bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Excisional Biopsy on the Accuracy of Sentinel Lymph Node Mapping in Early Stage Breast Cancer: Comparison with Core Needle Biopsy
Authors: Forghani Mohammad Naser , Memar Bahram , Jangjoo Ali , Zakavi Rasoul , Mehrabibahar Mostafa , Kakhki Vahid Reza Dabbagh , Kashani Ida , Hashemian Farnaz , Sadeghi Ramin
Published: June 2020

Despite the successful application of sentinel node mapping in breast cancer patients, its use in patients with a history of previous excisional biopsy of the breast tumors is a matter of controversy. In the present study we evaluated the accuracy of sentinel node biopsy in this group of patients and compared the results with those in whom the diagnosis of breast cancer was established by core needle biopsy. Eighty patients with early stage breast carcinoma were included into our study. Forty patients had a history of previous excisional biopsy and the remainder 40 had undergone core needle biopsy. Intradermal injections of 99mTc-antimony sulfide colloid as well as patent blue were both used for sentinel node mapping. Sentinel nodes were harvested during surgery with the aid of surgical gamma probe. All patients underwent standard axillary lymph node dissection subsequently. Detection rate was 97.5 per cent for both groups of the study. Number of detected sentinel node during surgery was not significantly different between groups. False negative rate was 0 per cent for both groups of the study. In conclusion sentinel node biopsy is reliable in patients with previous history of excisional biopsy of the breast tumors and has a low false negative rate.
Gastrointestinal Stromal Tumors: Actin Expression, a New Prognostic Factor?
Authors: Ruiz-Tovar Jaime , Diez-Tabernilla María , Housari Gada , Martinez-Molina Enrique , Sanjuanbenito Alfonso
Published: June 2020

The aim of this study is to analyze the clinical outcome of gastrointestinal stromal tumors (GISTs) and to determine new prognostic factors. We perform a retrospective study of all the patients diagnosed with GIST in any location and operated on between 2000 and 2008 at our institution. We analyzed 35 patients, 16 males (45.7%) and 19 females (54.3%), with a mean age of 64 ± 13.8 years. The tumors were located in the stomach in 22 patients (62.9%), in the small bowel in 10 (28.6%), and the retroperitoneum in three (8.6%). Referring to gastric GIST, endoscopy revealed an ulceration in the mucosa in five cases, suggesting an epithelial neoplasm. In all these cases, pathology of the biopsy specimen was nonconclusive. Survival rate at 1 and 5 years was 94.3 and 88.6 per cent, respectively. Disease-free survival at 1 and 2 years was 91.4 and 88.6 per cent, respectively. Analyzing prognostic factors, a lower disease-free survival was observed among patients with constitutional syndrome at diagnosis ( P = 0.000), small bowel GIST ( P = 0.037), and tumors not expressing actin ( P = 0.015). A lower global survival was observed among men ( P = 0,036), patients with an abdominal mass ( P = 0.033) or with constitutional syndrome ( P = 0.007) at diagnosis and tumors at a retroperitoneal location ( P = 0.0002). Gastric GIST may be confused with epithelial neoplasms, modifying the surgery. In our patients, masculine gender, constitutional syndrome and abdominal mass at diagnosis, small bowel and retroperitoneal location, and actin negative tumors are bad prognostic factors.
Usefulness and Safety of Open Tracheostomy by a Paramedian Approach for Cervical Infection: Esophageal and Tracheal Injury and Necrotizing Fascitis
Authors: Moriwaki Yoshihiro , Sugiyama Mitsugi , Iwashita Masayuki , Harunari Nobuyuki , Toyoda Hiroshi , Kosuge Takayuki , Arata Shinju , Suzuki Noriyuki
Published: June 2020

Tracheostomy is hardly performed in patients with cervical infection close to the site of the tracheostomy. This study aimed to present and clarify the usefulness and safety of open tracheostomy performed by the paramedian approach technique. The procedure is as follows. A 2.5-cm paramedian incision is made for the tracheostomy on the opposite side of infectious focus; the anterior neck muscles are dissected and split; the trachea is fenestrated by a reverse U-shaped incision; and the fenestral flap of the trachea is fixed to the skin. We used this technique in five patients. There were no complications such as bleeding, desaturation, and displacement of the tube; and there were no postoperative complications such as severe contamination or infection of the tracheostomy site from the nearby cervical wound, difficulty in securing the tracheostomy tube and connecting device to the ventilator, difficulties in daily management and care, or dislocation of the tracheostomy tube. All wounds resulting from the tracheostomy were kept separate from and not contaminated by the nearby dirty wounds. Open tracheostomy by the paramedian approach technique is useful and safe for patients with severe cervical infection requiring open drainage and long ventilatory management.
Reduction of Radiation Dose in Pediatric Brain CT is not Associated with Missed Injuries or Delayed Diagnosis
Authors: Arrangoiz Rodrigo , Opreanu Razvan C. , Mosher Benjamin D. , Morrison Chet A. , Stevens Penny , Kepros John P.
Published: June 2020

Increased accuracy of CTs in the identification of traumatic injuries compared with physical examination or conventional radiography is well documented. Our goal was to identify the most effective strategy for decreasing radiation exposure while retaining the benefits of computerized imaging. Based on a literature review and our trauma registry, the mortality risk of untreated injuries was compared with that of patients who received treatment of injuries diagnosed by CT. Because automated exposure control of tube current is not routinely used with brain CT, this region was identified as the initial focus for a dose-saving algorithm. CT settings were adjusted for children studies and the new settings were implemented into four protocols based on age. Images were compared and reviewed by radiologists for the ability to identify traumatic injuries. Effective dose (ED) was estimated using Monte Carlo simulations. The lifetime incidence and mortality for thyroid cancer and leukemia were assessed. In-hospital mortality of unidentified injury in trauma patients is 8.0%. Forty dose-saving CTs were performed and no injuries were missed. The ED decreased by 5.2-, 4.5-, 2.62-, and 2.5-fold in each group. Decreasing the ED is achievable, theoretically decreases the cancer risk and does not increase the missed injury rate.
Univariate and Multivariate Analysis of Prognostic Factors in the Surgical Treatment of Hilar Cholangiocarcinoma
Authors: Ramacciato Giovanni , Nigri Giuseppe , Bellagamba Riccardo , Petrucciani Niccolò , Ravaioli Matteo , Cescon Matteo , Del Gaudio Massimo , Ercolani Giorgio , Di Benedetto Fabrizio , Cautero Nicola , Quintini Cristiano , Cucchetti Alessandro , Lauro Augusto , Miller Charles , Pinna Antonio Daniele
Published: June 2020

Surgery is the only effective treatment able to improve survival of patients with hilar cholangiocarcinoma (CCA). However, the significance of prognostic factors on overall survival is still debated. We evaluated early and long-term outcomes of patients resected for hilar cholangiocarcinoma over a 3-year period to determine the role of prognostic factors and their effect on overall survival. Medical records of patients with hilar CCA who underwent resection between January 2001 and December 2004 were retrospectively reviewed. Univariate and multivariate analysis was performed to identify prognostic factors associated with survival. Thirty-two of 45 patients underwent surgical resection with curative intent. Morbidity was 24.4 per cent; perioperative mortality was 0 per cent. Overall median survival was 22.3 months. Well-differentiated tumor grading and R0 resection were independently associated with better survival at multivariate analysis. Aggressive surgery, including biliary resection combined with major hepatectomy, is a safe procedure with low morbidity and mortality in a tertiary referral hepatobiliary center. The main aim of an aggressive surgical approach is to obtain a microscopic margin-negative resection, which is associated with better prognosis. Another important prognostic factor is tumor grading, which is independently associated with survival.
Use of FDG-PET Imaging for Patients with Disseminated Cancer of the Appendix
Authors: Rohani Payam , Scotti Stephen D. , Shen Perry , Stewart John H. , Russell Gregory B. , Cromer Mary , Levine Edward A.
Published: June 2020

The goal of this study is to evaluate the use of positron emission tomography (PET) in evaluation of patients with peritoneal dissemination of carcinoma of appendiceal origin (PDA). Thirty-three patients with PDA, who had preoperative PET or PET/CT imaging, were analyzed. Using operative, pathology, and PET ± CT data, presence or absence of disease in each abdominal quadrant was noted and the use of 18fluoro-deoxy-glucose (FDG) PET for each quadrant was evaluated. The mean age was 52, and there were 17 males; 58 per cent had low-grade lesions. PET was positive in only 35 per cent of cases overall (30 and 41% sensitivity for low-grade and high-grade, respectively). PET without CT sensitivity for low-grade and high-grade lesions was 21 and 8 per cent, respectively. PET imaging has limited use for patients with PDA. We do not recommend the use of FDG-PET for patients with PDA from cancer of the appendix.
Do Flexion Extension Plain Films Facilitate Treatment after Trauma?
Authors: Duane Therèse M. , Scarcella Nicholas , Cross Justin , Wolfe Luke G. , Mayglothling Julie , Aboutanos Michel B. , Whelan James F. , Malhotra Ajai K. , Ivatury Rao R.
Published: June 2020

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.
Glucose Metabolism, Not Obesity, Predicts Mortality in Critically Ill Surgical Patients
Authors: Mowery Nathan T. , May Addison K. , Collier Bryan C. , Dossett Lesly A. , Gunter Oliver L. , Dortch Marcus J. , Diaz Jose J.
Published: June 2020

Our hypothesis was to determine if insulin resistance and hyperglycemia, rather than obesity, are predictive of mortality in the surgically critically ill. An observational study of an automated protocol in surgical and trauma intensive care units was performed. Two groups were created based on body mass index (BMI): Obese (OB) defined as BMI ≥ 30 (n = 338) and nonobese defined as BMI < 30 (n = 885). Euglycemia was maintained using an automated protocol using an adapting multiplier, which we used as our marker of stress insulin resistance. The primary outcome was hospital mortality. One thousand, two hundred and twenty-three patients met criteria with 73,225 glucose values. The OB group required more insulin (4.5 U/hr vs 3.2 U/hr, P ≤ 0.01) and had a higher mean multiplier (0.07 vs 0.06, P < 0.01) reflecting insulin resistance. There was no difference in mortality between OB and nonobese (11.6% vs 11.5%, P = 0.96). Logistic regression showed that insulin dose (odds ratio 0.864; 95% confidence interval 0.772-0.967, P = 0.01), and not BMI, was an independent predictor of survival in this population. Obesity is not an independent risk factor for mortality in the surgical critical care population. Insulin resistance and subsequent hyperglycemia are increased in obesity and are independent predictors of mortality.
Can Laparoscopic Ileocolic Resection be Performed with Comparable Safety to Open Surgery for Regional Enteritis: Data from National Surgical Quality Improvement Program
Authors: Kirat Hasan T. , Pokala Naveen , Vogel Jon D. , Fazio Victor W. , Kiran Ravi P.
Published: June 2020

Laparoscopic ileocolic resection is feasible for Crohn's disease but few studies adjust for the various preoperative, intraoperative, and postoperative variables that may confound comparisons with open surgery. The aim of this study is to compare outcomes after laparoscopic (LICR) and open ileocolic resection (OICR) performed for regional enteritis using National Surgical Quality Improvement Program (NSQIP) data. Retrospective evaluation of data prospectively accrued into the NSQIP database for patients undergoing ileocolic resection for Crohn's by LICR and OICR was performed. LICR (n = 104) and OICR (n = 203) groups had similar age ( P = 0.1), body mass index ( P = 0.9), smoking history ( P = 0.6), steroid use ( P = 0.7), diabetes ( P = 0.3), serum albumin ( P = 0.07), and American Society of Anesthesiologists class ( P = 0.13). LICR group had more female patients ( P = 0.005). Complications including surgical site infections ( P = 0.5), wound dehiscence ( P = 1), pneumonia ( P = 0.1), deep vein thrombosis ( P = 0.3), pulmonary embolism ( P = 1), urinary infection ( P = 0.1), and return to the operating room ( P = 0.2) were similar. LICR had shorter length of hospital stay than OICR ( P < 0.001). In current practice, as observed with the NSQIP data, LICR, performed by experienced surgeons, is comparable in safety to OICR and is associated with a shorter hospital stay.
Breast Cancer in the Young Patient
Authors: Sariego Jack
Published: June 2020

Patients under 40 years of age comprise about 5 per cent of the overall breast cancer population. These patients are often considered to have a more aggressive disease and are often treated differently as well. A review was performed of all breast cancer patients reported in the American College of Surgeons Cancer Database from 1998 to 2005. The study cohort included all patients less than 40 years of age. Data collected included stage at time of diagnosis, histologic type, and initial treatment performed. These data were then compared with those of patients age 40 or older. The 70,437 cohort patients identified comprised 5.0 per cent of all breast cancer patients reported. There was a statistically significant difference in stage at the time of presentation: 20 per cent of younger patients presented with advanced disease (stage III or IV) versus 13.5 per cent of older patients. A significantly greater percentage of younger patients also presented with infiltrating ductal carcinoma as opposed to the older population (76.9% vs 67.9%). A significantly greater percentage of young patients was treated with mastectomy when compared with the older population (47.7% vs 36.7%, respectively). This difference persisted even when data were controlled for stage. The younger breast cancer patient presents with more advanced disease, suggesting either a more aggressive disease or a greater delay in diagnosis. Also, at all stages, the young patient tends to be treated more “aggressively” surgically, suggesting that the prevailing concept that breast cancer is a “worse” disease in the young may be directing treatment options and patient choices.
Civilian and Military Trauma: Does Civilian Training Prepare Surgeons for the Battlefield?
Authors: Truitt Michael S. , Johnson Van , Rivera Manuel , Mangram Alicia , Lorenzo Manuel , Dunn Ernest
Published: June 2020

The management of trauma patients continues to be a major focus of resident training. The purpose of this review is to compare the mechanism and distribution of injuries in civilian and military trauma and to ascertain whether we are optimally preparing surgeons for the injuries seen on the battlefield. We performed a retrospective 5-year review of all trauma admissions to our urban trauma center (TC). We then compared this data with that recently acquired from Operation Iraqi Freedom (OIF). There were 7732 trauma patients seen during that time at our TC with 9.8 per cent sustaining gunshot wounds. Of those, 26 per cent sustained a gunshot wound to the thorax, and injuries to the abdomen and pelvis were sustained in 28.5 per cent. In total, truncal trauma accounted for 55 per cent of the injuries. Extremity injuries occurred in just 31 per cent. Data from OIF show the mechanism and distribution of injuries to be quite different. Improvised explosive devices accounted for greater than 50 per cent of the injuries in OIF. Truncal injuries accounted for just 14 per cent of the injuries seen and extremity injuries accounted for, a significant, 56 per cent of all the injuries observed. The civilian experience with gunshot wounds often focuses on truncal trauma, yet the military data show a need for knowledge of devastating injuries to the extremity. This divergent experience may be even more salient in the future as the battlefield is brought closer to home through domestic terrorism and the line is blurred between military and civilian trauma.
Single Incision Laparoscopic Surgery (SILS) Is Associated with Poorer Performance and Increased Surgeon Workload Compared with Standard Laparoscopy
Authors: Montero Paul N. , Acker Christina E. , Heniford B. Todd , Stefanidis Dimitrios
Published: June 2020

Little is known about the effectiveness and challenges of single incision laparoscopic surgery (SILS). We hypothesized that SILS would lead to decreased performance and increased surgeon workload compared with standard laparoscopy and that the use of angulated instruments during SILS would be beneficial. General surgery residents and fellows (n = 14) voluntarily performed the Fundamentals of Laparoscopic Surgery task 1 (peg transfer) using 1) standard laparoscopic instruments and port position, 2) standard laparoscopic instruments through a SILS port, and 3) angulated instruments through a SILS port in random order. Performance was assessed with an objective score and participant workload using a modified National Aeronautics and Space Administration Task Load Index (NASA TLX) workload assessment questionnaire. Participant performance was best with standard laparoscopy followed by SILS with angulated graspers and SILS with straight instruments (scores 218 ± 26 vs 131 ± 61 vs 91 ± 57; P < 0.001, respectively). In addition, participants indicated that standard laparoscopy was easier than SILS and their workload was 35 to 53 per cent higher when performing SILS. SILS was associated with decreased performance and increased surgeon workload compared with standard laparoscopy during the performance of a simulated task. SILS performance improved when angulated instruments were used but remained inferior to standard laparoscopy. This may translate into poorer operating room efficiency and safety.
Comparison of Blood Transfusion Free Pancreaticoduodenectomy to Transfusion-Eligible Pancreaticoduodenectomy
Authors: Choi Yoon Young , Seo Daekwan , Choi Dongho , Kim Jung Hoon , Lee Kyung-Jae , Ok Si Young
Published: June 2020

Even though the surgical techniques and perioperative care have improved, blood transfusions are still often required for the patients undergoing pancreaticoduodenectomy (PD). But complications from blood transfusions, poor prognosis of blood transfused patients, cost, and availability of blood products demand transfusion free (TF) surgery in the PD patients. The purpose of this study is to compare clinical outcome of TF pancreaticoduodenectomy with transfusion-eligible (TE) PD. We had investigated the possibility of blood TF treatments for the patients who underwent PD from December 2005 to August 2007. There were 41 cases of PD performed by one surgeon with the same method: 14 patients of the TF group and 27 patients of the TE group. Most of the TF group patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution. The results of statistical analysis between TF and TE group showed that there were no statistical differences in intraoperative data and postoperative outcomes, except preoperative hemoglobin levels, type of operations, and transfusion amount. To our best knowledge, this is the first successful PD program in selected patients as a series of operations without blood transfusion. TF PD can be done successfully in selected patients without severe complications.
Imaged Guided Transarterial Chemoembolization with Drug-Eluting Beads Loaded with Doxorubicin (DEBDOX) for Hepatic Metastases from Melanoma: Early Outcomes from a Multi-Institutional Registry
Authors: Brown Russell E. , Gibler Kaitlin M. , Metzger Tiffany , Trofimov Igor , Krebs Henry , Romero Francisco Diaz , Scoggins Charles R. , Mcmasters Kelly M. , Martin Robert C. G.
Published: June 2020

Patients with unresectable hepatic metastases from melanoma present a difficult clinical challenge due to lack of locoregional control and poor response to systemic chemotherapy. This study aims to examine the early outcomes of the novel treatment of unresectable hepatic metastases from melanoma with drug-eluting beads loaded with doxorubicin (DEBDOX) delivered via image guided transarterial chemoembolization. A multicenter prospective open registry of hepatic-directed therapy with drug-eluting beads was reviewed. Six patients underwent 12 DEBDOX treatments for liver-predominant, unresectable metastases from melanoma. Six adverse events (grade 1 or 2) were exhibited in three patients and were most commonly emesis, nausea, and pain. Over a median follow-up of 12 months (range: 6-17), response rates of 100 per cent, 83 per cent, and 60 per cent were observed at 3, 6, and 9 months respectively, based on standardized computed tomographic criteria. A median survival of 12.3 months after initial DEBDOX treatment was observed. Initial results for liver-directed therapy of hepatic-dominant metastatic disease from melanoma with DEBDOX demonstrate that this is a safe and well-tolerated treatment option with favorable response rates and survival characteristics at this point in follow-up. Salvage therapy with DEBDOX should be considered in the multidisciplinary therapy for this clinical dilemma.
Article Commentary: Surgical Workforce in the American South
Authors: Charles Anthony , Gaul Katie , Poley Stephanie
Published: June 2020

There exists a geographic maldistribution of surgeons with significant regional characteristics, which is associated with surgical access differentials that may be contributing to existing health disparities in the United States. We sought to evaluate the trends in the surgical workforce in southern states of the United States from 1981 to 2006 using the American Medical Association Masterfile data. Our study revealed that the general surgery workforce growth peaked in 1986 and has had negative growth per capita as a result of the consistent population growth, unlike other regions in the country. Furthermore, the change in the geographic distribution of general surgeons in the South was slightly greater than for surgical specialists between 1981 and 2006. Twenty-nine per cent of all southern counties with a collective population of 7.4 million people had no general surgeon in 2006. The failure of the general surgery workforce to grow with population expansion has resulted in a significant number of counties that do not meet the recommended standards of geographic access to surgical care. An adequate solution to surgical workforce demand is imperative for viable and successful implementation of healthcare reform, particularly in geographic regions with large healthcare access disparities.
Repair of High-Risk Incisional Hernias and Traumatic Abdominal Wall Defects with Porcine Mesh
Authors: Byrnes Matthew C. , Irwin Eric , Carlson Dana , Campeau Amy , Gipson Jonathon C. , Beal Alan , Croston J. Kevin
Published: June 2020

Complex ventral hernias represent a significant challenge to surgeons. We hypothesized that a wide underlay technique in combination with a novel biologic mesh would result in repair with a low recurrence rate. Medical records of patients undergoing ventral herniorrhaphy with Xen-Matrix biologic mesh were evaluated. All patients were evaluated for hernia recurrence both immediately and after 2 to 3 years. There were 57 patients included in the study. The overall recurrence rate was 7.2 per cent; however, all recurrences were early and were likely technical failures. The average duration of follow-up was 30.6 months with no further recurrences after the early technical failures. The average number of previous recurrences was 1.5. Fascial closure was obtained over the mesh in 84 per cent of patients, with component separation being necessary in 36 per cent of patients. Lack of fascial reapproximation over the mesh was associated with early recurrence (0 vs 55%, P < 0.0001). Complex ventral hernias can be repaired with a low recurrence rate. Our technique in combination with the XenMatrix biologic mesh provides for durable repair. Whenever possible, the fascia should be closed above the underlay mesh, because this technique provides a more durable repair than using the mesh as a “fascial bridge.”
Lingual and Facial Arteries Arising from the External Carotid Artery in a Common Trunk
Authors: Troupis Theodore G. , Dimitroulis Dimitrios , Paraschos Alexandros , Michalinos Adamantios , Protogerou Vassilis , Vlasis Konstantinos , Troupis George , Skandalakis Panayiotis
Published: June 2020

The present study describes analytically a rare case in which lingual and facial arteries arise together from an external carotid artery in a common trunk. Thirty anatomic dissections were performed on 15 cadavers in the macroscopic laboratory in the Department of Anatomy of the Medical School of National and Kapodistrian University of Athens. One common trunk from which originated lingual and facial arteries was found. The frequency of this morphology is measured at 6 per cent. The length of the common trunk is measured at 7.3 mm between its origin and its diversion at the facial artery and lingual artery, its diameter at 2.8 mm, its distance from carotid bifurcation at 7.9 mm, and from the superior thyroid artery at 3.3 mm. At the left side of the neck region, facial and lingual arteries arose separately. The anatomic variations of the branching pattern of the external carotid artery and the micrometric values of the vessels are especially important as a result of the numerous operations performed in the neck region that implicate various specialties such as general surgery, head and neck surgery, plastic surgery, and maxillofacial surgery.
Sensitivity of Computed Tomography in Detection of Perirectal Abscess
Authors: Caliste Xzabia , Nazir Shazia , Goode Terral , Street James H. , Hockstein Michael , Mcarthur Karina , Trankiem Christine T. , Sava Jack A.
Published: June 2020

Most patients with anorectal abscess are diagnosed clinically based on pain, erythema, warmth, and fluctuance. Some patients, however, present with subtle or atypical signs. CT is easily accessible and is commonly used for diagnosis and delineation of anorectal abscess. The purpose of this study is to determine the sensitivity of CT scan in detecting perirectal abscesses and to see if immune status impacts the accuracy of CT. A retrospective study was conducted to identify patients from 2000 to 2009 with International Classification of Diseases, 9th Revision code 566 (anal or rectal abscess). Patients included had a CT scan less than 48 hours before drainage. Patients with CT-positive abscess were compared with patients with CT-negative abscess. Patients were categorized as either immunocompetent or immunosuppressed based on documentation of diabetes mellitus, cancer, human immunodeficiency virus, or end-stage renal disease. One hundred thirteen patients were included in this study. Seventy-four (65.5%) were male and the average age was 47 years. Eighty-seven of 113 (77%) patients were positive on CT for anorectal abscess. Sixty of 113 (53%) patients included in this study were immunocompromised. CT missed 26 of 113 (23%) patients with confirmed perirectal abscess. Eighteen (69%) of these patients were immunocompromised compared with CT-positive patients (42 [48%], P = 0.05). The overall sensitivity of CT in identifying abscess was 77 per cent. CT lacks sensitivity in detecting perirectal abscess, particularly in the immunocompromised patient.
A Laparoscopic Splenectomy Allows the Induction of Antiviral Therapy for Patients with Cirrhosis Associated with Hepatitis C Virus
Authors: Shigekawa Yoshinobu , Uchiyama Kazuhisa , Takifuji Katsunari , Ueno Masaki , Hama Takashi , Hayami Shinya , Tamai Hideyuki , Ichinose Masao , Yamaue Hiroki
Published: June 2020

It is difficult to treat patients with cirrhosis-associated hepatitis C with pegylated interferon (PEG-IFN) and ribavirin because of thrombocytopenia-related hypersplenism. Both safety and clinical efficacy were retrospectively analyzed for patients who underwent a laparoscopic splenectomy (LS) from January 2003 to December 2007. A total of 35 patients with cirrhosis associated with hepatitis C virus had LS for thrombocytopenia before PEG-IFN and ribavirin therapy, and all patients had thrombocytopenia, which was a contraindication for antiviral therapy. The hepatopathy was Child A in 24 patients, Child B in 10 patients, and Child C in one patient. All 35 patients increased platelet count from 48,000 ± 15,000 to 155,000 ± 55,000/μl ( P < 0.0001) after LS. The median hospital stay and blood loss were 13.0 days (range, 8 to 57 days) and 342.0 mL (range, 5 to 2350 mL). There was no postoperative death. Twenty-nine (83%) patients had PEG-IFN and ribavirin therapy after LS; 18 had complete therapy and 11 had partial therapy. Of these, nine had a sustained virologic response. A laparoscopic splenectomy for patients with cirrhosis associated with hepatitis C virus can be performed safely and allows induction of antiviral treatment.
Breast MRI after Bilateral Mastectomy: Is It Indicated?
Authors: Vanderwalde Lindi H. , Dang Catherine M. , Tabrizi Robert , Saouaf Rola , Phillips Edward H.
Published: June 2020

Little is known about the use of breast MRI as a diagnostic or surveillance tool in patients after bilateral mastectomy. The objective of this study was to evaluate breast MRI after bilateral mastectomy. Participants consisted of 48 women with prior bilateral mastectomy who underwent breast MRI between 2003 and 2009. Seventy-nine breast MRIs were obtained. The median time between mastectomy and first MRI was 36 months. MRI was ordered most often by a medical oncologist (71%). Median age at bilateral mastectomy was 49 years (range, 33 to 72 years). Reasons for obtaining MRI included surveillance in 60 (76%), mass in eight (10%), lymph nodes in four (5%), pain in three (4%), and abscess in one (1%). Overall, 68 (86%) MRIs showed benign imaging findings only. Within the surveillance group, six patients had MRIs with findings that changed management; four patients had some residual breast tissue, and two patients had findings outside the breast that were better evaluated by CT or bone scan and were ultimately benign. MRI confirmed locoregional recurrence in two patients with highly suspicious physical findings. Overall, postmastectomy breast MRI had limited use, finding no unsuspected recurrences within our study group. Although MRI can be helpful to establish the presence of residual breast tissue after bilateral mastectomy, subsequent routine screening breast MRI should be questioned if no residual breast tissue is identified.
Prognostic Significance of Tumor Infiltrating Lymphocytes in Melanoma
Authors: Burton Alison L. , Roach Brent A. , Mays Michael P. , Chen Andrea F. , Ginter Brooke A.R. , Vierling Abbey M. , Scoggins Charles R. , Martin Robert C.G. , Stromberg Arnold J. , Hagendoorn Lee , Mcmasters Kelly M.
Published: June 2020

The prognostic significance of tumor infiltrating lymphocyte (TIL) response in cutaneous melanoma is controversial. This analysis of data from a prospective, randomized trial included patients with cutaneous melanoma ≥ 1.0 mm Breslow thickness who underwent wide local excision and sentinel lymph node (SLN) biopsy. Univariate and multivariate analyses were performed to determine factors associated with TIL response, disease-free survival (DFS), and overall survival (OS). A total of 515 patients were included; TIL response was classified as “brisk” (n = 100; 19.4%) or “non-brisk” (n = 415; 80.6%). Patients in the nonbrisk TIL group were more likely to have tumor-positive SLN (17.6% vs 7%; P = 0.0087). On multivariate analysis, nonbrisk TIL response, increased tumor thickness, and ulceration were significant independent predictors of tumor-positive SLN. By Kaplan-Meier analysis, 5-year DFS rate was 91 per cent for those with a brisk TIL response compared with 86 per cent in the nonbrisk group ( P = 0.41). The 5-year OS rates were 95 per cent versus 84 per cent in the brisk versus nonbrisk TIL groups, respectively ( P = 0.0083). However, on multivariate analysis, TIL response was not a significant independent factor predicting DFS or OS. TIL response is a significant predictor of SLN metastasis but is not a major predictor of DFS or OS.
Damage Control Resuscitation: From Emergency Department to the Operating Room
Authors: Duchesne Juan C. , Barbeau James M. , Islam Tareq M. , Wahl Georgia , Greiffenstein Patrick , Mcswain Norman E.
Published: June 2020

Damage control surgery emphasizes limited operations with control of bleeding and contamination. Traditional management centered upon correction of acidosis and hypotension with crystalloids. Damage control resuscitation (DCR) is permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy with fresh-frozen plasma (FFP), restricting use of crystalloids. We hypothesize a survival advantage in patients managed with DCR when compared with a historical cohort of patients. During the 2-year retrospective review, a 1-year period after institution of DCR was compared with a historical control. Resuscitation strategies were analyzed and stratified into emergency department (ED) resuscitation and intraoperative resuscitation. Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. Fifty-seven and 61 patients were managed during the Non DCR and DCR periods respectively. Baseline demographic patient characteristics and physiologic variables were similar between groups. ED DCR patients received less crystalloids: 1.1 versus 4.7 liters ( P = 0.0001), more FFP: 1.8 versus 0.5 ( P = 0.001). NonDCR had a lower initial systolic pressure in the operating room when compared with DCR: 81 mm Hg versus 95 mm Hg ( P = 0.03). DCR patients received less intraoperative crystalloids: 5.7 versus 15.8 liters ( P = 0.0001) and more FFP: 15.1 versus 6.2 ( P = 0.0001). DCR conveyed a survival benefit (Odds Ratio; 95% confidence interval: 0.40 (0.18-0.90), P = 0.024). NonDCR group had 13.2 days longer hospital length of stay. Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids. DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.
Article Commentary: Risk Factors of Pancreatic Fistula after Pancreaticoduodenectomy: A Collective Review
Authors: Ramacciato Giovanni , Mercantini Paolo , Petrucciani Niccolò , Nigri Giuseppe R. , Kazemi Andrea , Muroni Mirko , Del Gaudio Massimo , Balesh Albert , Cescon Matteo , Cucchetti Alessandro , Ravaioli Matteo
Published: June 2020

Postoperative pancreatic fistula (POPF) is the most frequent complication after pancreaticoduodenectomy, results in increased morbidity and mortality, and adversely affects length of stay and costs. Reported rates of postoperative pancreatic fistula vary from 0 per cent up to more than 30 per cent. Plenty of randomized trails and meta-analysis were published to analyze the ideal procedure, technique of anastomosis, and perioperative management of patients undergoing pancreaticoduodenectomy; however, results are often discordant and clear evidence on the ideal management and surgical technique to reduce POPF rate is not yet provided. This collective review examined the current evidence about risk factors contributing to postoperative pancreatic fistula and delineates methods of diagnosis and treatment of this universally dreaded complication.
Individualized Management of Hepatic Diseases in Hereditary Hemorrhagic Telangiectasia
Authors: Song Xie , Chen Hong-Qiang , Chen Yu-Xin , Cheng Yu , Qu Chuan-Qiang , Liu En-Yu , Guo Sen , Xu Ke-Sen , Niu Jun , Shou Nan-Hai
Published: June 2020

Liver involvement in patients with hereditary hemorrhagic telangiectasia (HHT) has not been fully characterized in China. The clinical manifestations, imaging studies, results of treatment in six patients and symptomatic liver involvement were analyzed. Patients included three women and three men with age from 35 to 62 years old. Two patients presented with shortness of breath, one patient with anemia and splenomegaly, and one with chronic gastrointestinal bleeding; the remaining two were asymptomatic. CT and CT angiography (CTA) showed arterioportal and arteriovenous shunting in liver. CTA showed at least one enlarged hepatic artery in all patients. One patient received ligation of the enlarged arteries with subsequent disappearance of symptoms at 56-month follow-up. The patient with gastrointestinal bleeding received interventional embolotherapy and resolved; interventional therapy to embolize the enlarged hepatic arteries was unsuccessful in another patient and the patient died of heart failure and liver dysfunction 38 months later. The patient with splenomegaly received a splenectomy and bandage of an enlarged hepatic artery. One of the two patients with no symptoms died of liver dysfunction 41 months after diagnosis. The other showed abnormal liver function and ascites, and traditional Chinese medicinal herb was used with no effect 21 months later. The symptoms disappeared after systemic medical treatment. Individualized and active therapy is advantageous and proper for patients with HHT.
Bronchoalveolar Lavage in the Diagnosis of Ventilator-Associated Pneumonia: To Quantitate or Not, That is the Question
Authors: Riaz Omer J. , Malhotra Ajai K. , Aboutanos Michel B. , Duane Therese M. , Goldberg Aaron E. , Borchers C. Todd , Martin Nancy R. , Ivatury Rao R.
Published: June 2020

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105 CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two ( Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.
Intraoperative Assessment of Breast Cancer Specimens Decreases Cost and Number of Reoperations
Authors: Uecker John M. , Bui Eric H. , Foulkrod Kelli H. , Sabra John P.
Published: June 2020

It is the aim of our study to determine if the assessment of intraoperative breast cancer margins leads to decreased incidence of repeat operations and decreased cost. We collected data prospectively from two hospitals in Austin, TX, University Medical Center at Brackenridge (UMCB) and Seton Northwest Hospital (SNW), over a 2-year period. Comparison was made to see if intraoperative margin assessment affected total surgical costs and need for reoperation. One hundred and seven cases met criteria for inclusion in the study (UMCB = 45, SNW = 62). Intraoperative margin assessment was used in zero cases at SNW (0%) and in 17 at UMCB (38%). Intraoperative assessment was used in 16 per cent of total cases. Sixty per cent of cases at SNW required subsequent return to the operating room. Twenty-four per cent of cases at UMCB required subsequent reoperation ( P < 0.05). The average number of surgical interventions required was 1 ± 0.3 with intraoperative assessment, 2 ± 0.6 without, ( P < 0.05). Total surgical costs were $15,341 ± $4,328 with intraoperative assessment and $22,013 ± $13,821 without ( P < 0.05). Use of intraoperative margin assessment for breast cancer operations leads to both a decrease in reoperations as well as a decrease in total operative costs.
Babesiosis as a Cause of Fever in Patients Undergoing a Splenectomy
Authors: Wormser Gary P. , Lombardo Gary , Silverblatt Fredric , El Khoury Marc Y. , Prasad Aakanksha , Yelon Jay A. , Sanda Alina , Karim Sadiqa , Coku Lindita , Savino John A.
Published: June 2020

Babesiosis is an emerging infection most commonly acquired from a tick bite. We describe three hospitalized patients with fever attributable to babesiosis after a splenectomy. Splenectomy was done because of splenic enlargement due to unsuspected babesia infection in one patient and because of splenic perforation due to babesiosis in a second patient. The third patient underwent splenectomy for trauma and acquired babesiosis postoperatively from a blood transfusion. Our cases demonstrate the need to be vigilant for babesiosis in patients undergoing splenectomy.
Innovative Technique to Reduce Incidence of Frey's Syndrome after Parotid Surgery
Authors: Singh Neeraj , Kohli Monica , Kohli Harjeet
Published: June 2020

Frey's syndrome was first described by Lucia Frey, a Polish neurologist in 1923. It is well accepted that it involves injury to the branches of the auriculotemporal nerve with subsequent aberrant regeneration. Due to this abnormal communication, the skin glands and vessels are always stimulated at the same time as eating and mastication, which results in symptoms such as flushing and sweating. The incidence of Frey's syndrome in the literature has been variously described from 6 to 96 per cent. We analyzed the chart of 18 patients who had parotidectomy from March 2002 to December 2009. All procedures were performed by a single surgeon at the same facility. A total of 16 superficial and three total parotidectomies were done; one patient had bilateral parotidectomy. Oxidized regenerated cellulose (Interceed) was used after 10 surgeries (study group) and no adjuvant was used after nine surgeries (control group). All of the surgeries were done using similar technique. All the patients were followed-up with for a period of about 6 months postoperatively. The absolute risk reduction associated with the placement of an Interceed was 11 per cent. The small number of cases (n = 19) and an empty cell limits statistical analysis (a Fisher's exact test revealed a P value of 0.44). Clearly the low number of procedures restricted the power to test these differences. The development of Frey's syndrome is a very disabling but under-reported complication. The placement of a temporary barrier like Interceed may help in the prevention of Frey's syndrome without increasing any complications.
Early Laparoscopic Cholecystectomy Is the Appropriate Management for Acute Gangrenous Cholecystitis
Authors: Choi Sae Byeol , Han Hyung Joon , Kim Chung Yun , Kim Wan Bae , Song Tae-Jin , Suh Sung Ock , Kim Young Chul , Choi Sang Yong
Published: June 2020

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications. We determined whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. The medical records of 116 patients with acute gangrenous cholecystitis admitted to the Korea University Guro Hospital between January 2005 and December 2009 were reviewed. The early operation group, those patients who had cholecystectomies within 4 days of the diagnosis, was compared with the delayed operation group, who had cholecystectomies 4 days after the diagnosis. Of the 116 patients, 57 were in the early operation group and 59 were in the delayed operation group. There were no statistical differences between the groups with respect to gender, age, body mass index, operative methods, major complications, duration of symptoms, mean operative time (98 vs 107 minutes), or postoperative hospital stay. However, the total hospital stay was significantly longer in the delayed operation group. More patients underwent preoperative percutaneous cholecystostomy in the delayed operation group (3.5 vs 15.3%). Early laparoscopic cholecystectomy for acute gangrenous cholecystitis is safe and feasible. There is no advantage to postponing an urgent operation in patients with acute gangrenous cholecystitis.
Making Liver Transection Even Safer: A Novel Use of Microwave Technology
Authors: Christian Derick J. , Khithani Amit , Jeyarajah D. Rohan
Published: June 2020

Hepatic surgery has evolved significantly in the past decade. The current article describes the largest series of patients in United States undergoing liver resective therapy with the use of microwave technology for liver precoagulation. Glisson's capsule was incised after securing inflow and outflow control. Two antennae, 2 cm apart, connected to a 915-MHz generator, were inserted 5 cm into liver parenchyma at a 130° angle. Once the parenchyma was firm and changed its color to gray, the antennae were advanced along the line of transection. The parenchyma was divided with electrocautery. Intra- and postoperative data were analyzed. Thirty-five patients (24 men) underwent liver resections. Diseases treated were colorectal metastases (n = 9), hepatic adenoma (n = 3), gallbladder cancer (n = 3), hepatocellular carcinoma (n = 4), neuroendocrine tumor (n = 2), cholangiocarcinoma (n = 5), hemangioma (n = 2), focal nodular hyperplasia (n = 2), metastatic gastrointestinal stromal tumor (n = 1), hydatid cyst (n = 1), hepatoid carcinoma (n = 1), hepatolithiasis (n = 1), and suspected metastatic breast cancer (n = 1). Resections done were right hepatectomy (n = 19), segmental resection (n = 5), left hepatectomy (n = 4), extended right hepatectomy (n = 4), Segment IVb and Segment Vresections during radical cholecystectomy (n = 2), and left lateral sectionectomy (n = 1). Median operative time for major resection was 188 and 251 minutes for minor resection. There was one postoperative mortality. Bile leak needing stenting occurred in one patient. Median blood loss for major resection was 500 mL and 265 mL for minor resection. Intraoperative transfusion was required in nine major and one minor resections. Other complications were ileus in four, deep vein thrombosis in two, intra-abdominal abscess in one, and cardiac events in two patients. Liver precoagulation with microwave technology is a novel and efficient technique with minimal morbidity and mortality for liver transection.