bluuebunny/crossref_metadata_2025 huggingface dataset:
Repair of Recurrent Pectus Deformities
Authors: De Ugarte Daniel A. , Choi Edmund , Fonkalsrud Eric W.
Published: November 2022

A paucity of information is available regarding the surgical repair of recurrent pectus deformities (RPD). From 1993 through 2001 35 patients ranging in age from 6 to 51 years (mean, 23 years) underwent repair of RPD a mean of 11 years after the original repair: modified Ravitch repair (31), prosthetic implantation (three), and Nuss procedure (one). All patients had accompanying symptoms including decreased stamina (76%), chest discomfort (53%), asthma (33%). The repair performed was dependent on the findings at operation. A modified Ravitch procedure with Adkins strut was performed for 21 patients. Three had reattachment of mobile costal cartilages and/or xiphoid process to the sternum; three patients had autologous bone or cartilage grafts, three had muscular reconstruction, and two had resection of a localized cartilage protrusion. Three patients could not be reconstructed safely. Very good to excellent results were achieved for 32 patients (mean follow-up, 24.8 months). There were no deaths or major complications. Minor complications occurred in five patients. The mean blood loss was 105 mL. The mean hospital stay was 2.8 days. We conclude that although it is technically difficult RPD can be repaired with low morbidity, short hospital stay, and very good physiologic and cosmetic results.
Nonoperative Management of Blunt Renal Trauma: A Prospective Study
Authors: Toutouzas Konstantinos G. , Karaiskakis Marios , Kaminskl Anna , Velmahos George C.
Published: November 2022

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (March 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3–5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score ≥15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 ± 1.72 vs 1.87 ± 1.4 liters, P = 0.003) and blood transfusions (2.40 ± 2 vs 0.42 ± 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.
Is Duplex Ultrasonography an Effective Single Modality for the Preoperative Evaluation of Peripheral Vascular Disease?
Authors: Alexander Jason Q. , Leos Seema M. , Katz Steven G.
Published: November 2022

The purpose of this study was to determine whether duplex ultrasonography can be used as an effective modality for the preoperative evaluation of lower-extremity arterial occlusive disease. The records of all patients undergoing both color flow duplex scanning and contrast arteriography of the lower extremities during a 13-month period were reviewed. Comparisons between the two modalities were made at the femoral, popliteal, and tibial artery levels. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for duplex scanning using angiography as the gold standard. Three hundred fifteen arterial segments were evaluated. Color flow imaging overestimated the degree of stenosis in seven vessels and underestimated the degree of stenosis in four vessels. Overall duplex ultrasonography accurately determined lower-extremity arterial anatomy as defined by contrast arteriography with a sensitivity of 96.9 per cent, a specificity of 96.2 per cent, a positive predictive value of 94.6 per cent, a negative predictive value of 97.8 per cent, and an overall accuracy of 96 per cent The accuracy of duplex ultrasonography must be determined in each individual vascular laboratory. Once this is satisfactorily accomplished color flow scanning may be used as the single imaging modality for lower-extremity arterial occlusive disease in selected patients deemed to be at high risk for contrast angiography.
Superior Long-Term Results of Renal Transplantation in Children under 5 Years of Age
Authors: Ojogho Okechukwu , Sahney Shobha , Cutler Drew , Abdelhalim Fouad , Hasan Mateen , Baron Pedro , Concepcion Waldo
Published: November 2022

Despite improving overall results of pediatric renal transplantation children under 5 years of age remain a high-risk group with poorer outcomes often because of a higher rate of surgical complications. This retrospective report details a 12-year experience at a single center and examines the outcome in this high-risk group of patients. We reviewed the medical records of 21 children under 5 years of age who received renal transplantation at Loma Linda University Medical Center between July 1988 and August 2000. The patients were evaluated regularly by the same pediatric nephrologist throughout the study period at our outpatient clinic. Mean recipient age was 3 ± 1.2 (range 2–5) years; weight at transplantation was 13.3 ± 5.4 kg. Ten (48%) patients received living related donor (LRD) kidneys and 11 (52%) received cadaver (CAD) kidneys. Mean donor ages for CAD and LRD were 14.4 ± 10 years and 26.6 ± 4.9 years, respectively. The mean cold ischemia time (CAD only) was 23.3 ± 10.6 hours. Renal dysplasia (n = 8) and obstructive uropathy (n = 5) were the most common primary diagnoses. Maintenance immunosuppression consisted of Azathioprine or mycophenolate mofetil (MMF), cyclosporine or tacrolimus and prednisone. Mean follow-up was 80.1 ± 51.4 months. Twelve (57%) grafts have a follow-up >5 years. Patient survival was 100 per cent Overall graft survival at one, 3, 5, and 10 years were 95, 95, 88, and 88 per cent respectively. Graft survival for LRD recipients was 100 per cent No graft was lost as a result of a technical problem or vascular thrombosis. One graft each was lost because of delayed graft function complicated by severe cytomegalovirus infection and chronic rejection. At one year the mean serum creatinine was 0.6 ± 0.2 mg/dL with a mean calculated glomerular filtration rate of 93 ± 32 mL/min. All 17 children who are now of school age are attending school. We conclude that excellent rehabilitation and superior long-term patient and graft survival can be achieved with renal transplantation in children of this age group with the use of good surgical techniques and close follow-up.
Carotid Endarterectomy Using Regional Anesthesia: A Benchmark for Stenting
Authors: Stoneburner John M. , Nishanian Garabed P. , Cukingnan Ramon A. , Carey Joseph S.
Published: November 2022

Regional block (RB) anesthesia for carotid surgery offers the advantage of continuously monitoring the awake patient's neurologic status during carotid cross-clamping. We retrospectively studied our experience with RB for carotid endarterectomy (CEA) procedures performed during the period January 1, 1995 through December 31, 2001. A total of 388 consecutive CEA procedures were performed; RB was used in 314 and general anesthesia (GA) in 74. Three patients required conversion from RB to GA. GA was used only in patients who could not tolerate a block or needed combined coronary artery bypass grafting (CABG) and carotid surgery. New ipsilateral stroke did not occur in RB patients; one patient extended a previous stroke. Three in-hospital deaths occurred; these were all cardiac-related. In GA patients undergoing CEA without CABG (CEA only, n = 58), one stroke and no deaths occurred. The combined stroke and mortality rate for all CEA-only patients was 1.3 per cent (five of 372). RB allows 90 per cent of procedures to be performed without shunting, thus facilitating endarterectomy and patch angioplasty. CEA performed under RB is similar to carotid stenting because both procedures allow monitoring of the awake patient's neurologic status. The very low procedural complication rate in this study warrants the consideration of carotid surgery under regional block as a benchmark for future carotid angioplasty and stenting studies.
A Study of the Patient Factors Affecting Reconstruction after Mastectomy for Breast Carcinoma
Authors: Panieri Eugenio , Lazarus Dirk , Dent David M. , Hudson Don A. , Murray Elizabeth , Werner I. Dudley
Published: November 2022

Breast shape may be retained after surgery for breast cancer with either wide local excision (WLE) and radiotherapy or mastectomy (M) and immediate reconstruction (M+R). We determined the proportions of patients who would be suitable for these options, would accept them, and if they declined M+R their reasons for doing so. Over a 10-month period 177 women were assessed at a combined breast clinic by general and plastic surgeons and by radiation oncologists. A prospective record was made of the patient demographic data, the clinical decisions (and their reasons), and the patient choices (and their reasons). A transverse rectus abdominis myocutaneous flap was the commonest method of reconstruction. One hundred thirty-five (76%) were judged to be suitable for locoregional surgery. Of these M+R was offered to 83 patients, whereas 53 were not considered because of combinations of cosmetic considerations (31), risk factors (25), old age (13), and oncological factors (nine). Fifty-one of the 83 (61%) offered M+R declined it because they preferred a simpler procedure (34), regarded breast appearance as unimportant (15), preferred breast conservation (five), did not have a partner (three), felt that they were too old (two), or had religious reasons (two). Ultimately 69 (51%) underwent M, 34 (25%) WLE, and 32 (24%) M+R. There was no correlation between acceptance or not of M+R and age, race, employment, education level, or marital status. We conclude that many patients were suitable for M+R, but fewer than half accepted it; this decision was unrelated to age, race, employment, or marital status.
Serial Abdominal Closure Technique (the “SAC” Procedure): A Novel Method for Delayed Closure of the Abdominal Wall
Authors: Kafie Fernando E. , Tessier Deron J. , Williams Russell A. , Podnos Yale D. , Cinat Marianne , Lekawa Michael , Wilson Samuel E.
Published: November 2022

Abdominal compartment syndrome may occur after any elective or emergent abdominal operations that are complicated by postoperative hemorrhage or in the trauma patient who has massive fluid replacement for intra-abdominal bleeding. Once the abdomen is decompressed the type of closure varies as much as the surgeon performing the procedure. We have devised a simple, reproducible, inexpensive, and safe method to close the abdomen at the bedside. Serial abdominal closure (SAC) was performed on three patients 45, 54, and 14 years of age who had developed abdominal compartment syndrome secondary to an upper gastrointestinal bleed requiring massive transfusion, a tear of the superior mesenteric vein, and a grade 4 liver laceration respectively, all necessitating abdominal decompression. All three patients had their abdominal wounds closed at the bedside over the course of several days with our SAC technique. Subsequent postoperative course was uneventful and the abdominal wall was free of defects at one-year follow-up. SAC is an efficient, inexpensive, and easily reproducible method of managing the open abdomen. The use of SAC prevented abdominal closure-related complications such as enteric fistula and hernia formation in our three patients.
Recurrent Spigelian Hernia: A Case Report
Authors: Losanoff Julian E. , Richman Bruce W. , Jones James W.
Published: November 2022

Only seven cases of spigelian hernia recurrence have been previously reported. We report the case of a 75-year-old male patient who presented with extremely large hernia after four unsuccessful suture repairs over 12 years. The abdominal wall defect was repaired with Marlex mesh. The advantage of using prosthetic mesh in both primary and recurrent spigelian hernia is supported by recent clinical research data indicating a generalized collagen metabolism disorder in patients with primary and recurrent hernia. Mesh repair allows for tension-free anatomic restoration of distorted tissues associated with repair failures.
Technical Limitations of Sentinel Node Biopsy in Breast Cancer: A Single Surgeon's Experience
Authors: Patel Nilesh A. , Dusi Debra , Bragdon Gwynne , Julian Thomas B.
Published: November 2022

Few studies have attempted to critically identify patient- and tumor-related factors that limit sentinel node biopsy (SNB). These studies have been limited by sample size and surgeon variability. The present study attempts to enumerate these limitations in a unique group of patients. One hundred twenty-five SNBs performed by a single surgeon between May 1997 and June 2001 were reviewed. Overall SNB was successful in 96 per cent of patients with a 97 per cent correlation with the axillary node dissection. Sentinel node identification was not affected by age, tumor size, tumor location, prior segmental resection, or neoadjuvant therapy. No false negatives were noted in the neoadjuvant group. The use of blue dye alone significantly understaged patients when compared with isotope alone ( P = 0.02). SNB is a highly accurate method to identify axillary metastases and its limitations are not affected by patient or tumor related factors. In the present study SNB detection by both isotope and blue dye has been shown to be superior to blue dye alone. This finding demonstrates that these limitations may be overcome with the standardization of the technique used.
Low-Dose Adjuvant Interferon for Stage III Malignant Melanoma
Authors: Inman J. Lucas , Russell Greg B. , Savage Paul , Levine Edward A.
Published: November 2022

The role of interferon as adjuvant therapy in stage HI melanoma has recently been questioned. Prospective randomized studies have shown conflicting results regarding the efficacy of adjuvant treatment. The purpose of this study was to examine the use of low-dose adjuvant interferon α2-b (IFN) in stage III melanoma patients treated at a single institution. This study was a retrospective analysis of 60 stage III melanoma cases from Wake Forest University treated between 1983 and 1998. Cases were identified via the tumor registry. All patients underwent standard lymphadenectomy after diagnosis. After recovery from surgery patients were offered low-dose IFN (3 million units subcutaneous TIW for 1 month and then 6 million units subcutaneous TIW for 11 months) as adjuvant therapy for stage HI melanoma. The patients were followed up jointly by medical and surgical oncology. There were 39 male and 21 female patients with mean age of 60.0 (range 37–89) years. The average number of positive nodes was 3.6 (median = 1) for the treated group and 1.8 (median = 1) for those untreated ( P = 0.71). The average tumor thickness was similar between groups: 4.71 versus 4.88 mm for the IFN and observation groups respectively. The IFN group (N = 25) that received low-dose treatment had a median survival of 7.9 years with a 5-year survival rate of 69 per cent. The 35 cases that did not receive interferon had a median survival of 6.5 years and a 5-year survival rate of 52 per cent. These survival rates were not significantly different ( P = 0.91). The median disease-free survival for patients who did not receive IFN treatment was 2.4 years and 1.4 years for the treated group ( P = 0.19). The data show that there was similar survival for those who did and did not receive the low-dose IFN treatment. Although only large prospective trials can conclusively exclude a small survival time this experience suggests that there is no significant survival advantage to low-dose adjuvant IFN therapy for stage HI melanoma patients. Hopefully upcoming cooperative group trials will clarify the potential value of adjuvant IFN in this setting. However, although the toxicity of this regimen was mild we suggest that low-dose adjuvant IFN for stage HI melanoma should not be utilized outside the setting of a clinical trial.
Bacterial Lipopolysaccharide-Stimulated Release of Tumor Necrosis Factor-α from the Isolated Rat Heart: The Effect of Aprotinin and Forskolin
Authors: Mckinney William , Newman Walter H. , Webb Jerry G. , Castresana Manuel R.
Published: November 2022

Aprotinin has been reported to reduce plasma levels of inflammatory cytokines associated with cardiopulmonary bypass (CPB). Because CPB is also associated with elevated levels of bacterial lipopolysaccharide (LPS) and LPS stimulates release of inflammatory cytokines from the heart we tested the hypothesis that aprotinin would inhibit cardiac release of tumor necrosis factor-α (TNF) provoked by LPS. Isolated rat hearts were perfused Langendorf style. After 30 minutes of equilibration LPS (100 ng/mL) was infused for 60 minutes. Timed samples of coronary effluent were collected at 0, 30, 60, 90, 120, and 150 minutes after the initiation of LPS for the measurement of coronary flow and the determination of TNF and cyclic AMP. Other hearts were perfused with buffer containing aprotinin [137 kallikrein-inhibiting units (KIU)/mL or 250 KIU/mL] and then infused with LPS. An additional group received forskolin (10 μM) and LPS. In hearts perfused as controls with buffer alone no TNF was detected in the coronary effluent. In hearts perfused with LPS TNF was reliably detected in the coronary effluent at 60 minutes (606 ± 450 pg/min) and increased with time to a level of 1792 ± 650 pg/min at 150 minutes. The addition of aprotinin had no significant effect on LPS-stimulated TNF release. For instance in hearts perfused with 137 KIU/mL aprotinin LPS-stimulated release at 150 minutes was 2141 ± 732 pg/min and in hearts perfused with 250 KIU/mL LPS-stimulated TNF release was 2049 ± 789 pg/min. Forskolin administration was associated with release of cyclic AMP from the heart and completely inhibited LPS-stimulated TNF release. We conclude that LPS stimulated release of TNF from the heart. Adding aprotinin to the perfusion buffer in either high or low concentrations did not attenuate LPS-stimulated cytokine release. Elevating myocardial cyclic AMP with forskolin completely attenuated LPS-stimulated TNF release.
Synchronous Occurrence of Glioblastoma Multiforme and Esophageal Adenocarcinoma
Authors: Beech Derrick J. , Madan Atul K. , Aliabadi-Wahle Shaghayegh , Hays Angela N. , Long William P.
Published: November 2022

Synchronous malignancies are rare occurrences for which there may be a genetic link between two cancers or which may be simply coincidental. Although glioblastoma multiforme and esophageal adenocarcinoma have few clinical similarities there are no known biochemical or genetic links between the two malignancies. This case discussion details the synchronous occurrences of these two lesions and highlights possible clinical, biochemical, and genetic commonalities.
Laparoscopic Repair of a Recurrent Chronic Traumatic Diaphragmatic Hernia
Authors: Frantzides Constantine T. , Madan Atul K. , O'Leary Patrick J. , Losurdo John
Published: November 2022

Traditionally the approach to a long-standing traumatic diaphragmatic hernia has been a closure of the diaphragmatic defect via a thoracotomy. The evolution of minimally invasive surgery has allowed surgeons to challenge many of the traditional approaches. Herein we describe the first reported case of laparoscopic repair of recurrent chronic traumatic diaphragmatic hernia as well as review the current literature on minimally invasive surgery for traumatic diaphragmatic hernia. With proper advanced laparoscopic skills and techniques laparoscopic diaphragmatic herniorrhaphy for a chronic and recurrent defect is a safe and viable option.
Dexon Mesh Splenorrhaphy for Intraoperative Splenic Injuries
Authors: Berry Mark F. , Rosato Ernest F. , Williams Noel N.
Published: November 2022

The preferred management option for intraoperative splenic injuries is organ repair and preservation rather than splenectomy given the important immunologic function of the spleen. Wrapping the injured spleen with a Dexon mesh has been shown to be an effective alternative to splenectomy for significant splenic bleeding. However, this technique uses a foreign body that carries a theoretical infectious risk particularly in cases in which the alimentary tract has been opened. This study was undertaken to evaluate whether Dexon mesh splenorrhaphy when used for intraoperative splenic injuries was associated with significant infectious complications. The clinical courses of 23 patients who had Dexon mesh splenorrhaphy performed at a university teaching hospital for intraoperative splenic injury from 1991 to 1999 were reviewed. Eleven patients (48%) had their gastrointestinal tract opened during the surgery. No patients developed an intra-abdominal abscess or required reoperation for bleeding. The most common postoperative complications were left lower lobe atelectasis (18 patients, 78%), postoperative fever (13 patients, 56%), and left pleural effusion (12 patients, 52%). Dexon mesh splenorrhaphy effectively controls splenic bleeding due to intraoperative injury without significant infectious complications.
Resection of Central Hepatic Malignant Lesions
Authors: Jacobs Michael , McDonough John , Remine Stephen G.
Published: November 2022

Tumors within the central hepatic region can be managed by various operative techniques. The aim of hepatic resection should be to render the patient free of disease while limiting the excision of functioning parenchyma. Technical feasibility, improved anatomical understanding, and advanced support services have enabled access to lesions previously considered unresectable. Various surgical options and outcomes from a single surgeon's experience are presented. Thirty-three patients underwent surgical resection for central hepatic lesions adjacent to the anterior hilar plate from 1980 to 2001. The mean patient age was 55.7 years (range 34–82). The mean lesion size was 7.7 cm (2–21). Malignant lesions were most commonly encountered in segments IV and V (43%). The most common resection performed was a central hepatic resection (55%) followed by right trisegmentectomy (27%). Resections were primarily performed for metastatic colon cancer (48%), cholangiocarcinoma (25%), and hepatocellular carcinoma (15%). The 5-year survival was 45 per cent for metastatic colon cancer, 20 per cent for cholangiocarcinoma, and 66 per cent for hepatocellular carcinoma. The overall morbidity was 43 per cent, and there was a single mortality. The size, location, and extension of hepatic tumors are important factors that may predict the extent of hepatic resection. Small centrally located focal lesions are amenable to central hepatic resection with biliary reconstitution hence limiting extensive resections. Valuable 5-year patient survival and a low mortality rate were achieved.
Sentinel Lymph Node Biopsy Lowers the Rate of Lymphedema When Compared with Standard Axillary Lymph Node Dissection
Authors: Golshan Mehra , Martin W. Jason , Dowlatshahi Kambiz
Published: November 2022

Arm edema occurs in 20 to 30 per cent of patients who undergo axillary lymph node dissection (ALND) for carcinoma of the breast. Sentinel lymph node biopsy (SLNB) in lieu of ALND for staging of breast cancer significantly lowers this morbidity. We hypothesized that SLNB would have a lower lymphedema rate than conventional axillary dissection. Patients who underwent SLNB were compared with those who underwent level I and II axillary node dissection. A total of 125 patients were evaluated with 77 patients who underwent SLNB and 48 patients who underwent ALND. The arm circumference 10 cm above and 10 cm below the olecranon process was measured on both arms. In this series a difference in arm circumference greater than 3 cm between the operated and nonoperated side was defined as significant for lymphedema. Lymphedema was seen in two of 77 (2.6%) patients in the SLNB group as compared with 13 of 48 (27%) ALND patients. Given the above data patients who underwent sentinel lymph node biopsy show a significantly lower rate of lymphedema than those who had axillary lymph node dissection. This has an important impact on long-term postoperative management of patients with breast cancer.
The Effects of Varying Oxygen Conditions and Immunoglobulin A on Barrier Defense to Bacterial Invasion
Authors: Baylor Alfred E. , Diebel Lawrence N. , Liberati David M. , Dulchavsky Scott A. , Diglio Clement A. , Brown William J.
Published: November 2022

Tissue oxygenation is a critical factor in host defense against bacteria. Gut mucosal tissue oxygenation (partial pressure of O2) is normally low putting the gut at risk of invasion by luminal microbes. Secretory immunoglobulin (Ig) A (sIgA) is the principal immune defense at mucosal surfaces. The protective effect of IgA under low oxygen conditions is unknown. We studied the interaction of varying O2environments and sIgA on protection against bacterial invasion in our in vitro model. Cell monolayers of Madin-Darby canine kidney (MDCK) cells transfected with the cDNA for polymeric immunoglobulin receptor were established in a two-chamber cell culture system. A commensal strain of Escherichia coli (108colony-forming units) was added to the apical medium and cell cultures were placed in either a 5, 21, or 95 per cent O2environment at 37° C. Polyclonal sIgA (100 μg/mL) was added to the apical chamber in subsets. Basal medium was sampled at intervals and bacterial translocation quantitated. The cell monolayers of MDCK transfected cells then had 100 μg/mL IgA added to the basal compartment at 4° C for 2 hours followed by various oxygen environments for 90 minutes. Afterwards apical medium was removed at one, 3, and 12 (overnight) hours. The bacterial translocation data showed a significance increase in translocation with hypoxia. Both increased oxygen and IgA abrogated these effects significantly. The transcytosis of IgA was increased during hypoxic conditions. Normal and hyperoxic conditions did not produce any significant difference in IgA transcytosis. We conclude that O2and sIgA are protective against bacterial invasion at epithelial surfaces. Effects to either boost O2delivery to the gut or enhance mucosal IgA production and delivery may be protective in the critically ill surgical patient.
Postoperative Surveillance of Differentiated Thyroid Carcinoma: A Selective Approach
Authors: Conrad Mark F. , Pandurangi Keshav K. , Parikshak Manesh , Castillo Eduardo D. , Talpos Gary B.
Published: November 2022

This review was conducted to evaluate the selective use of 131I whole-body scanning (WBS) and radioablation (RA) after thyroidectomy for patients with differentiated thyroid carcinoma (DTC). A review of patients undergoing thyroidectomy for DTC between July 1, 1980 and December 31, 1999 was performed. Postoperative surveillance involved a selective RA protocol based on a modification of the AMES criteria (age, metastases, extent of cancer, size, and multifocality of tumor). Lower-risk patients were followed by yearly thyroglobulin (Tg) levels and physical examinations (PE) whereas higher-risk patients additionally underwent WBS and RA when appropriate. Three hundred forty-three patients were identified; of these 27 per cent had positive lymph nodes or metastatic disease at their initial operation. Two hundred thirteen (64%) patients underwent postoperative WBS with 174 (82%) requiring RA. One hundred thirty (36%) low-risk patients were followed with yearly Tg and PE that when abnormal led to WBS and RA. No additional patient morbidity or mortality resulted from this protocol. Factors identified during multivariate analyses as being predictive of occult metastasis and recurrence ( P < 0.05) included tumor size and lymph node status. These data support a selective approach to the postoperative surveillance of DTC using Tg and PE to monitor low-risk patients and WBS for those with a higher risk of recurrence.
Selective Management of Penetrating Truncal Injuries: Is Emergency Department Discharge a Reasonable Goal?
Authors: Conrad Mark F. , Patton Joe H. , Parikshak Manesh , Kralovich Kurt A.
Published: November 2022

We undertook this retrospective review to examine the appropriateness of a protocol for the selective emergency department (ED) workup of asymptomatic penetrating truncal injuries. Records of consecutive patients presenting to our urban Level I trauma center with penetrating truncal injuries between January 1, 1997 and September 2000 were reviewed. Data obtained included: patient demographics, ED workup, ED disposition, complications, and follow-up. Selective ED workup included hospital triple-contrast CT, admission for observation, and local wound exploration for selected anterior abdominal stab wounds. Four hundred fifty-five patients presented with penetrating truncal wounds during the study period. One hundred ninety-four patients were taken directly to the operating room, 136 were discharged based solely on physical examination and plain radiographs, 18 were admitted for observation without ED workup, and 107 had selective ED workup. Sixty-two patients (58% of those selectively worked up) were discharged home after negative ED workup, 18 were managed operatively, and 27 were managed nonoperatively. There were two missed injuries that were later identified and managed with no complications. Follow-up was available on 66 per cent of ED workup patients (range 1–42 months). We conclude that selective management of certain penetrating truncal injuries appears appropriate. Patients having a negative selective ED workup can be safely discharged thereby avoiding the cost and resource utilization associated with hospital admission.
Gastric Bypass for Morbid Obesity in Patients 50 Years or Older: Is Laparoscopic Technique Safer?
Authors: Gonzalez Rodrigo , Lin Edward , Mattar Samer G. , Venkatesh Kota R. , Smith C. Daniel
Published: November 2022

Some physicians have considered age ≥50 years as a relative contraindication for bariatric surgery. Recent reports demonstrated the safety and efficacy of Roux- en-Y gastric bypass (RYGB) in this patient subgroup, but comparisons between laparoscopic technique (LT) and open technique (OT) have not been reported. A review of 52 patients ≥50 years old who underwent RYGB between January 1999 and April 2002 was conducted. Demographics, operative data, and outcomes were assessed. Preoperative and postoperative renal and hepatic functions, electrolytes, anemia studies, and hematology results were compared. Patients were divided into LT and OT groups and operative outcomes were compared. The percentage of excess body weight loss was 66 ± 4 per cent at mean follow-up of 12 months. Blood samples drawn after a mean of 8 ± 2 months revealed no postoperative metabolic alterations. RYGB resulted in a reduction of the number of patients with hyperglycemia, hypertension, degenerative joint disease, gastroesophageal reflux disease, and continuous positive airway pressure-dependent sleep apnea ( P < 0.05). The LT resulted in fewer intensive care unit admissions and shorter length of stay. RYGB is safe and well tolerated in patients ≥50 years resulting in no renal, hepatic, or electrolytic alterations. Weight loss and control of obesity-related comorbidities are satisfactory. The LT results in fewer intensive care unit admissions and shorter length of stay than the OT.
Current Management of Common Bile Duct Stones in a Teaching Community Hospital
Authors: Patel Ajay P. , Lokey Jonathan S. , Harris James B. , Sticca Robert P. , McGill Eric S. , Arrillaga Abenamar , Miller Richard S. , Kopelman Tammy R.
Published: November 2022

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.
Nontherapeutic Laparotomies Revisited
Authors: Haan James , Kole Kerry , Brunetti Ami , Kramer Mary , Scalea Thomas M.
Published: November 2022

A wide variability exists in the reported incidents of complications following nontherapeutic laparotomy for trauma. We undertook this study to examine the decision-making leading to and complication rates related to the use of nontherapeutic laparotomy in an era of nonoperative management. We conducted a retrospective chart review of all nontherapeutic laparotomies as defined by the operating surgeon performed between May 1998 and May 2001. A total of 50 patients (6%) underwent nontherapeutic laparotomies predominantly for penetrating injury. The most frequent preoperative reason for nontherapeutic laparotomy was the question of hollow viscous or diaphragmatic injury on preoperative studies. Peritoneal signs on examination and peritoneal penetration on wound exploration were also frequent indications for surgery. Significant complication rates were low at approximately 12 per cent. Total length of stay was 7.3 days and 5 days if patients with significant other associative injuries were excluded. Overall morality was 4 per cent and unrelated to the nontherapeutic laparotomy in all cases. Overall incidence of nontherapeutic laparotomy has decreased with the use of abdominal helical CT and triple-contrast CT to evaluate penetrating injuries. Despite these advances diaphragmatic and hollow viscous injuries remain a concern. Although overall serious complication rates were low the use of nontherapeutic laparotomy adds significantly to length of stay and complications.
Hand-Assisted Laparoscopic Colectomy: A Single-Institution Experience
Authors: Cobb William S. , Lokey Jonathan S. , Schwab Donald P. , Crockett Jay A. , Rex James C. , Robbins James A.
Published: November 2022

The purpose of this study was to examine the results of a single institution experience with hand-assisted laparoscopic colon resection for benign disease. We conducted a retrospective study of consecutive cases performed by experienced laparoscopic surgeons at a single institution. From August 1999 to June 2001, 37 patients underwent hand-assisted laparoscopic colon resection. Seventeen patients were male, and 20 were female. Median patient age was 58 years (range 20–80). Indications for surgery were: polyp (13), uncomplicated diverticular disease (eight), complicated diverticular disease (i.e., colovesicular fistula, phlegmon, etc.) (seven), chronic constipation (four), rectal prolapse (two), ulcerative colitis (one), endometriosis (one), and fecal incontinence (one). Procedures performed were: sigmoidectomy (14), right colectomy (nine), low anterior resection (seven), subtotal colectomy (five), cecectomy (one), and transverse colectomy (one). Variables examined were: conversion to open procedure, operative time, blood loss, time to return of flatus, length of postoperative hospital stay, and complications. There were no deaths. One case was converted to celiotomy (unable to rule out malignancy). The median operative time was 122 minutes (range 32–240) with a median operative blood loss of 132 mL (range 0–300). Return of flatus was noted (median) at postoperative day 3 (range 1–5), and the median length of stay after operation was 4 days (range 2–8). One patient developed a superficial wound infection, and there was one pelvic abscess (drained percutaneously). One patient developed urinary retention. There were no reoperations. In this single-institution experience hand-assisted laparoscopic elective colectomy for benign disease was successful in both straightforward and complicated cases. A low conversion rate to celiotomy and favorable operative times compared with published “pure” laparoscopic results suggest a flatter learning curve for handoscopy while retaining the benefits of “minimally invasive” surgery such as early return of flatus and short postoperative hospital stay. For these reasons hand-assisted laparoscopy should be considered an acceptable technique in elective colon resection for benign disease.
Operative Management and Outcome of Iliac Vessel Injury: A Ten-Year Experience
Authors: Haan James , Rodriguez Aurelio , Chiu William , Boswell Sharon , Scott Jane , Scalea Thomas
Published: November 2022

The purpose of this study is to review demographics and examine and stratify risk factors related to the outcome of operatively treated iliac vascular injuries. We conducted a retrospective review of 78 cases of iliac vessel injury. Patients with blunt and penetrating injury had statistically similar length of hospital stay and intensive care unit stay, incidence of shock, and mortality. Shock on admission and bleeding hematoma are linked, and shock increased mortality with an odds ratio of 5.2 ( P = 0.002). A review of operative technique and outcome demonstrated a low mortality of 25 per cent in arterial bypass of an isolated arterial injury versus a mortality of 83 per cent in the combined injury group. Patients treated with primary repair of venous injuries had a lower incidence of shock and mortality compared with patients treated with venous ligation. We conclude that, if matched for severity of injury and physiologic instability, the mechanism of injury does not affect mortality. Shock is the most significant prognostic factor for mortality. Operative management must be based on presence of shock.
Effect of Hyperglycemia and Nitric Oxide Synthase Inhibition on Heat Tolerance and Induction of Heat Shock Protein 72 κDa in Vivo
Authors: Swiecki Christopher , Stojadinovic Alexander , Anderson Jimie , Zhao Aiping , Dawson Harry , Shea-Donohue Terez
Published: November 2022

Diabetes and nitric oxide synthase (NOS) inhibition both exacerbate mesenteric ischemia/reperfusion injury. Heat shock protein 72 (HSP-72) protects against κDa ischemia/reperfusion damage in vivo. The effect of diabetes on HSP-72 expression in vivo is unknown. The aim of this study was to determine the effects of diabetes and NOS inhibition on HSP-72 induction in vivo. Rats were assigned to four groups: control (C), streptozotocin-induced diabetic (D), acute hyperglycemia (A), and L- Nω-nitro-l-arginine treated (L). Rats were subjected to hyperthermia and allowed to recover for 4 hours. Intestine and liver samples from heated (H) and nonheated (NH) rats were analyzed for HSP-72 by Western blot. HSP-72 levels were increased significantly in CH compared to CNH rats. No deaths occurred in CH rats; however, death rates were significant in AH, DH, and LH rats. DH rats died earlier than LH and AH rats. HSP-72 in liver and intestine was reduced significantly in LH rats. When compared with CH rats the surviving AH and DH rats exhibited similar HSP-72 levels in the liver. Diabetes, acute hyperglycemia, and L- Nω-nitro-l-arginine treatment lower heat stress tolerance. NOS is required for HSP-72 expression, but not survival. Diabetics who survive heat stress moderately express HSP-72. Characterization of altered thermotolerance and HSP-72 may provide mechanisms for the deranged diabetic stress response.
[18F]Fluorodeoxyglucose Positron Emission Tomography Surveillance of Hepatic Metastases from Prostate Cancer Following Radiofrequency Ablation: A Case Report
Authors: Ludwig Vinicius , Hopper Orlin W. , Martin William H. , Kikkawa Rita , Delbeke Dominique
Published: November 2022

The liver is the organ most commonly involved with metastatic disease. Surgical resection of hepatic metastases is the only potentially curative therapy, but it is possible in only 20 per cent of the patients. Radiofrequency ablation (RFA) of hepatic lesions is a therapeutic option for unresectable hepatic metastases. Today there is no clear consensus about which imaging technique is the most reliable to monitor RFA therapy. [18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is a new imaging modality allowing evaluation of glucose metabolism that has become established for monitoring therapy and early detection of recurrence of various types of malignant tumors. We present a case report of a 61-year-old man treated for prostate carcinoma 3 years earlier who presented with rising serum prostate-specific antigen (PSA) levels. A CT scan demonstrated two hepatic metastases that were treated with RFA because the patient refused surgery. During 3 years of follow-up hepatic recurrence was monitored with serum PSA levels, CT of the abdomen, and FDG-PET imaging on multiple occasions. On three separate occasions FDG-PET revealed hypermetabolic foci despite no definite evidence of recurrence on CT. Furthermore FDG-PET imaging 2 months after the last RFA therapy showed two large photopenic areas without evidence of hypermetabolism consistent with successful RFA therapy. Serum PSA levels correlated better with FDG-PET than CT results. We conclude that in this patient FDG-PET imaging was more accurate than CT for monitoring recurrence of hepatic metastases from prostate carcinoma after RFA therapy. PET demonstrated hypermetabolic foci when there was recurrence and no evidence of hypermetabolism early after successful RFA therapy. In addition FDG-PET imaging helped to guide the placement of the RFA probe to the most metabolically active part of the tumor.
Recurrent Eosinophilic Mastitis
Authors: Komenaka Ian K. , Schnabel Freya R. , Cohen Jason A. , Saqi Anjali , Mercado Cecilia , Horowitz Elizabeth , Hamele-Bena Diane , Joseph Kathie-Ann
Published: November 2022

Systemic diseases rarely present with manifestations in the breast. Disorders such as sarcoidosis and pyoderma gangrenosum have been described to produce signs and symptoms in the breast. Peripheral eosinophilia is a systemic disease associated with a finite group of conditions including asthma, allergic or atopic disease, collagen vascular disease, and parasitic infection. In addition it has been described in association with several malignancies. A 50-year-old woman with a history of asthma and significant eosinophilia presented with an enlarging breast mass. Complete excision of the mass revealed eosinophilic mastitis. Two years later the patient again presented with a large mass in the same breast. Repeat excision demonstrated the same pathology. The clinical significance of this lesion is important because it presents as an enlarging, painless, dominant mass. Excision is necessary for management and to conclusively rule out malignancy. Its recurrence despite excision to negative margins, however, may indicate that control of the eosinophilia—and possibly the underlying disorder—is important to prevent further recurrence.
Necrotizing Soft Tissue Infections: Improved Outcomes with Modern Care
Authors: Tillou Areti , Hill Charles R. , Brown Carlos , Velmahos George
Published: November 2022

The outcome of necrotizing soft tissue infections (NSTI) remains unchanged despite advances in care. Reasons cited are changing patterns of causative factors, delays in diagnosis, and inadequate antibiotic coverage and surgical treatment. To document outcomes of NSTI after aggressive management and to identify risk factors of mortality and prolonged hospital stay, we reviewed all our patients with NSTI admitted from January 2000 to January 2002. Causative factors, comorbid conditions, site of NSTI, physiologic parameters, symptoms, diagnostic tests, therapeutic interventions, and outcomes were analyzed. Patients were treated aggressively with antibiotics, admission to ICU, and frequent surgical debridements. Of 46 patients identified, 28 (61%) were admitted in ICU, and eight (17%) died. The patients who died had higher admission white blood cell counts (46 ± 22 vs 22 ± 10 x 103/mm3, P = 0.01), higher admission pain score (8 ± 1 vs 5 ± 3, P = 0.02), longer intervals from admission to antibiotic administration (16 ± 20 vs 6 ± 12 hours, P = 0.02), and fewer surgical debridements (2.6 ± 1.1 vs 3.6 ± 1.7, P = 0.04). No independent risk factors of mortality or ICU admission were identified. We concluded that severe local pain and a significantly elevated white blood cell count on admission should alert the physician to the presence of severe infection and prompt the initiation of expeditious aggressive treatment.
Influence of Transmetatarsal Amputation in Patients Requiring Lower Extremity Distal Revascularization
Authors: Glass Holly , Rowe Vincent L. , Hood Douglas B. , Yellin Albert E. , Weaver Fred A.
Published: November 2022

When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent ( P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.