after LRYGB would be useful. This investigation tested the hypothesis that postoperative leak rates are lower after LRYGB with the routine use of intraoperative endoscopy (EN). Consecutive patients who underwent LRYGB were included. Intraoperative leak testing with air and methylene blue through an orogastric tube (OG) was used in the first 200 patients. Intraoperative endoscopy was used after the first 200 patients. There were 400 patients in this study. Preoperative demographics did not differ between groups. The intraoperative leak rate of the EN group was double the OG group (8 vs 4%; P = not significant), although the difference was not statistically significant. The OG group had a postoperative leak rate of 4 per cent with a mortality rate of 1 per cent. The EN group had a postoperative leak rate of 0.5 per cent with a mortality rate of 0 per cent. The difference in leak rates was statistically significant ( P < 0.04). Despite the issues of learning curve, EN demonstrates more intraoperative leaks than OG, indicating EN may be a more sensitive test than OG. Routine use of EN is associated with less postoperative leaks after LRYGB.
Laparoendoscopic Single Site Cholecystectomy: The First 100 Patients
Authors: Hernandez Jonathan M. , Morton Connor A. , Ross Sharona , Albrink Michael , Rosemurgy Alexander S.
Published: June 2020

Laparoendoscopic single site (LESS) surgery promises improved cosmesis and possibly less pain. However, given the small series reported to date, true estimates of the advantages and possible disadvantages of LESS surgery remain unknown. This study was undertaken to evaluate the first 100 patients undergoing LESS cholecystectomy at our institution. Patients referred for cholecystectomy since November 2007 were considered for LESS cholecystectomy. Outcomes, including blood loss, operative time, complications, and length of stay, were recorded. Outcomes are compared with an uncontrolled concurrent group of patients undergoing multi-incision laparoscopic (i.e., conventional) cholecystectomy. One hundred patients with a median age of 44 years underwent LESS cholecystectomy; 30 patients with a median age of 46 years underwent conventional cholecystectomy over the same time period. Median operative time (70 vs 66 minutes, P = 0.67, Mann-Whitney) and hospital length of stay (1 vs 1 day, P = 0.81, Mann-Whitney) were not different for patients undergoing LESS or multi-incision cholecystectomies, respectively. Five patients undergoing LESS cholecystectomy had postoperative complications: cystic duct stump leak (one), pain control issues (three), and urinary retention (one). LESS cholecystectomy is a safe and effective alternative to conventional cholecystectomy. It can be undertaken without added operative time and provides patients with minimal, if any, scarring.
Liver Resection Using a Four-Prong Radiofrequency Transection Device
Authors: Wagman Lawrence D. , Lee Byrne , Castillo Erick , El-Bayar Hisham , Lai Lily
Published: June 2020

Multiple techniques are available for division of hepatic parenchyma. This is the largest United States report examining the use of the Habib 4X tissue coagulator (AngioDynamics, Queensbury, NY). The objective was to collect standard parameters associated with successful, benchmarked liver surgery outcomes using this new device, and in particular, examine the risk of margin failure. Ninety-four consecutive operations using the Habib 4X were analyzed with special attention to local failure at resection margin, blood loss/transfusion, and operative times. An institutional review board approved protocol allowed collection and analysis of demographic information and outcomes for intraoperative, perioperative, and long term follow-up. Eighteen patients had biopsy only. Thirty-one had lobar resections and 46 had wedge or segmental resections. There were 30 primary hepatic and 46 metastatic tumor diagnoses. There were a total of 33 (43%) recurrences with a mean time to recurrence of 212 days (range 15-974). Of the 27 intrahepatic recurrences, four (15%) were at the margin. The OR time ranged from 115 to 642 minutes (average 283 min). The average recorded blood loss was 427 mL; 11 patients were transfused (average 0.43 units). The Habib 4X is a safe tool to use when evaluating the parameters of blood loss, transfusion, and margin recurrence.
The Management of Terminal Ileum Diverticulitis
Authors: Park Hyoung-Chul , Lee Bong Hwa
Published: June 2020

Terminal ileum diverticulitis is a very rare disease that may lead to an acute abdomen mimicking appendicitis. Because of its rarity, an optimal treatment for this disease has not been established yet. In this study, we evaluated the clinical features and outcomes of nonoperative management of terminal ileum diverticulitis, including suspected perforation. From 2000 to 2007, 346 patients were treated for acute symptomatic right-sided diverticulitis. Radiographic evaluation revealed that nine patients (2.6%) had terminal ileum diverticulitis. All patients presented with pain in the right lower quadrant. The clinical features and outcomes, including recurrence, were evaluated from a collected database and by phone interview. The average age of the patients was 43.7 years. Radiographic imaging was used to diagnose diverticulitis in all patients. Two of nine patients had suspected perforated diverticulitis, and three patients had multiple diverticula. Nonoperative management was successfully carried out on these patients. The average hospital stay was 8 days and the duration of antibiotic treatment was 6.4 days. The median follow-up was 36 months, and patients showed no recurrence within this interval. Nonoperative management may be feasible to treat terminal ileum diverticulitis.
Cognitive Performance of Morbidly Obese Patients Seeking Bariatric Surgery
Authors: Lokken Kristine L. , Boeka Abbe G. , Yellumahanthi Kishore , Wesley Mary , Clements Ronald H.
Published: June 2020

Bariatric surgery is efficacious for the treatment of severe obesity; however, little empirical research exists describing the demographic, psychosocial, and cognitive characteristics of patients presenting for the surgery. One hundred and sixty-nine morbidly obese patients seeking bariatric surgery underwent a presurgical psychological assessment, including cognitive testing. Morbidly obese individuals seeking bariatric surgery were similar in education, income status, and IQ compared with normative data. IQ was average, did not correlate with body mass index, and reflected a normal distribution. As a group, bariatric surgery patients endorsed minimal levels of depression and low levels of psychopathology. Obese individuals did demonstrate specific cognitive deficits on tests of executive function (e.g., problem solving and planning) when compared with normative data. This data suggests that bariatric surgery patients differ very little from other surgical populations on most demographic and psychosocial variables. The data does provide evidence for specific cognitive deficits in the area of executive functions at baseline in morbidly obese adults seeking bariatric surgery.
Florida's Trauma Surgeons: A Vanishing Breed
Authors: Kerwin Andrew J. , Tepas Joseph J. , Schinco Miren A. , Graham Darrell
Published: June 2020

The delivery of trauma and emergency surgical care is in a state of crisis. We hypothesized that this looming crisis was already manifested in Florida. The trauma medical directors of the 20 state designated trauma centers were surveyed for information pertaining to number of available surgeons for trauma call, number of night calls/month, age of the current trauma surgeons, and the estimated number of years each surgeon planned to continue taking call. We also queried trauma medical directors about recruitment of additional trauma surgeons. Fourteen directors responded. Each program had at least four surgeons taking trauma call on average 5.3 nights/month. Sixty-three per cent of surgeons taking call were less than 50-years-old. Thirty surgeons (39.5%) planned to discontinue trauma call within 10 years, leaving 46 surgeons (60.5%) presently committed to longer than 10 years of call. Nine programs were actively recruiting. Five programs (50%) were recruiting for < 1 year, three programs (30%) were recruiting for 1 to 2 years, and two programs (20%) were recruiting > 2 years. Florida's trauma surgeons are a vanishing breed. Given the recruiting difficulties, the diminishing numbers of Florida's general surgeons will have to fill the gaps.
The Natural History of Resected Pancreatic Cancer without Adjuvant Chemotherapy
Authors: Hernandez Jonathan M. , Morton Connor A. , Al-Saadi Sam , Villadolid Desireé , Cooper Jennifer , Bowers Carl , Rosemurgy Alexander S.
Published: June 2020

Diagnostic imaging, surgical care, and perioperative morbidity and mortality have significantly improved for patients undergoing resections for pancreatic adenocarcinoma. This study was undertaken to define the natural history and patterns of recurrence of resected pancreatic cancer without neoadjuvant or adjuvant therapies using current standards of care. Sixty-one patients underwent pancreatectomy without neoadjuvant or adjuvant therapy. Tumors were staged according to the American Joint Committee on Cancer (AJCC) classification system. CT scans were obtained every 3 months and recurrence categorized as: liver only, local, distant, multiple sites, or clinical. Median survival after pancreatectomy was 12 months. Cancer recurred in 51 (84%) patients. The radiographic site of initial recurrence did not generally impact survival; patients initially recurring at multiple sites had significantly abbreviated median survival of 5.6 months. AJCC stage was found to correlate with disease-free and overall survival, although tumor size alone did not. The presence of lymphatic metastasis correlated with disease-free but not overall survival. Overall survival after pancreaticoduodenectomy remains poor in the absence of neoadjuvant or adjuvant therapy. AJCC stage is the best predictor of disease-free and overall survival; tumor size, lymph node status, and site of recurrence alone do not impact survival in a meaningful way.