bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety and Effectiveness of Enoxaparin as Venous Thromboembolism Prophylaxis after Gastric Cancer Surgery in Japanese Patients
Authors: Yanagita Takeshi , Kusanagi Hiroshi
Published: June 2020

Routine prophylaxis for venous thromboembolism (VTE) has been recommended after surgery not only in the West but also in Asia recently. The primary objective of this study was to investigate the safety and effectiveness of enoxaparin as a prophylaxis in patients undergoing distal, proximal, or total gastrectomy (TG) for gastric cancers. A total of 565 patients who underwent gastrectomy for gastric cancer were reviewed retrospectively. About 256 patients received postoperative prophylaxis with enoxaparin (2000 international unit twice daily for at least six days) and compression stockings; these patients were assigned to the enoxaparin group. About 257 patients comprised a historical control group, who used only compression stockings as a thromboprophylaxis. All patients underwent the same rehabilitation programs during the perioperative period. None of the patients developed symptomatic venous thromboembolism in either the enoxaparin group or the control group. The complication rate of bleeding was not significantly different between the two groups. Only one patient who used three antiplatelet agents concomitantly with enoxaparin required reoperation for anastomotic site bleeding. The usage of enoxaparin for venous thromboembolism prophylaxis is safe for Japanese patients after gastrectomy. But, cautious application is still needed especially when used concomitantly with other antiplatelet agents.
Polyp Detection Rates among Body Mass Index Categories at First Screening Colonoscopy
Authors: Terlizzi Joseph , Zheng Andrew , Fuzesi Sarah , Beekley Alec , Moleski Stephanie , Phillips Benjamin , Isenberg Gerald , Goldstein Scott
Published: June 2020

In the United States, obesity is an epidemic and colorectal cancer is the second deadliest cancer for men and women. A link between obesity and colorectal adenomas and carcinoma has been suggested but not proven. We sought out to determine if obesity was associated with increased rates of polyp formation. All patients undergoing a first screening colonoscopy by one of the participating endoscopists at Thomas Jefferson University Hospital from January 2012 to March 2015 were considered for the study. Their demographics, body mass index (BMI), and colonoscopy findings were recorded at the time of the procedure and prospectively maintained in our database. The final pathologic diagnosis was recorded for each participant as it became available. A total of 758 subjects were included. Of these, 22 per cent had a BMI <25 kg/m2, 29 per cent had a BMI between 25 and 29.9 kg/m2, and 49 per cent had a BMI of at least 30 kg/m2. Overall, 21.9 per cent of the participants were found to have at least one adenomatous polyp. The polyp detection rates were 24.4 per cent in the group with a BMI less than 25, 20.5 per cent in the overweight group, and 21.6 per cent in the obese group. Our study included 56 super obese individuals with a BMI ≥45 kg/m2. About 17.9 per cent of subjects in the super obese group had an adenomatous polyp. There were no differences in the incidence of adenomatous polyps between BMI categories in our study.
Outcome Evaluation of Laparoscopic and Open Nissen Fundoplication in Children—A Systematic Review and Meta-Analysis
Authors: Lei Xing , Ren Qingquan , Yang Yang , Bai Tiecheng
Published: June 2020

Our aim was to estimate the efficacy of laparoscopic and open Nissen fundoplication (ONF) in the treatment of gastroesophageal reflux disease (GERD) in children. An electronic systematic review of the published literature was conducted in Cochrane Library, MEDLINE (PubMed), and EmBase in October 2015 in English and without time restrictions. The participants, interventions, and comparisons in the clinical question translated directly into eligibility criteria for study inclusion and exclusion. Study information extraction and methodological quality assessments were accomplished by two reviewers independently. Methodological quality was assessed by using the “Criteria for judging risk of bias in the ‘Risk of bias’ assessment tool.” Odds ratio (OR) with 95 per cent confidence interval was computed as summary statistics. Fixed-effects model was used and a pooled OR was calculated with the Mantel–Haenszel method initially. If the studies were heterogeneous, then the DerSimonian and Laird random effects model was used for meta-analysis. Outcome indices included mortality of patients, recurrence of GERD, reoperation of GERD, patients with complications, length of postoperative hospital stay, and surgery duration of laparoscopic Nissen fundoplication (LNF) and ONF. Statistical analyses were carried out by using Review Manager 5.2. The duration of follow-up varied between two days and four years. Children operated with LNF had a higher recurrence rate of GERD than those undergoing ONF. The pooled OR of LNF versus ONF was 2.98 (95% confidence interval = 1.29–6.87) while the heterogeneity was I2 = 47 per cent and P = 0.13. Statistical analysis showed that there was no significant difference for mortality, reoperation, and complication. The mean duration of surgery was significantly longer in the LNF than the ONF group while the results of length of postoperative hospital stay remained inconformity. In this meta-analysis, children operated with LNF had a higher recurrence rate of GERD than those undergoing ONF. Meanwhile, when considering the outcomes of mortality, reoperation, and complications, there was no significant difference. The mean duration of surgery was significantly longer in the LNF than the ONF group while no consistent conclusion of length of postoperative hospital stay was found.
Lymph Node Micrometastasis Cannot be Considered as Positive Lymph Node in Nonmetastatic Colorectal Cancer
Authors: Hong Kwang Dae , Um Jun Won , Min Byung Wook , Ji Woong-Bae , Choi Jung-Woo , Kim Young-Sik
Published: June 2020

The prognostic value of micrometastasis in colorectal cancer (CRC) remains controversial. The study investigated whether lymph node (LN) micrometastasis can have prognostic value in CRC as compared with macrometastasis. The study included 488 patients with curatively resected stage I, II, or III CRC treated between 2004 and 2011. Immuohistochemical staining with monoclonal antibody CAM 5.2 was performed on negative LNs by hematoxylin-eosin staining. The prognostic value of LN micrometastasis was investigated in multivariate analysis. Regression analysis was performed to identify a causal relationship between micro- and macrometastasis. Survival differences were compared between conventional N staging and hypothetic N staging taking micrometastasis in the positive node. A total of 93 patients (19.1%) showed LN micrometastasis. Patients with micrometastasis had more advanced tumor characteristics in terms of tumor size, grade, T stage, N stage, lymphatic invasion, and vascular invasion. In multivariate analysis, micrometastasis was not related with recurrence. Preoperative carcinoembryonic antigen level, neural invasion, and macrometastasis were independent risk factors in the analysis. Regression analysis showed that there was not a causal relationship between micro- and macrometastasis (R2 = 0.004, P = 0.153). When the cumulative numbers of micro- and macrometastatic LNs were calculated together, the discriminative power of survival difference between each node stage became less prominent, compared with conventional N staging. LN micrometastasis is related with advanced tumor characteristics, but does not reflect poor prognosis in nonmetastatic CRC. Micrometastasis cannot be considered as positive LN to predict poor prognosis.
Low Abdominal Wall Thickness May Predict Percutaneous Endoscopic Gastrostomy Complications
Authors: James Melissa K. , Ho Vanessa P. , Tiu Simon P. , Tom Richard J. , Klein Taylor R. , Melnic Gloria M. , Schubl Sebastian D.
Published: June 2020

Although percutaneous endoscopic gastrostomy (PEG) tube placement is a common and safe procedure to provide enteral feeding, some patients develop complications. The aim of this study was to identify risk factors for the development of post-PEG complications. We hypothesized that patients with low albumin, diabetes, higher body mass index (BMI), thicker abdominal walls, or psychomotor agitation would have more complications. A 2-year retrospective review was performed on patients who received a PEG tube at a single institution. Variables collected included age, preoperative albumin, BMI, abdominal wall thickness (AWT), psychomotor agitation, pre-operative diabetes mellitus, and mortality. A total of 91 patients (70.3% male) were identified (mean age 58.7 years, SD 18.6). Seventeen patients (18.7%) had post-PEG complications and the 30-day mortality rate was 14.3 per cent. Mortality was not attributable to tube placement. Patients with complications weighed less (P = 0.005) and had a lower BMI (P = 0.010) than patients without complications. Additionally, patients with complications had significantly lower AWT (P = 0.02), mean AWT was 21.6 mm (SD 7.6) versus 27.6 mm (SD 8.1) in the noncomplication patients. AWT was the only factor independently associated with post-PEG complications (P = 0.047). There was no significant association between complications and mortality. Continued investigation on how to limit post-PEG complications remains imperative. In our population, lower AWT was independently associated with complications. Preoperative measurement of AWT by pre-procedural imaging can potentially be used to predict the risk of post-PEG complications.
Where We Fail: Location and Timing of Failure to Rescue in Trauma
Authors: Chung Jennifer J. , Earl-Royal Emily C. , Delgado M. Kit , Pascual Jose L. , Reilly Patrick M. , Wiebe Douglas J. , Holena Daniel N.
Published: June 2020

Failure to rescue (FTR) is an outcome metric that reflects a center's ability to prevent mortality after a major complication. Identifying the timing and location of FTR events could help target efforts to reduce FTR rates. We sought to characterize the timing and location of FTR occurrences at our center, hypothesizing that FTR rates would be highest early after injury and in settings of lower intensity of care. We used data, prospectively collected from 2009 to 2013, on patients ≥16 years old with minimum Abbreviated Injury Score ≥2 from a single institution. Major complications (per Pennsylvania Trauma Systems Foundation definitions), mortality, and FTR rates were examined by location [prehospital, emergency department, operating room, intensive care unit (ICU), and interventional radiology] and by day post admission. Kruskal-Wallis and chi-squared tests were used to compare variables (P = 0.05). Major complications occurred in 899/6150 (14.6%) of patients [median age: 42, interquartile range (IQR): 25–57; 56% African American, 73% male, 76% blunt; median Injury Severity Score: 10, IQR: 5–17]. Of 899, 111 died (FTR = 12.4%). Compared with non-FTR cases, FTR cases had earlier complications (median day 1 (IQR: 0–4) versus 5 (IQR: 2–8), P < 0.001). FTR rates were highest in the prehospital (55%), emergency department (38%), and operating room (36%) settings, but the greatest number of FTR cases occurred in the ICU (52/111, 47%). FTR rates were highest early after injury, but the majority of cases occurred in the ICU. Efforts to reduce institutional FTR rates should focus on complications that occur in the ICU setting.
Synchronous Open Heart Surgery and Laparoscopic Cholecystectomy: An Observational Case Study with 28 Patients
Authors: Erdogan Mustafa Bilge , Kaplan Mehmet , Kazaz Hakki , Salman Bulent
Published: June 2020

Acute cholecystitis (AC) may be a severe problem and may increase the mortality rate and hospital stay in patients who undergo open heart surgery (OHS), due to its aggressive course; therefore, AC should be treated as soon as possible. We aimed to present data on our synchronous cardiac and laparoscopic cholecystectomy (LC) operations performed for AC complicating patients with cardiac disease and who were waiting to undergo OHS. Between January 2008 and September 2014, we performed 2773 OHSs in Medical Park Gaziantep Hospital. Among these, 28 (1%) patients underwent concomitant LC in the same session by the same experienced surgeon. The mean age of the patients was 61.4 ± 9.1 years, and the proportion of males was 71.4 per cent. Acalculous cholecystitis was found in 42.9 per cent of the patients. Patients stayed in the intensive care unit for 3.1 ± 1.4 days and were discharged from the hospital after 16.5 ± 6.3 days. Postoperative 2-year follow-up was completed in all patients with a mean follow-up period of 3.4 ± 2.0 years. The overall complication rate was 28.6 per cent. LC-related complications were seen in four patients. No inhospital mortality was observed. Only one patient who underwent mitral valve replacement and tricuspid valve repair died in the second year after the operation due to congestive heart failure. Three patients died due to noncardiac reasons in the follow-up period. By increasing the experiences of surgeons in laparoscopic surgery in critically ill patients, LC can be safely performed concurrently in patients scheduled for OHS.
Analysis of All-Terrain Vehicle Trauma Data: Implications for Increased Regulation and Injury Prevention
Authors: Ho Cathy V. , Dunne James R. , Stroud Wesley R. , Fonseca Alvaro H. , Davis Frank E. , Bromberg William J.
Published: June 2020

To determine the incidence and severity of all-terrain vehicle crashes (ATVCs) compared with motorcycle crashes (MCCs) in all critically injured patients. Prospective data were retrospectively reviewed on 1840 patients involved in ATVCs and MCCs admitted to a rural level one trauma center over 16 years. ATVC patients (n = 655) were younger (25 vs 38, P < 0.0001), more likely female (20% vs 11%, P < 0.001), less severely injured (13.5 vs 16, P < 0.0001), had similar Glasgow Coma Score (13.3 vs 13.4, p = NS), less helmet use (6% vs 69%, P < 0.0001), more closed head injuries (59.7% vs 54.3%, P < 0.05), more facial injuries (16.9% vs 12.5%, P < 0.05), and lower mortality rate (2.8% vs 5.9%, P < 0.01) compared with MCC patients (n = 1172). Pediatric patients involved in ATVC were more common (29.8% vs 4.8%, P < 0.001), had decreased helmet use (12% vs 59%, P < 0.001) and decreased mortality (3.5% vs 14.3%, P < 0.01). Further injury prevention efforts regarding helmet use and increased regulations regarding ATVCs are needed to decrease the morbidity associated with these recreational vehicles.
Bladder Fill after Laparoscopic Inguinal Hernia Repair Reduces Time to Discharge
Authors: Wormer Blair A. , Ross Samuelw , Walters Amanda L. , Kuwada Timothy S.
Published: June 2020

Laparoscopic inguinal herniorrhaphy (LIH) has a relatively high risk of urinary retention. Bladder dysfunction may delay discharge after LIH. We hypothesized that filling the bladder before Foley catheter removal decreases time to discharge (TTD) after LIH. A secondary aim was to determine incidence of postoperative urinary retention (POUR) after bladder fill (BF). We reviewed a consecutive series of total extraperitoneal and transabdominal preperitoneal LIH procedures performed by a single surgeon at our institution from 2010 to 2013. All patients were catheterized during LIH, and selected patients received a 200-mL saline BF before Foley catheter removal. Patients were required to void >250 mL before discharge. TTD and incidence of POUR were compared between the BF and no-BF groups. A total of 161 LIH cases were reviewed. BF was performed in 89/161 (55%) of cases. TTD was significantly shorter in the BF versus the no-BF group (222 vs 286 minutes, respectively; P < 0.01). Patient and operative characteristics were similar between the BF and no-BF groups (P > 0.05). Incidence of POUR in the BF and the no-BF group was 10.1 and 16.7 per cent, respectively; however, this difference was not significant (P = 0.22). No postoperative urinary tract infection occurred in either group. In conclusions, postoperative BF significantly reduces TTD after LIH. Further studies may help to determine whether shorter postanesthesia care unit time and lower POUR rates associated with BF can lower LIH procedural costs and increase patient satisfaction.
The Pennsylvania Trauma Outcomes Study Risk-Adjusted Mortality Model: Results of a Statewide Benchmarking Program
Authors: Wiebe Douglas J. , Holena Daniel N. , Delgado M. Kit , Mcwilliams Nathan , Altenburg Juliet , Carr Brendan G.
Published: June 2020

Trauma centers need objective feedback on performance to inform quality improvement efforts. The Trauma Quality Improvement Program recently published recommended methodology for case mix adjustment and benchmarking performance. We tested the feasibility of applying this methodology to develop risk-adjusted mortality models for a statewide trauma system. We performed a retrospective cohort study of patients ≥16 years old at Pennsylvania trauma centers from 2011 to 2013 (n = 100,278). Our main outcome measure was observed-to-expected mortality ratios (overall and within blunt, penetrating, multisystem, isolated head, and geriatric subgroups). Patient demographic variables, physiology, mechanism of injury, transfer status, injury severity, and pre-existing conditions were included as predictor variables. The statistical model had excellent discrimination (area under the curve = 0.94). Funnel plots of observed-to-expected identified five centers with lower than expected mortality and two centers with higher than expected mortality. No centers were outliers for management of penetrating trauma, but five centers had lower and three had higher than expected mortality for blunt trauma. It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance.
The Feasibility and Time Required for Routine Health Literacy Assessment in Surgical Practice and Effect on Patient Satisfaction
Authors: Eubanks Ryan D. , Nodora Jesse N. , Hsu Chiu-Hsieh , Bagley Marian , Bouton Marcia E. , Martinez Maria Elena , Komenaka Ian K.
Published: June 2020

Patients with limited health literacy (HL) have higher likelihood of problems with communication and may decrease patient satisfaction. This study was performed to determine the time required for routine HL assessment and its effect on patient satisfaction. Retrospective review over four years of consecutive patients who attended a breast clinic who underwent HL assessment as part of routine care. A total of 3126 consecutive patients from 2010 to 2014. Of the 3126 patients (96.9%), 3030 of were capable of undergoing HL assessment. No patients refused assessment, but one patient was inadvertently missed [3029 of 3030 patients (99.9%)]. The average age was 45 years and 10.5 years of education. The average time required was 1:57 minutes. Only 19 per cent of patients had adequate HL. Per each 1000 patients the time decreased (2:07, 1:58, 1:47; P < 0.001). Newest Vital Sign score did not change with time (1.6, 1.8, 1.7; P = NS). Patient satisfaction ratings increased during each subsequent year of HL assessments (P = 0.002). Routine HL assessment is feasible in surgical practice. HL assessment allows for identification of patients at risk for mis-communication. Implementation of communication strategies as described on the AMA website can improve patient-clinician communication and improve patient satisfaction.
A Multidisciplinary Child Protection Team Improves the Care of Nonaccidental Trauma Patients
Authors: Draus John M.
Published: June 2020

We initiated a multidisciplinary Child Protection Team (CPT) as a subgroup of our pediatric multidisciplinary trauma peer review committee. Meetings are held monthly. Nonaccidental trauma (NAT) patients from the preceding month are reviewed. The meeting has two parts. During the open part, detectives and child protective services (CPS) workers are invited to discuss specific cases. The closed part focuses on improvement of specific processes and future outcomes. Attendance is recorded and minutes are kept. We sought to review accomplishments of this group. We retrospectively reviewed the minutes from our CPT meetings conducted between February 2014 and April 2015. We tracked attendance, cases reviewed, process improvement projects, and corrective action plans. Meeting attendance was very good—78 per cent. During the 15-month study period, we had 141 suspected NAT patients; 96 were reviewed at our meetings. CPS workers attended 53 per cent of the meetings; 13 investigations were discussed. We established a clinical practice guideline for the evaluation of NAT patients. We created a mechanism to improve compliance with follow-up skeletal surveys. Six corrective letters were sent to individuals notifying them of care concerns and opportunities for improvement. Equipment needs were identified, and we obtained a digital camera and speaker phone. We have conducted multiple educational sessions to increase awareness. Our CPT meeting has improved the care of our NAT patients and provided better communication between our hospital staff and CPS workers. We have improved inhospital processes for our NAT patients. We have provided educational opportunities to outside care providers.
Nomogram-Derived Prediction of Postoperative Ileus after Colectomy: An Assessment from Nationwide Procedure-Targeted Cohort
Authors: Rencuzogullari Ahmet , Benlice Cigdem , Costedio Meagan , Remzi Feza H. , Gorgun Emre
Published: June 2020

Postoperative ileus (POI) is a clinical burden to health-care system. This study aims to evaluate the incidence and predictors of POI in patients undergoing colectomy and create a nomogram by using recently released procedure-targeted nationwide database. Patients who underwent elective colectomy in 2012 and 2013 were identified from American College of Surgeons National Surgical Quality Improvement Program using the new procedure-targeted database. Demographics, comorbidities, and 30-day postoperative outcomes were evaluated. Variables in the final step-wise multiple logistic regression model for each outcome were selected in a stepwise fashion using Akaike's information criterion. A nomogram was created to aid in the calculation of POI risk for individual patients. A total of 29,201 patients met the inclusion criteria; 3834 (13.1%) developed POI with a male predominance (55.9%). Patients who developed ileus had longer length of hospital stay (11 vs 5 days; P < 0.001) and operative time (200 vs 174 minutes; P < 0.001). In the stepwise logistic regression model, the following variables were found to be independent risk factors for POI: older age (P < 0.001), male gender (P < 0.001), American Society of Anesthesiologists class III/IV (P < 0.001), open approach (P < 0.001), preoperative septic conditions (P < 0.001), omission of oral antibiotic before surgery (P < 0.001), right colectomy or total colectomy vs other procedures (P < 0.001), smoking (P = 0.001), decreased preoperative serum albumin level (P < 0.001), and prolonged operating time (P < 0.001). All postoperative complications were more frequently occurred in patients with POI. The nomogram accurately predicted POI with a concordant index for this model of 0.69. The use of minimal invasive techniques, control of preoperative septic conditions, oral antibiotic bowel preparation and shorter operative time are associated with a decreased rate of POI. External validation is essential for the confirmation and further evaluation of our logistic regression model and nomogram.
Is Percutaneous Cholecystostomy a Good Alternative Treatment for Acute Cholecystitis in High-Risk Patients?
Authors: Papis Davide , Khalifa Eiman , Bhogal Ricky , Nair Amit , Khan Saboor , Hamady Zaed , Ahmed Jawad , Marangoni Gabriele
Published: June 2020

Cholecystectomy is the treatment of choice for acute cholecystitis but the management of high-risk surgical patients is a difficult dilemma. Percutaneous cholecystostomy (PC) could represent a safer and less invasive option. The aim of the study was to assess the outcomes of PC in high-risk patients. This is a retrospective single-center study; data were collected from our hospital electronic record system. From February 2009 to March 2014, there were 753 patients admitted with acute cholecystitis. Of these 39 were considered high risk for surgery and underwent PC during their hospital stay. The radiological approach was transperitoneal in 29 patients and transhepatic in 10 patients. Median follow-up was 19 months. There were 27 males (69.2%) and 12 females (30.8%) with a mean age of 72 years (range 41–90 years). Twenty-seven patients had PC as definitive treatment (group A) and 12 patients as a bridge to cholecystectomy (group B). There were no postprocedure complications. Five patients in group A were readmitted once with another episode of cholecystitis after PC (18.5%), one patient in group B was readmitted with cholecystitis after two years before proceeding to cholecystectomy, and two patients were readmitted after cholecystectomy (16.6%) for intra-abdominal collections treated with percutaneous radiological drainage. Seven patients died (17.9%) as a result of severe biliary sepsis during their index hospital admission. PC is a safe approach in high-risk patients with acute cholecystitis and can provide satisfactory long-term results when cholecystectomy is not a viable option.
Favorable Outcomes in Blunt Chest Injury with Noninvasive Bi-Level Positive Airway Pressure Ventilation
Authors: Udekwu Pascal , Patel Sahill , Farrell Meagan , Vincent Rhonda
Published: June 2020

Recent clinical research in patients with blunt chest injury has focused on the benefits of surgical fixation of rib fractures. Noninvasive ventilation (NIV) has been demonstrated to prevent the need for intubation and ventilation in posttraumatic respiratory failure. The preemptive use of NIV in patients with rib fractures has not been extensively studied. Our study evaluated the outcomes of patients with ≥3 rib fractures and hospitalized for ≥ 4 days. Seventy-one patients treated with NIV were compared with 270 patients without NIV. NIV patients were older (65.8 vs 56.5 years) had more rib fractures (6.25 vs 5.32) and a higher body mass index (31 vs 27.8) than the comparison group, P < 0.05, but did not have an increased mortality or incidence of respiratory failure. NIV patients did have a statistically significant increase in length of stay compared to control (12.8 vs 8.8, P < 0.05). In the total sample, worse clinical outcomes were associated with older age, increased number of and bilateral rib fractures, higher Injury Severity Score, lower Glasgow Coma Scale, and higher body mass index. Outcomes in the most severely injured group of patients treated with NIV were comparable to other studies using surgical fixation of rib fractures and epidural pain control.
Minimally Invasive Incision and Drainage Technique in the Treatment of Simple Subcutaneous Abscess in Adults
Authors: Salfity Hai V. , Valsangkar Nakul , Schultz Melissa , Salfity Joseph , Stanton-Maxey Katie Jo , Zarzaur Ben , Feliciano David V. , Laughlin Michelle R.
Published: June 2020

A minimally invasive (MI) approach using small incisions and vessel loops for drainage of simple perianal abscesses has been described in the pediatric population with decreased postoperative pain and comparable results to the traditional incision and drainage (I&D). The hypothesis was MI I&D will yield similar outcomes in adults. Patients who underwent I&D of perianal abscesses at an urban hospital from January 2008 to December 2015 were identified by Current Procedural Terminology code. Patients below 18 years of age, with inflammatory bowel diseases, or fistulae were excluded. Recurrences, readmissions, operative time, length of stay, complications, and costs were compared. There were 47 traditional and 96 MI I&D with no significant differences in demographics, average body mass index, and abscess size. No significant differences were noted in recurrences, readmissions, length of stay, operative time, or costs (P > 0.05). Postoperative complications occurred more frequently in the traditional group (P < 0.01) with a lower rate of follow-up (P < 0.05). MI I&D for simple anal abscesses in adults is associated with better compliance and fewer complications than the traditional approach. Although further studies are needed to determine if MI I&D confers superiority, this approach should be considered as first-line treatment for uncomplicated perirectal abscesses in adults.
Presenting Stage in Colon Cancer is Associated with Insurance Status
Authors: Lawrence David , Weigel Lauren , Dale Paul , Smith Betsy , Honaker Michael D.
Published: June 2020

Colorectal cancer continues to be the third most common cause of cancer death in the United States. Access to health care is also a nationwide problem. The purpose of the current study is to see if insurance status is associated with stage of colon cancer at presentation. The tumor registry was queried for all patients with colon cancer from 2009 to 2014. Demographics, including insurance status was statistically analyzed to determine if an association existed between insurance status and stage of colon cancer at the time of presentation. There were 434 patients identified that underwent colonic resection during the study period; 224 were female and 210 were male. Of the 434 patients, 388 were insured and 46 were uninsured. When insurance status was compared with stage at diagnosis there was a statistically significant difference between the two groups. For patients that were uninsured, 13.01 per cent presented with stage I disease, 15.22 per cent with stage II disease, 34.78 per cent with stage III disease, and 36.96 with stage IV disease. For insured patients, 24.03 per cent present with stage I disease, 26.10 with stage II disease, 23.26 per cent with stage III disease, and 29.61 per cent with stage IV disease (P = 0.047). Access to health care continues to be a large problem and results in patients without insurance presenting with a high stage of disease.
Outcomes after Mastectomy and Lumpectomy in Octogenarians and Nonagenarians with Early-Stage Breast Cancer
Authors: Merrill Ameliay , Brown Doris R. , Klepin Heidi D. , Levine Edward A. , Howard-Mcnatt Marissa
Published: June 2020

Prospective studies have shown equal outcomes after mastectomy or breast conservation in patients with invasive breast cancer; however, many of these studies excluded elderly patients. We identified patients in their eighties and nineties with clinical stage 0 to II breast cancer undergoing mastectomy or lumpectomy with or without radiation from the prospective sentinel lymph node database at Wake Forest Baptist Health and analyzed their treatment and survival. Of 92 patients, 24 (26.1%) underwent mastectomy, 22 (23.9%) lumpectomy with radiation, and 46 (50.0%) lumpectomy alone. Significant differences were noted in tumor size (P = 0.018), nodal status (P = 0.013), and stage (P = 0.011) between the groups. Only 7.6 per cent of patients had chemotherapy, whereas 51.1 per cent took antiestrogen therapy. Recurrence occurred in 11 patients. In univariate analysis, overall survival did not differ by surgery. Age was the only factor that increased risk of death (HR = 1.19, P = 0.028). In this age group, neither tumor factors nor the type of local treatment significantly influenced overall survival. Octogenarians and nonagenarians with early-stage breast cancer undergoing breast-conserving surgery with or without radiation have equivalent survival to patients having a mastectomy.
An Analysis of Factors that Predict Hospital Readmission after Surgery for Perforated Appendicitis
Authors: Millien Jeffanne E. , Townsend Michael , Goldberg Joshua , Fuhrman George M.
Published: June 2020

We performed this study to develop an understanding of why patients were readmitted after appendectomy for perforated appendicitis. Patients who required surgery for perforated appendicitis during a recent five-year period were identified. We recorded the demographic data, length of symptoms, length of stay, vital signs, laboratory findings, surgical approach, length of surgery, time to readmission, length of readmission, and intervention required after readmission. We divided the cohort into two groups depending on whether the patient was readmitted. We used chisquared analysis and t test to determine differences between the two groups. We identified 86 patients, with 14 (16.3%) requiring readmission. The only factors that predicted readmission were longer appendectomy surgery (P = 0.03) and open surgery (P = 0.04). After readmission, one patient required reoperation, and two required percutaneous abscess drainage. The remaining 11 patients were readmitted for a median of two days, received intravenous fluids, and required no additional clinically significant management. Patients requiring longer and open surgery are at an increased risk for hospital readmission after resection of a perforated appendix. Efforts to reduce readmission will likely be most successful if hydration and brief periods of clinical observation can be arranged when necessary for patients after discharge from surgery.
Percutaneous Needle Biopsies of the Breast in Women Younger than 35 Years: Minimally or Excessively Invasive?
Authors: Abou-zamzam Aida , Somers Scott , Cora Cherie , Pairawan Seyed , Lum Sharon
Published: June 2020

Percutaneous needle biopsy (PNB) of the breast is commonly used for diagnosis of breast pathology, but has been less studied in young women. We sought to determine the effectiveness and necessity of PNB in patients younger than 35 years of age. The charts of sequential patients <35 years who underwent PNB between February 2013 and May 2016 were reviewed; 181 PNB were performed in 127 patients. Median age was 30 years (13–34). Indications for PNB were Breast Imaging Reporting and Data System (BIRADS) ≥4 in 137 (75.7%) cases, with mass on imaging in 139 (76.8%). Carcinoma was diagnosed in 12 (6.6%), PNB in eight unique patients (6.3%). Other PNB pathology included atypia in four (2.2%) patients; papillary lesion, five (2.8%); benign lymph node, 10 (5.5%); fibroepithelial lesion, 15 (8.3%); benign breast tissue, 63 (34.8%); and fibroadenoma, 72 (39.8%). Women with atypia or malignancy were older than those with benign findings (30.9 vs 28.0 years, P = 0.002). No other patient or imaging factors were significantly associated with pathologic diagnosis on PNB. Routine PNB for all BIRADS 4 findings may be over-used in young women as most results are benign and subsequent surgical findings are concordant. Improved diagnostic accuracy of breast imaging is warranted to reduce unnecessary procedures.
Anatomic Location is the Primary Determinant of Survival for Paragangliomas
Authors: Fischer Trevan , Gaitonde Shrawan , Jones Maris , Bandera Bradley , Goldfarb Melanie
Published: June 2020

Paragangliomas (PGL) are rare neuroendocrine tumors. This study describes the largest collection of PGLs and evaluates factors that impact survival. Patients with PGL from 1998 to 2013 in the NCDB were reviewed. Independent predictors of overall survival (OS) were identified for patients with non-central nervous system (CNS) tumors. Of 867 PGLs, the primary site was CNS (39.9%), abdomen/pelvis (A&P) (21.0%), head and neck (H&N) (17.5%), thoracic (15.1%), bladder (3%), or unspecified (3.5%). Of 521 non-central nervous system (CNS) PGLs, there were differences in sex, comorbidities, treatment facility, tumor size, treatment modality (P < 0.001). Five-year OS for this cohort was 66 per cent and 10-year OS was 51 per cent. Median OS differed significantly between primary sites (H&N 106.0 months, thoracic 89.0 months, A&P 81.7 months, bladder 69.7 months, and unspecified 27.2, P < 0.001). After controlling for multiple factors, age greater than 50 (HR 1.97; CI 1.38–2.81), primary site A&P (HR 2.01; CI) 1.17–3.48) or bladder (HR 4.03; CI 1.64–9.89) as compared with H&N, distant metastasis (HR 2.25; CI 1.44–3.53) and those who did not receive surgery (HR 2.85; CI 1.89–4.31) all exhibited decreased OS. This is the largest series of PGLs and the first to demonstrate significant survival differences based on PGL site. Abdominal/pelvic and bladder PGLs had the lowest survival in addition to patients that did not have a surgical resection, those with distant metastases, and >50 years of age.
Laparoscopy Can Safely be Performed in Frail Patients Undergoing Colon Resection for Cancer
Authors: Ho Be , Lewis Aaron , Paz I. Benjamin
Published: June 2020

The present study aims to evaluate the role of laparoscopy in frail patients undergoing colorectal surgery for colorectal cancer. A review of the 2011 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was performed to identify frail patients (using a frailty index), who underwent resection for colorectal cancer. Univariable and multivariable analyses were performed to evaluate 30-day mortality and Clavien–Dindo grade IV (CD-IV) complications. A total of 52,087 patients with colorectal cancer were identified, of which frailty accounted for 2.63 per cent (index score ≥5). Patients above the age 85 were considered frail 6.8 per cent of the time and accounted for 24.5 per cent of patients with frailty. Laparoscopic surgery was performed in 32.9 and 53.1 per cent of patients with and without frailty (P < 0.001). Patients with frailty were less likely to die within 30 days of surgery if younger (P = 0.004), performed electively (P < 0.001), or laparoscopically (P < 0.001). On multivariate analysis, laparoscopy and elective surgery were associated with better perioperative survival; whereas, older age, male sex, and tobacco use were associated with 30-day mortality. Laparoscopy and lower body mass index were associated with fewer Clavien–Dindo grade IV complications. Although laparoscopy is performed less commonly in the frail, this study indicated better perioperative outcomes for patients undergoing elective surgery who were <85 years old.
Abdominal Trauma Revisited
Authors: Feliciano David V.
Published: June 2020

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.
Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis
Authors: Hirajima Shoji , Koh Toshimori , Sakai Tomohito , Imamura Taisuke , Kato Shunji , Nishimura Yukihisa , Soga Koji , Nishio Minoru , Oguro Atsushi , Nakagawa Noboru
Published: June 2020

We use open cholecystectomy (OC) to treat severe cholecystitis in cases in which we are worried that inflammation might cause anatomical changes in Calot's triangle. Furthermore, in cases of severe cholecystitis in which marked inflammation leads to fibrosis, we perform subtotal cholecystectomy (SC), i.e., incomplete gallbladder resection. Laparoscopic SC (LSC) without cystic duct dissection is considered to be effective at reducing the incidence of serious complications in patients with severe cholecystitis. The cases of 246 patients who underwent cholecystectomy for benign gallbladder disease between January 2011 and May 2015 were evaluated retrospectively. Of these patients, 14 were treated with LSC, and 19 underwent OC. Moreover, three patients in the LSC group underwent LSC without cystic duct ligation because it was considered that it would be difficult to dissect and ligate the cystic duct. The LSC group suffered significantly less intra-operative blood loss than the OC group. However, the operative times of the two groups were similar. Moreover, the duration of the postoperative hospitalization period was significantly shorter in the LSC group than in the OC group. Next, we compared the long-term outcomes of the SC and total cholecystectomy groups, regardless of the surgical method. No cases of cholecystitis or gallbladder cancer were encountered in either group. It is suggested that LSC is safe, effective, and helps to prevent serious complications in cases of severe cholecystitis that require conversion to OC, regardless of whether cystic duct ligation is performed.
Conditional Survival-Based “Abbreviated” Routine Cancer Surveillance for Pathologic Stage IB Melanoma
Authors: Kukar Moshim , Gabriel Emmanuel , May Rebecca , Cho Edward , Lichtenthal Michelle , Groman Adrienne , Skitzki Joseph , Francescutti Valerie , Kane John M.
Published: June 2020

A negative sentinel lymph node biopsy (SLNB) for stage IB (T1b/T2a N0) melanoma would predict an excellent long-term prognosis. Combined with the concept of conditional survival, an “abbreviated” cancer surveillance strategy was implemented to reduce the number of visits and total length of follow-up. Retrospective review of all pathologic stage IB melanoma patients (negative SLNB) at a single institution between 2006 and 2008 after implementation of an “abbreviated” cancer surveillance; clinic visits every six months for five years followed by one annual visit (total follow-up six years). Patient demographics, tumor characteristics, and information regarding recurrences were obtained. Recurrence-free, disease-specific, and overall survival were calculated. Eighty-seven patients underwent the “abbreviated” cancer surveillance. Median age was 55.4 years and 50.6 per cent were male. Median Breslow thickness was 1.1 mm (range 0.5–2.0 mm) and 1.1 per cent were ulcerated. Primary tumor site was 49 per cent extremities, 39 per cent trunk, and 12 per cent head/ neck. Median follow-up was 68.6 months. Five-year recurrence-free, disease-specific, and overall survivals were 89, 95, and 88 per cent, respectively. During surveillance, 10 patients had concerning symptoms or physical findings prompting subsequent workup, all of which were negative for recurrence/metastases. There were only three true melanoma recurrences; all were distant metastases and presented symptomatically between scheduled follow-up visits. In light of the excellent prognosis for pathologic (SLNB negative) stage IB melanoma, an “abbreviated” cancer surveillance schedule based on conditional survival would reduce both direct and indirect costs in this cohort. The few recurrences were symptomatic and unlikely to have changed with more intensive surveillance.
Descriptive Analysis of Venous Thromboembolism in Georgia Trauma Centers Compared with National Trauma Centers Participating in the Trauma Quality Improvement Program
Authors: Lassiter Randi L. , Ashley Dennis W. , Medeiros Regina S. , Adam Bao-ling , Nesmith Elizabeth G. , Johns Tracy J. , Atkins Elizabeth V. , Dente Christopher J. , Ferdinand Colville H.
Published: June 2020

This study was designed to compare the incidence of venous thromboembolism (VTE) in Georgia trauma centers with other national trauma centers participating in the Trauma Quality Improvement Program (TQIP). The use of chemoprophylaxis and characteristics of patients who developed VTE were also examined. We conducted a retrospective observational study of 325,703 trauma admissions to 245 trauma centers from 2013 to 2014. Patient demographics, rate of VTE, as well as the use, type, and timing of chemoprophylaxis were compared between patients admitted to Georgia and non-Georgia trauma centers. The rate of VTE in Georgia trauma centers was 1.9 per cent compared with 2.1 per cent in other national trauma centers. Overall, 49.6 per cent of Georgia patients and 45.5 per cent of patients in other trauma centers had documented chemoprophylaxis. Low molecular weight heparin was the most commonly used medication. Most patients who developed VTE did so despite receiving prophylaxis. The rate of VTE despite prophylaxis was 3.2 per cent in Georgia and 3.1 per cent in non-Georgia trauma centers. Mortality associated with VTE was higher in Georgia trauma centers compared with national TQIP benchmarks. The incidence of VTE and use of chemoprophylaxis within Georgia trauma centers were similar to national TQIP data. Interestingly, most patients who developed VTE in both populations received VTE prophylaxis. Further research is needed to develop best-practice guidelines for prevention, early detection, and treatment in high-risk populations.
Surgery for Acromioclavicular Dislocation: Factors Affecting Functional Recovery
Authors: Zhang Jun , Ying Zhengran , Wang You
Published: June 2020

The objective of the study is to compare the clinical outcomes of two different interventions for Rockwood type III (or above) acromioclavicular dislocation and study the factors influencing postoperative functional recovery. A total of 60 patients with Rockwood type III (or above) acromioclavicular dislocation were included in the study. Patients were divided into two groups based on the surgical intervention: Clavicular Hook Plate Fixation (Group A) and EndoButton technique of Coracoclavicular Ligament Reconstruction (Group B). Constant shoulder score was employed for the assessment of functional recovery before and after the surgery. Statistical analysis was performed in terms of age, gender, obesity (body mass index), Constant shoulder score, compliance of rehabilitation guidance, and the amount of reduction loss. The Constant score was significantly improved after surgery (P < 0.05). The score was better in Group B compared with Group A in the sixth month after surgery (P < 0.05), but showed no significant difference in the fifteenth month. Compliance with rehabilitation guidance significantly affected the values of the Constant score after the surgery (P < 0.05). Clavicular Hook Plate and EndoButton technique both are effective ways to treat Rockwood type III (or above) acromioclavicular dislocation. However, EndoButton technique is more effective for early functional recovery. Patients’ compliance with rehabilitation guidance is critical for the functional recovery after surgery.