bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing Dust Using the Electrocautery Pencil with Suction Combined with the Infusion Catheter in Mastectomy
Authors: Hou Ming-Feng , Lin Gau-Tyan , Tang Chao-Shun , Chu Ying-Lan , Liu Hsiu-Chin , Huang Tsung-Jen , Chao Yu-Ying , Yang Chun-Yuh
Published: November 2022

The dust from the vaporized tissue released during a mastectomy presents a hazard to the patients and the operating room personnel. More dust has been noted using the conventional electrocautery pencil in dissecting breast tissue than with the metal knife used in the past. It is very important to reduce the hazardous dust released during mastectomy. For this study 80 patients undergoing mastectomy for breast cancer from March to June 2001 were divided into two groups: 1) those whose dissections were performed with a combination of an electrocautery pencil and suction with an intravenous infusion catheter (40 cases) and 2) those whose dissections were performed with the conventional method in which the electrocautery pencil was handled by the surgeon and the metal suction tube was used separately by an assistant (40 cases). During mastectomy the personal air sampler was affixed to the operator's neck to collect the dust from the vaporized tissue. The concentrations of the total dust were significantly lower in the combined electrocautery-suction method (mean 5.56 ± 3.26 μg/m3) than in the conventional method (mean 34.81 ± 4.83 μg/m3) during mastectomy ( P < 0.05). Although the operating time and blood loss were less in the combined method than in the conventional method this difference was not statistically significant ( P > 0.05). The combined method of using the electrocautery pencil for dissecting breast tissue along with the intravenous infusion catheter reduced the concentrations of the total dust from the vaporized tissue plume. Furthermore this method reduces the hazards of dust to the surgeons and operating room personnel. Additionally the cost of this combined method is lower than that of the conventional method.
Transcatheter Arterial Chemoembolization with or without Radiofrequency Ablation in the Management of Patients with Advanced Hepatic Malignancy
Authors: Bloomston Mark , Binitie Odion , Fraiji Elie , Murr Michel , Zervos Emmanuel , Goldin Steven , Kudryk Bruce , Zwiebel Bruce , Black Thomas , Fargher Scott , Rosemurgy Alexander S.
Published: November 2022

Transcatheter arterial chemoembolization (TACE) is efficacious against hepatic malignancies by rendering tumors ischemic while delivering high-dose chemotherapy. The added benefit of radiofrequency ablation (RFA) has not been determined. We sought to review our experience with TACE with or without RFA in the treatment of hepatocellular carcinoma and colorectal liver metastases in patients not amenable to resection. TACE and RFA were undertaken in 13 patients with hepatocellular carcinoma (n = 7) or colorectal liver metastases (n = 6). Concurrently 24 patients underwent TACE alone for hepatocellular carcinoma (n = 15) or colorectal liver metastases (n = 9). Patients undergoing TACE with or without RFA were similar in age, gender, and diagnosis. Overall follow-up was 9.1 months ± 7.1. One-year survival was greater in patients undergoing TACE with RFA than with TACE alone (100% vs 67%, P = 0.04). Mean survival was longer after TACE with RFA compared with TACE alone (25.3 months ± 15.9 vs 11.4 months ± 7.3, P < 0.05). No patients suffered significant complications. The addition of RFA to TACE improves survival in patients with unresectable primary or metastatic hepatic malignancies. RFA with TACE should be in the armamentarium of surgeons caring for patients with malignant liver lesions.
Benign Anatomical Mistakes: Right and Left Coronary Ligaments
Authors: Mirilas Petros , Skandalakis J.E.
Published: November 2022

Peritoneal attachments of the liver to the diaphragm include the falciform ligament, the left triangular ligament, and the coronary ligament with the right triangular ligament. It is often surgically convenient when the gastroesophageal junction is explored to refer to a “right” and a “left” coronary ligament, but this is anatomically unjustified. To reassess the issue there are no “right” and “left” coronary ligaments; there are only the left triangular ligament and the complex of coronary and right triangular ligament. The latter is the lateral unification of the layers of the coronary ligament. The liver is posteriorly connected to the diaphragm, and therefore the coronary ligament has superior and inferior layers rather than anterior and posterior layers. Embryologically these ligaments reflect the remnants of the developmental pathways of the liver in the septum transversum, and in the mature organism they are peritoneal connections. Besides the liver is suspended in the bare area mostly by fibrous attachments and by the hepatic veins. Consequently the term “ligament” for these structures has to be revised. Therefore we suggest the terms “left triangular peritoneal attachment” of the liver and “coronary peritoneal attachment” instead of “left triangular ligament” and “coronary ligament.”
High-Frequency Percussive Ventilation as a Salvage Modality in Adult Respiratory Distress Syndrome: A Preliminary Study
Authors: Paulsen Stephen M. , Killyon Garry W. , Barillo David J.
Published: November 2022

Despite multiple advances in critical care patients with severe adult respiratory distress syndrome (ARDS) can exhaust the capability of conventional ventilation; this results in respiratory failure and death. High-frequency percussive ventilation (HFPV), which was initially utilized for salvage of burn patients with smoke inhalation injury refractory to conventional ventilation, has evolved as a standard of burn care. Based on our experience with HFPV in burn patients the burn team was consulted to provide salvage ventilation for non-burn surgical intensive care unit patients with refractory respiratory failure. Over a 14-month period ten patients with refractory ARDS from multiple causes were treated. Retrospective chart review was performed. Respiratory parameters were assessed before and 24 hours after initiation of HFPV. Mean values of fraction of inspired oxygen (Fio2), pH, partial pressure of O2 in arterial blood (Pao2), partial pressure of CO2 in arterial blood (Paco2), HCO3, oxygen saturation in arterial blood (Sao2), Pao2/Fio2, and peak inspiratory pressure were compared. Significant improvement in oxygenation was reflected by increases in Sao2, Pao2, and the Pao2/Fio2 ratio in the first 24 hours of HFPV. No significant increase in peak inspiratory pressure was documented by conversion from conventional ventilation to HFPV. No hemodynamic changes directly associated with HFPV were noted. Seven of ten patients failing conventional ventilation survived to hospital discharge after salvage therapy with HFPV. We advocate further studies of HFPV in non-burn patients with ARDS both as salvage therapy and as replacement for conventional ventilation for the initial treatment for ARDS.
In Vitro Immunomodulatory Effects of Herbal Products
Authors: Wilasrusmee Chumpon , Siddiqui Josephine , Bruch David , Wilasrusmee Skuntala , Kittur Smita , Kittur Dilip S.
Published: November 2022

Immunosuppressive drugs have been developed from natural products such as soil and fungi, which are also the sources of some commonly used herbal products. However, the effect of herbal products on immune response has not been investigated. Because these products can affect the host immune system they can induce either rejection or tolerance after a transplant procedure. To investigate the effects of ten commonly used herbal products on transplant-related immune function we performed in vitro lymphocyte proliferation tests using phytohemagglutinin, mixed lymphocyte culture (MLC) assay, and interleukin (IL)-2 and IL-10 production from MLC. Dong quai, ginseng, and milk thistle had nonspecific immunostimulatory effects on lymphocyte proliferation, whereas ginger and green tea had immunosuppressive effects. Dong quai and milk thistle increased alloresponsiveness in MLC, whereas ginger and tea decreased these responses. The immunostimulatory effects of dong quai and milk thistle were consistently seen in both cell-mediated immune response and nonspecific lymphoproliferation, whereas that of ginseng was not The immunosuppressive effect of green tea and ginger were mediated through a decrease in IL-2 production, but the immunostimulatory effects of dong quai and milk thistle were not. We conclude that green tea, dong quai, ginseng, milk thistle, and ginger have effects on in vitro immune assays that may be relevant in transplantation in humans.
Massive Incisional Hernia of the Bowel and Urinary Bladder: A Case Report
Authors: Boughey Judy C. , Nottingham James M.
Published: November 2022

Abdominal hernias are not rare in women, but incisional bladder herniation is uncommon. Incisional hernias are an iatrogenic condition caused by protrusion of the abdominal viscera through the abdominal fascia. Omentum and small intestines are by far the most common viscera involved, and the condition is diagnosed on clinical examination either visually or by palpation of an abdominal bulge. We describe a case of bladder and bowel herniation through a lower transverse abdominal incision (Pfannenstiel), which followed emergent operative intervention for ectopic pregnancy.
Dialysis Access-Induced Superior Vena Cava Syndrome
Authors: Madan Atul K. , Allmon Jon C. , Harding Michael , Cheng Stephen S. , Slakey Douglas P.
Published: November 2022

Vascular thrombosis is a complication of dialysis access and thrombosis of the superior vena cava by indwelling dialysis catheters access can cause superior vena cava syndrome. We describe a case of superior vena cava syndrome resulting from a dialysis access catheter placed in the internal jugular vein. Although surgical intervention is often needed to treat dialysis access-related superior vena cava syndrome this patient required only conservative measures for resolution of the syndrome. In this paper we describe the presentation, diagnosis, and management of this case. A review of dialysis access thrombosis complications and treatment options is also presented.
Benign Anatomical Mistakes: Inferior Pulmonary Ligament
Authors: Mirilas Petros , Siatitsas Yanis , Skandalakis J.E.
Published: November 2022

The term inferior pulmonary ligament needs to be revised. There is no superior component to oppose the inferior. By all means the pulmonary ligament is not a ligament, and the term ligament should be reserved for regularly oriented thick connective tissue bundles between bones. The term triangular ligament describes its shape but not its topography. For most surgeons the broad ligament refers, rather, to the ligament of the uterus. Embryologically pulmonary ligament is a “meson” i.e., a remnant of the developmental pathway—the pleural fold in this case—and taking this into consideration the most convenient term seems to be mesopneumonium. Its upper part is related to the hilar area, and its lower free border is what we call pulmonary ligament. We suggest the term mesopneumonium to describe the whole “meson” from the mediastinum to the hilum, which corresponds better to topography, embryology, and function.
Lymphatic Mapping for Gastric Adenocarcinoma
Authors: Hundley Jon C. , Shen Perry , Shiver Stephen A. , Geisinger Kim R. , Levine Edward A.
Published: November 2022

The role of lymphadenectomy for gastric carcinoma has been debated for decades. Lymphatic mapping has revolutionized the treatment of melanoma and breast cancer. However, its potential utility in guiding lymphadenectomy for gastric carcinoma is unknown. Therefore we initiated a trial to investigate lymphatic mapping for gastric carcinoma at Wake Forest University Baptist Medical Center. Lymphatic mapping for gastric carcinoma was attempted in 14 cases of gastric carcinoma. Mapping was performed by perilesional injection of isosulfan blue and the first node in the draining basin was harvested and sent fresh to pathology. Sentinel lymph nodes (SLNs) were evaluated by hematoxylin and eosin (H&E) staining. Immunohistochemical analysis was performed on all SLNs that were found to be negative on initial histologic studies. Radical gastrectomy with celiac node dissection was performed in all cases. SLNs were identified in 14 cases. In one case the technique was abandoned because of bulk nodal disease. The average number of SLNs found in each case was 2.8 with a range of one to five. Eight of 14 patients were found to have SLNs positive for metastatic carcinoma. In seven of these patients pathologic analysis of the final resection specimen confirmed the presence of nodal disease. In one case carcinoma was found in a SLN on touch preparation and no nodal disease was noted in the resection specimen. Immunohistochemical studies performed on SLNs found to be negative on initial H&E histologic analysis failed to reveal the presence of carcinoma. The overall sensitivity and specificity were found to be 72.7 and 75 per cent, respectively. Lymphatic mapping is technically possible in the setting of gastric carcinoma and SLNs can be successfully identified in the majority of cases. Upstaging occurred in one case which may have ramifications for adjuvant therapy. SLN positivity accurately predicts the presence of additional nodal disease beyond the SLN in the final resection specimen (positive predictive value 89%). However, SLN negativity does not definitively prove that the remaining nodal basin is free of disease (negative predictive value 50%). Lymphatic mapping for gastric carcinoma is a promising technique worthy of further investigation.
Surgical Experience in Fifty-Five Consecutive Reoperative Fundoplications
Authors: Heniford B. Todd , Matthews Brent D. , Kercher Kent W. , Pollinger Harrison , Sing Ronald F.
Published: November 2022

Laparoscopic antireflux surgery has dramatically changed the way heartburn and regurgitation have been managed over the last 10 years. The possibility of surgical correction with limited morbidity has resulted in a substantial increase in the number of fundoplications performed. Given that the rate of operative failure can be expected to be constant the need for surgical management of recurrent symptoms will become more prevalent. Between August 1996 and December 2001 55 patients presented with recurrent symptoms after a previous antireflux surgery. The presentation, management, and operative outcomes of patients undergoing reoperative fundoplication were studied. The 55 patients (25 male and 30 female) had a mean age of 47.1 years (range 22–69 years). Mean laparoscopic operative time was 234 minutes (range 180–330 minutes), and mean open time was 261 minutes (range 150–390 minutes). A laparoscopic repair was attempted in 45 patients and was completed without conversion in 37 (82.3%); seven of the eight patients requiring conversion had at least one prior open antireflux procedure. Average length of stay was 4.6 days (range one to 46 days); laparoscopic patients were in the hospital an average of 2 days (range one to 6 days). There were eight (12.7%) perioperative complications, no esophageal leaks, and no deaths. Average follow-up was 21.3 months (range 1–65 months). In patients who had a definitive antireflux procedure (53) 49 (92.5%) reported good to excellent outcomes; four had fair outcomes. All stated they were improved. Four patients reported occasional dysphagia, three reported intermittent nausea, five have infrequent to frequent chest pain, and four have diarrhea at least weekly. Despite being technically difficult reoperative fundoplication effectively alleviates dysphagia, regurgitation, and reflux symptoms in the majority of patients with low operative morbidity. The operation can be completed laparoscopically in most of those whose original operation was performed laparoscopically.
Thigh Compartment Syndrome after Acute Ischemia
Authors: Best Irwin M. , Bumpers Harvey L.
Published: November 2022

Thigh compartment syndrome (TCS) is a poorly recognized clinical condition that may follow reperfusion of acutely ischemic thigh muscles. The anterior muscle group appears to be at greatest risk because of its layered arrangement. Intense pain, swelling, and elevated compartment pressures characterize the early presentation in the affected muscle group. If untreated myonecrosis, myoglobinuria, and renal failure may result. TCS was observed in a patient who was treated for a gunshot wound to the left thigh. The superficial femoral and profunda femoris veins as well as the profunda femoris artery were disrupted. The superficial femoral vein and profunda femoris artery injuries were repaired but the mangled branches of the profunda femoris vein were ligated. Postoperatively he developed intense thigh pain, swelling, and elevated compartment pressures. Lateral thigh fasciotomy, extensive debridement of necrotic muscle, and delayed wound closure resulted in a full recovery. Physicians should recognize the numerous clinical circumstances that could lead to TCS—particularly those associated with trauma or physical activity. Timely recognition and intervention may be both limb and life saving. Associated irreparable injury to the profunda femoris vein may aggravate this condition.
Benign Anatomical Mistakes: Incidentaloma
Authors: Mirilas Petros , Skandalakis J.E.
Published: November 2022

The concept of the “incidentaloma,” a totally asymptomatic nonfunctional tumor that is clinically and biochemically silent and discovered “incidentally” in a totally asymptomatic patient, is a by-product of the evolving diagnostic techniques of the last three decades. Various authors have used the concept for “incidental” findings during diagnostic workup for symptoms unrelated to adrenal disease, or for “incidental” adrenal tumors unrelated to symptoms that could potentially be of adrenal origin. “Incidentaloma” has been used to encompass a wide and heterogeneous spectrum of pathologic entities including adrenocortical and medullary tumors, benign or malignant lesions, hormonally active or inactive lesions, metastases, infections, granulomas, infiltrations, cysts and pseudocysts, hemorrhages, and pseudoadrenal masses. The term “incidentaloma” does not indicate whether the mass is functional, or malignant, or adrenocortical in origin. “Incidentaloma” has also appeared in the literature in reference to other endocrine organs such as pituitary, thyroid, and parathyroids, as well as the liver or kidney. We question the scientific justification for this neologism and suggest that it should be abolished. Questionable lesions should be clearly and simply described as “incidentally found.”
Oral Antibiotics in the Management of Perforated Appendicitis in Children
Authors: Gollin Gerald , Abarbanell Aaron , Moores Donald
Published: November 2022

After appendectomy for perforated appendicitis children have traditionally been managed with intravenous broad-spectrum antibiotics for 5 to 10 days and then until fever and leukocytosis have resolved. We prospectively evaluated a protocol of hospital discharge on oral antibiotics when oral intake is tolerated—regardless of fever or leukocytosis—in a consecutive series of 80 children between one and 15 years of age who underwent appendectomy (38 open and 42 laparoscopic) for perforated appendicitis. At discharge subjects began a 7-day course of oral trimethoprim/sulfamethoxazole and metronidazole. Patients were discharged between 2 and 18 days postoperatively (mean 5.3 days). Sixty-six were discharged on oral antibiotics, and 28 of these had persistent fever or leukocytosis. Two patients (2.5%) developed postoperative intra-abdominal abscesses while inpatients. Wound infections developed in seven patients (8.8%) four of whom were on intravenous antibiotics. Among the 66 children who were discharged on oral antibiotics without having had an inpatient infectious complication there were three wound infections (4.4%). None of these patients had a fever or leukocytosis at discharge. We conclude that after appendectomy for perforated appendicitis children may be safely discharged home on oral antibiotics when enteral intake is tolerated regardless of fever or leukocytosis.
Are Preoperative Serum Calcium, Parathyroid Hormone, and Adenoma Weight Predictive of Postoperative Hypocalcemia?
Authors: Strickland Pamela L. , Recabaren James
Published: November 2022

The objective of this study is to determine whether preoperative serum calcium, parathyroid hormone, or adenoma weight is predictive of postoperative hypocalcemia after removal of a parathyroid adenoma. A retrospective chart review was performed for consecutive parathyroidectomy patients over a 6-year period at a community-based teaching institution. Patients with renal failure (serum creatinine >1.7), hyperplastic disease, and parathyroid carcinoma were excluded. The outcome measures were postoperative serum calcium and the presence of signs or symptoms such as paresthesias, anxiety, or Chvostek's sign. One hundred forty-one patients underwent parathyroidectomy during the study period. Fifty-four patients were excluded as a result of hyperplastic disease, renal failure, carcinoma, or unavailable records. Of the remaining 87 patients 25 (28.7%) developed hypocalcemia (serum calcium <8.0), and ten patients (11.5%) developed symptoms. The mean preoperative calcium levels for the normocalcemic and hypocalcemic groups were 10.9 and 10.6, respectively (P < 0.217). The mean preoperative parathyroid hormone levels (normal 10–54) were 214 and 139, respectively (P < 0.305), and the mean adenoma weights were 1.059 and 1.337 g respectively (P < 0.343). This study demonstrates no statistically significant difference in the mean preoperative serum calcium levels, parathyroid hormone levels, or adenoma weight between normocalcemic and hypocalcemic patients postoperatively.
Complications of Hemodialysis Access in HIV-Positive Patients
Authors: Gorski Tito F. , Gorski Yara C. , Muney John
Published: November 2022

As long-term arteriovenous (AV) access for hemodialysis becomes more prevalent in human immunodeficiency virus (HIV)-positive patients it is important to evaluate the complications associated with each surgical technique. The records of 37 consecutive HIV-positive patients undergoing surgery for AV hemodialysis access were reviewed. Cases were analyzed for age, gender, presence of acquired immunodeficiency syndrome (AIDS), surgical procedure, and complications. AV fistulas were performed primarily in 23 patients, and prosthetic grafts were used in 14. There was no difference between these two groups in regard to age (P = 0.510), gender (P = 0.620), or presence of AIDS (P = 0.97). Complications requiring one or more reoperations occurred in four patients (17%) after AV fistulas and in seven patients (50%) after AV grafts (P = 0.035). When reoperations were accounted for a total of 28 AV fistulas and 20 AV grafts were performed with an overall complication rate of 21 and 70 per cent respectively (P = 0.001). Complications after AV grafts included thrombosis (40%), infection (25%), and aneurysm (5%). Thrombosis was the only complication observed after AV fistula (21%). The complication rate after AV access in HIV-positive patients was significantly greater after AV graft insertion than after AV fistulas, which resulted in a higher rate of reoperation. AV fistula when feasible should be considered the procedure of choice in this group of patients.
Intensive Care Unit Outcome of Vehicle-Related Injury in Elderly Trauma Patients
Authors: Hui Thomas , Avital Itzhak , Soukiasian Harmik , Margulies Daniel R. , Shabot M. Michael
Published: November 2022

Vehicle-related trauma is a common mechanism of injury in elderly (age ≥65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.
A Novel Approach to the Treatment of Gunshot Injuries to the Sacrum
Authors: Dunne James R. , Bochicchio Grant V. , Scalea Thomas M.
Published: November 2022

Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5–9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.
Trends in Preparation for Colorectal Surgery: Survey of the Members of the American Society of Colon and Rectal Surgeons
Authors: Zmora Oded , Wexner Steven D. , Hajjar Luay , Park Taeseok , Efron Jonathan E. , Nogueras Juan J. , Weiss Eric G.
Published: November 2022

The utility of antibiotic and mechanical preparation for colorectal surgery is controversial, and numerous different regimens are used. The aim of this study was to detect trends in preparation for surgery among American colon and rectal surgeons. Members of the American Society of Colon and Rectal Surgeons practicing in the United States were surveyed with a postal questionnaire regarding their routine preparations for colon and rectal surgery. Five hundred fifteen (40%) of the 1295 questionnaires sent were returned. Eighty-one per cent of the respondents had completed an accredited colorectal training program, and the average experience in practice was 13.7 (±8.7) years. Half of the surgeons felt that prophylactic oral antibiotic is essential, 41 per cent felt it was doubtful, and 10 per cent considered oral prophylaxis unnecessary. Despite these statements 75 per cent of the surgeons routinely utilized oral antibiotics (96% of them used a combination of two drugs), 11 per cent used them selectively, and only 13 per cent omitted oral prophylaxis from their practice. Similarly although the usefulness of intravenous antibiotics was questioned by 11 per cent of the surgeons 98 per cent routinely used them. The average number of postoperative doses was two (±1.9). Although 10 per cent of the surgeons questioned the importance of mechanical preparation more than 99 per cent routinely used it. Forty-seven per cent of the surgeons used sodium phosphate, 32 per cent used polyethylene glycol, and 14 per cent alternated between these two options. We conclude that although the use of oral antibiotic prophylaxis for colorectal surgery is controversial among surgeons it is still routinely practiced by 75 per cent. Intravenous antibiotic prophylaxis and mechanical cleansing, however, are still a dogma and almost invariably used. There is a trend toward the use of a shorter course of postoperative intravenous antibiotics and the use of sodium phosphate for mechanical cleansing.
Liposarcoma of the Spermatic Cord Masquerading as an Incarcerated Inguinal Hernia
Authors: Hassan J. Matthew , Quisling Susannah V. , Melvin Willie V. , Sharp Kenneth W.
Published: November 2022

We present a rare case of liposarcoma of the spermatic cord. There are only 61 reports in the literature. The presenting complaint is usually a painless bulge in the inguinal or scrotal region. Our patient presented with a new-onset inguinoscrotal swelling that was misdiagnosed preoperatively as an incarcerated indirect hernia. The treatment for a spermatic cord liposarcoma is radical orchiectomy with high ligation of the cord. Radiation therapy is recommended in addition to surgery in situations with evidence of tumor with propensity for more aggressive behavior (i.e., high-grade tumor, lymphatic invasion, inadequate margin, or recurrence). The current literature, diagnosis, and management of malignant tumors of the spermatic cord are reviewed.
Perianal Mucinous Adenocarcinoma: Unusual Case Presentations and Review of the Literature
Authors: Schaffzin David M. , Stahl Thomas J. , Smith Lee E.
Published: November 2022

Perianal mucinous adenocarcinoma is a rare cancer constituting 3 to 11 per cent of all anal carcinomas. It may arise de novo or from a fistula or abscess cavity. We present two cases of this disease process. Case One is a 52-year-old man with a chronic history of perianal abscesses who presented to the emergency room with a large bowel obstruction. He required diversion and wide local excision with lateral internal sphincterotomy for relief of the obstruction. Pathology from the excised material revealed the unexpected diagnosis of invasive mucinous adenocarcinoma of the anus. Case Two is a 59-year-old man with a chronic history of complex fistulas and abscesses who presented to our office with a horseshoe fistula and deep postanal space abscess. Because of the nonhealing nature of the wound, biopsies from the abscess crater, fistulous tract, and the perianal skin opening were taken. The pathology department identified the specimens as invasive mucinous adenocarcinoma of the anal canal. This is an aggressive cancer often misdiagnosed clinically as benign pathology. A high index of suspicion and biopsy of fistulous tracts and abscesses are the keys to early diagnosis and treatment. With combination chemotherapy and radiation therapy in conjunction with aggressive surgical resection long-term survival might be obtained.
Greater Local Recurrence Occurs with “Berry Picking” than Neck Dissection in Thyroid Cancer
Authors: Musacchio Michael J. , Kim Anthony W. , Vijungco Joseph D. , Prinz Richard A.
Published: November 2022

Managing cervical lymph node metastases in well-differentiated thyroid cancer with either “berry picking” (BP) or anatomic neck dissection (AND) has not been shown to alter survival. Nevertheless local control of thyroid cancer is important. The purpose of this study is to determine whether the local recurrence rate of well-differentiated thyroid cancer is equivalent with BP versus AND. A retrospective analysis revealed 41 patients with well-differentiated thyroid cancer and cervical node metastases seen by a single surgeon from 1985 to 2002. A total of 83 initial and repeat neck operations were performed (nine BPs, 30 central neck dissections, and 44 modified radical neck dissections). Recurrence of cancer, intervention for recurrence, and complications of the BP and AND groups were evaluated. All nine (100%) patients undergoing a limited BP operation had local recurrence of cancer. Only three of the 32 (9%) patients undergoing an initial formal neck operation had local recurrence of tumor. The recurrences after BP (100%) were significantly greater than the recurrences after AND (9%) ( P < 0.001). The incidence of surgical complications with BP and AND was not different. Six of 32 (19%) initial formal neck dissection patients and four of nine (44%) BP patients had surgical complications. We conclude that BP is associated with greater local recurrence of thyroid cancer. Patients with nodal metastases should be managed with ANDs.
Paravertebral Block: An Alternative to General Anesthesia in Breast Cancer Surgery
Authors: Najarian Melissa M. , Johnson Jeanne M. , Landercasper Jeffrey , Havlik Paul , Lambert Pamela J. , McCarthy David
Published: November 2022

Alternative forms of anesthesia in breast cancer patients have been sought to reduce the untoward effects of general anesthesia. The purpose of this study was to compare paravertebral block (PVB) and general anesthesia (GA) in terms of pain control, postoperative nausea and vomiting, and resumption of diet in patients undergoing operations for breast cancer. A retrospective chart review was performed on all patients (289) undergoing breast cancer surgery from May 1, 1999 through December 31, 2000 with PVB or GA. The PVB (n = 128) and GA (n = 100) groups had similar demographics. Postoperative narcotics were given to 80.8 and 93 per cent of PVB and GA patients, respectively ( P < 0.01), after an average of 216 and 122 minutes from the end of surgery ( P = 0.028). The PVB group received 6.2 narcotic units compared with 10.1 in the GA group ( P = 0.04). Postoperative nausea and vomiting was present in 16.8 and 24 per cent of patients in the PVB and GA groups, respectively ( P = 0.12). A diet was tolerated on the same day of surgery by 98.4 and 82 per cent of PVB and GA patients, respectively ( P < 0.01). The complication rate of PVB was 1.8 per cent. PVB resulted in better postoperative pain control and earlier resumption of diet compared with GA. The good success rate and low complication rate of PVB make it well suited for breast cancer surgery and can eliminate the need for GA in patients with serious comorbidities.
Factors Influencing Outcome in Delayed Primary Closure of Contaminated Abdominal Wounds: A Prospective Analysis of 181 Consecutive Patients
Authors: Bender Jeffrey S.
Published: November 2022

Delayed primary closure (DPC) is an accepted method in the management of contaminated abdominal wounds. Clinical factors predicting its success have not been studied. Over a 14-year period 181 patients presenting to a single surgeon with Class IV abdominal wounds were managed by a standardized protocol. Initial saline gauze packing was left undisturbed until the wound was visually inspected on postoperative day 3. Clean wounds were closed using Steri-Strips. Visible purulence was managed by dressing changes. There were 103 males and 78 females with an average age of 48.5 years (range, 11–92 years). DPC was performed on 144 patients of whom four (2.8%) developed wound infections. The factors associated with the development of wound pus before DPC in the remaining patients were: requirement for mechanical ventilation for more than 72 hours, presence of severe pre-existing systemic disease, and trauma. Other diagnoses, length and type of incision, and presence of shock had no effect on outcome. An intra-abdominal abscess developed in 11 patients with early wound purulence versus none in those undergoing DPC ( P < 0.001). DPC is a safe wound management technique that can be effectively applied in the large majority of patients with dirty abdominal wounds. The appearance of wound purulence before DPC is a harbinger that identifies those patients at risk for late intra-abdominal infections.
Minimally Invasive Surgery for Pediatric Solid Neoplasms
Authors: Sailhamer Elizabeth , Jackson Carl-Christian A. , Vogel Adam M. , Rang Sam , Wu Yeming , Chwals Walter J. , Zimmerman Beth T. , Hill Charles B. , Liu Donald C.
Published: November 2022

The role of minimally invasive surgery (MIS) in children with solid neoplasms is slowly evolving. MIS appears to be an ideal way to obtain diagnostic information (i.e., tissue biopsy) in children with solid neoplasms, but its role as an ablative/curative technique is controversial. We examined the safety, reliability, and outcome of decisions made on the basis of MIS performed in children with solid neoplasms. A total of 28 children (19 boys and nine girls; age range, 14 months to 17 years) with solid neoplasms underwent 29 MIS procedures between July 1, 2000 and June 30, 2002. Complications, biopsy results, and outcomes were reviewed. Successful ablation via MIS was defined as clear microscopic margins on permanent pathology and no evidence of remnant disease on follow-up diagnostic radiological examination. There were 20 thoracoscopic and nine laparoscopic procedures. Laparoscopy included purely diagnostic without tissue biopsy or simply determination of resectability (two), incisional biopsy (two), and excisional biopsy (five; two adrenalectomy and three oophorectomy). Thoracoscopy included 15 lung biopsies and five biopsies of mediastinal masses. Diagnostic accuracy was 100 per cent in all cases. MIS as an ablative technique was successful in 10 of 10 cases. No children were found retrospectively to have been inadequately treated via MIS. We conclude that MIS can be used safely and successfully to diagnose children with suspicious solid neoplasms. Furthermore MIS may have a role as an ablative/curative technique in carefully selected circumstances.
Isolated Internal Iliac Artery Aneurysm Resection and Reconstruction: Operative Planning and Technical Considerations
Authors: Philpott Jonathan M. , Parker Frank M. , Benton Cammy R. , Bogey William M. , Powell C. Steven
Published: November 2022

Isolated iliac artery aneurysms are rare but dangerous aneurysms associated with a high incidence of rupture (between 14 and 70%). Rupture is frequently associated with an exceedingly high mortality primarily because of the elusive nature of the presenting symptoms and the resulting major delays in treatment. Accordingly these aneurysms are best managed aggressively. Although emerging endovascular techniques show promise surgical resection and reconstruction remains the gold standard for definitive management and has withstood the test of time with excellent durable and unparalleled results. That said, from an operative perspective these aneurysms are technically demanding and remain one of the more formidable technical challenges in vascular surgery. To highlight the key elements involved in a successful repair we present a right internal iliac artery aneurysm with an associated contralateral common iliac artery occlusion, review the necessary preoperative planning and the available surgical treatment options, and detail the technical steps leading to a successful reconstruction. Careful operative planning is critical. Inadequate preoperative studies, inadequate preoperative decision making, and a poorly formulated operative strategy can lead to catastrophic results. Some of the most feared complications include pelvic venous injury with resulting massive hemorrhage and postoperative pelvic ischemia (with resulting rectal and/or spinal cord ischemia) which occurs as a result of inadequate contralateral collateral pelvic blood flow when the internal iliac artery is not reimplanted. Accordingly the preoperative workup must include a careful analysis of the adequacy of the contralateral pelvic blood flow to supply collateral flow in the event that the internal iliac is not reimplanted. In the presence of compromised contralateral internal iliac perfusion, resection and reconstruction or an alternative form of pelvic revascularization is mandatory. Excellent and unencumbered exposure is mandatory for a safe and successful repair. The retroperitoneal approach as illustrated in this case is strongly recommended. Although it is challenging excellent results can be achieved by resection of the aneurysm and reconstruction.
Mini-Laparotorny Cholecystectomy in the Era of Laparoscopic Cholecystectomy: A Community-Based Hospital Perspective
Authors: Oyogoa Sylvanus O. , Komenaka Ian K. , Ilkhani Rahman , Wise Leslie
Published: November 2022

Laparoscopic cholecystectomy is clearly the gold standard for symptomatic cholelithiasis. Open cholecystectomy is now reserved for difficult and problematic cases. The purpose of this paper is to propose that mini-laparotomy cholecystectomy (minicholecystectomy) can be as effective as laparoscopic cholecystectomy. This paper compares the two techniques in well-matched patients. In addition mastery of this technique is practical and rewarding and should be part of the repertoire of the general surgeon. We conducted a retrospective review of the experience of a single surgeon at a community-based teaching hospital over a 2-year period for minicholecystectomy and laparoscopic cholecystectomy. Sixty-six patients were matched for age, sex, body surface area, and Acute Physiology and Chronic Health Evaluation II score. The absolute cost was lower for the minicholecystectomy group than for the laparoscopic cholecystectomy group. The operating room times were not significantly different in the two groups ( P value 0.79). The average length of stay and the average amount of intramuscular analgesia required for the two groups were also not significantly different ( P values 0.69 and 0.35, respectively). Although subjective postoperative satisfaction was equal for both groups the minicholecystectomy group had no complications whereas the laparoscopic group had two (myocardial infarction and cystic duct stump leak) complications. We conclude that minicholecystectomy can be used as a viable alternative to laparoscopic cholecystectomy especially in patients who cannot tolerate laparoscopic procedures and in areas where cost containment is critical.
Multimodality Management of Locally Advanced Rectal Cancer
Authors: Moore Harvey G. , Guillem Jose G.
Published: November 2022

Despite the routine use of adjuvant chemoradiation for curatively resected stage II and III rectal cancer a significant percentage of patients ultimately fail locally and/or distally; this underscores the need for continued improvement in the efficacy of combined-modality therapy and quality of rectal cancer resection. The recognition of the significance of lateral or circumferential margins of resection has paralleled the widespread use of total mesorectal excision. In addition to facilitating negative margins of resection and local control, sharp mesorectal techniques also facilitate identification and preservation of pelvic autonomic nerves thereby greatly reducing the incidence of urinary and sexual dysfunction following radical resection. Lastly, restorative options can result in excellent bowel function in carefully selected patients undergoing a “very low” anterior resection. Efforts are currently directed at identifying the subset of locally advanced rectal cancer patients who may be adequately treated with a resection alone thereby avoiding the added morbidity of adjuvant radiation and chemotherapy.
Inhibition of Graft Coronary Arteriosclerosis after Heart Transplantation
Authors: Soukiasian Harmik J. , Czer Lawrence S.C. , Wang Hai-Mei , Luthringer Daniel , Wang Charles , Kamlot Andreas , Quartel Adrian , Trento Alfredo
Published: November 2022

Graft coronary arteriosclerosis (GCA) is the leading cause of long-term mortality after heart transplantation (HTx). The goal of this study was to demonstrate that inhibition of immune-mediated injury by cyclosporine (CsA) protects the allograft from GCA. ACI-to-Lewis rat allografts were disparate in major and nonmajor histocompatibility loci. Isografts (Lewis-Lewis) were controls. Treatment groups received either olive oil or CsA at 2.5, 5, 10, or 20 mg/kg/day for 3 months. Histology (elastin) and immunohistochemistry using monoclonal antibodies to CD4, CD8, CD45R, RT1B, CD11b/c, CD25, and α-actin was performed to examine the epicardial and intramyocardial coronary arteries. Computerized image morphometry was utilized to measure intimal and medial thickness and area. Rats receiving olive oil or CsA at 2.5 mg/kg/day had severe rejection and no graft survival. CsA at 5 mg/kg/day resulted in less severe rejection with significant intimal and medial proliferation ( P < 0.001). CsA at 10–20 mg/kg/day paralleled Lewis-Lewis isograft outcomes and inhibited arteriosclerotic vascular changes in the allograft ( P < 0.001). Perivascular T-helper cells and macrophages were a characteristic finding with low-dose CsA but rare with higher CsA doses. In this new model of accelerated GCA in rats, immune-mediated antigen-dependent vasculopathy as a result of inadequate immunosuppresion is fundamental in the development of GCA, which appeared equally in epicardial arteries and intramyocardial arterioles. CsA prevents GCA in a dose-dependent fashion in the rat allograft.
Symptoms before and after Laparoscopic Cholecystectomy for Gallstones
Authors: Lublin Matthew , Crawford David L. , Hiatt Jonathan R. , Phillips Edward H.
Published: November 2022

Between 1989 and 1995, 1380 patients underwent laparoscopic cholecystectomy for symptomatic cholelithiasis by a single surgical group at a large private teaching hospital. Thirteen hundred surveys were mailed, and 573 (44.3%) were completed at least 6 months postoperatively. Pain and nonpain symptoms were present preoperatively in 432 (75%) and 457 (80%) patients, respectively. Postoperatively, pain and nonpain symptoms were present in 141 (25%) and 247 (43%) patients, respectively ( P < 0.05). All nonpain symptoms were significantly reduced postoperatively except for diarrhea ( P < 0.05). Longer duration of pain, age < 40, frequent episodes of pain, postprandial pain, and increased sites of pain preoperatively were all predictive of a higher incidence of persistent postoperative pain ( P < 0.05). Persistent nonpain symptoms were more likely if diarrhea, fatty food intolerance, age < 40, or both pain and nonpain symptoms were present preoperatively ( P = 0.05) and less likely if only pain symptoms were present preoperatively ( P = 0.0001). This series quantifies symptom-specific outcomes for the surgeon. While most symptoms improve, a significant number of pain and nonpain symptoms persist after laparoscopic cholecystectomy. With these data, surgeons can modulate postoperative expectations and advise on the possible persistence of symptoms.