bluuebunny/crossref_metadata_2025 huggingface dataset:
The Use and Modification of Clinical Pathways to Achieve Specific Outcomes in Bariatric Surgery
Authors: Yeats Melania , Wedergren Sue , Fox Nicole , Thompson Jon S.
Published: June 2020

Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The groups were similar with respect to gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, and EBL. Operative time was significantly less in groups II and III compared to group I (82% and 68% vs. 38% <180 minutes, P < 0.05). LOS was shorter in groups II and III compared to group I (62% and 42% vs. 20% with a 4-day LOS, P < 0.05). Duration of nasogastric tube decompression was successfully decreased in group III when compared to groups I and II (76% vs. 14% and 6% 1 day or less, P < 0.05). Complication rates were significantly lower in group III as well (14% vs. 36% and 28%, P < 0.05). Standardizing patient care with a clinical pathway decreases LOS after bariatric surgery. An established clinical pathway can then be used to further modify patient care in order to achieve specific goals, such as shortened time of nasogastric decompression. This goal was accomplished without compromising patient outcome.
A Gastrointestinal Stromal Tumor Discovered in a Resected Hemorrhoidal Donut after Stapled Hemorrhoidopexy: Report of a Case
Authors: Firoozmand Eiman , Binder Scott , Thompson Andrew , Hoffman Gary H.
Published: June 2020

We report a case of a 47-year-old woman found to have a rectal gastrointestinal stromal tumor discovered on routine pathological examination of the resected hemorrhoidal donut after a stapled hemorrhoidopexy. There was no evidence of metastatic spread. No further therapy will be instituted.
In the Wake of Hurricane Isabel: A Prospective Study of Postevent Trauma and Injury Control Strategies
Authors: Gagnon E.B. , Aboutanos M.B. , Malhotra A.K. , Dompkowski D. , Duane T.M. , Ivatury R.R.
Published: June 2020

Preventing hurricane-related injuries (HRI) has historically centered on the pre-event and event phases of the disaster. To date, no study has focused on injuries occurring during the postevent phase. We examined HRI that occurred after Hurricane Isabel struck a U.S. urban city. HRI presenting 1 week prior to the hurricane were collected from emergency department electronic records. HRI that presented to our level 1 trauma center were prospectively collected for 1 week after the hurricane. Nine hundred seventy-eight patients with possible HRI were identified. Fifty-one patients with trauma directly attributed to the hurricane were used for analysis. The number of HRI occurring before, during, and after the hurricane were 7 (14%), 3 (6%), and 41 (80%), respectively. The majority of HRI (37%) occurred on posthurricane day 1. Head, chest, upper and lower extremities accounted for 9 (18%), 8 (16%), 13 (26%), and 14 (28%) of HRI. More than one third of HRI patients were admitted to the hospital, and 12 (24%) underwent an operation. The average hospital length of stay was 4.7 days. Of our trauma alerts, 75 per cent had an Injury Severity Score (ISS) >8, and 20 per cent had an ISS >15. Tree-related injuries (TRI) accounted for 59 per cent of HRI. Males, ages 50–60, had the highest incidence of injury (63%). Significant injuries occur in the wake of a hurricane. Optimization of disaster preparation must include prevention strategies targeted to the postevent recovery phase of disasters.
Treatment and Outcomes of Melanoma with a Breslow's Depth Greater than or Equal to One Millimeter in a Regional Teaching Hospital
Authors: Scott John D. , Mckinley Brian P. , Bishop Aundie , Trocha Steven D.
Published: June 2020

Local control and regional lymph node evaluation are the primary treatment goals for cutaneous primary melanoma. Historically, primary lesions were excised with large 3- to 5-cm radial margins. Recent clinical trials have suggested that similar survival and recurrence rates can be achieved with smaller margins of excision. In addition to excision of the primary lesion, the presence or absence of nodal metastasis is the single most powerful predictor of survival in patients with melanoma. Based on the available trials, the standard of care for a melanoma 1 mm or greater in depth is a wide local excision with a 2-cm margin and a sentinel lymph node biopsy (SLNB). The application of this standard in regional teaching hospitals is unknown. We performed a retrospective review of a cancer registry at a teaching hospital in South Carolina. This analysis included all patients who underwent surgery for melanoma at our institution between July 1997 and March 2003. Our single inclusion criterion was that the primary melanoma had to be 1 mm or greater in depth. Only 42 per cent of the patients underwent excision with a radial margin >2 cm, and only 60 per cent of the patients underwent SLNB. As time progressed, the use of SLNB at our institution increased; but, even as late as 2003, some patients did not receive SLNB. Adherence to standards did not appear to have an effect on overall survival. In conclusion, the current standard for the treatment of invasive melanoma greater than or equal to 1 mm in thickness is a 2-cm margin of excision and a SLNB. In this regional teaching hospital, surgical treatment and staging of melanoma did not strictly adhere to the standard.
Complete Androgen Insensitivity Syndrome: The Role of the Endocrine Surgeon
Authors: Alvarez Nicolas R. , Lee Theresa M. , Solorzano Carmen C.
Published: June 2020

Androgen insensitivity syndrome (AIS) is an X-linked recessive disorder characterized by varying degrees of feminization secondary to androgen receptor insensitivity. We report a case of a 34-year-old female with complete androgen insensitivity who presented with a history of primary amenorrhea and two intra-abdominal gonads found on CT scan. The patient underwent successful laparoscopic bilateral gonadectomy without complications. AIS is present in 1:20,000 to 64,000 males; complete androgen insensitivity is seen in 2–5:100,000 phenotypic females and should therefore be considered in any otherwise healthy female with abnormal pubertal development and infertility. Although controversial, most endocrinologists agree that gonadectomy may be performed after puberty with minimal risk of testicular neoplasm.
National Study of the Effect of Patient and Hospital Characteristics on Bariatric Surgery Outcomes
Authors: Carbonell Alfredo M. , Lincourt Amy E. , Matthews Brent D. , Kercher Kent W. , Sing Ronald F. , Heniford B. Todd
Published: June 2020

The influence of patient and hospital demographics on gastric bypass (GB) outcomes is unknown. We analyzed year 2000 data from the Nationwide Inpatient Sample database for all GB patients. In 2000, 5876 GB were performed in the 137 sample hospitals (M:F, 14%:86%). Length of stay (LOS, days), charges, comorbidities, and morbidity were higher for those aged >60 years compared to <40 years. LOS, charges, comorbidities, morbidity, and mortality were highest in males. LOS was longest in African Americans compared to Caucasians and Hispanics. Charges and comorbidities were greatest in African Americans and Hispanics compared to Caucasians. Medicare and Medicaid-insured patients have higher LOS, charges, comorbidities, morbidity, and mortality compared to privately insured and self-pay patients. Lower income patients have higher LOS and total charges. Nonteaching hospitals have an increased LOS and charges and treat patients with more comorbidities compared to teaching hospitals. LOS, charges, and morbidity are directly proportional to hospital size. Urban hospitals have lower LOS and higher charges compared to rural hospitals. As hospital GB volume increases, LOS, charges, and morbidity decrease with no mortality effect. After controlling for all other covariates, male gender, increased age, and large hospital size were predictors of increased morbidity. Having had a complication predicted increased mortality, while female gender had a protective effect. Patient income, insurance status, and race did not play a role in morbidity or mortality. Neither academic, teaching status of the hospital or hospital gastric bypass volume influenced patient outcomes. Patient and hospital demographics do affect the outcomes of patients undergoing GB. Increasing age, male gender, and surgery performed in large hospitals are predictors of morbidity. Male gender and postoperative complications predict increased mortality. Neither comorbidities, race, payer, income, hospital academic status, location, nor hospital volume affect the outcome after GB.
Ten Years of Laparoscopic Adrenalectomy: Lesson Learned from 104 Procedures
Authors: Ramacciato Giovanni , Paolo Mercantini , Pietromaria Amodio , Paolo Buniva , Francesco D'Angelo , Sergio Petrocca , Antonio Stigliano , Vincenzo Toscano , Micaela Piccoli , Gianluigi Melotti
Published: June 2020

The purpose of this study was to evaluate the short- and long-term results of 104 consecutive laparoscopic adrenalectomies performed during a period of 10 years in two specialist centers. One hundred four patients underwent laparoscopic adrenalectomy in two specialist centers in Italy between 1994 and 2003. Indications to laparoscopic adrenalectomy were aldosterone-secreting adenoma (20%), pheochromocytoma (24%), cortisol-secreting adenoma (11.5%), incidentaloma (26.9%), multiple endocrine neoplasia (MEN) type 2A (2.8%), adrenal metastases from lung cancer (3.8%), adrenal cyst (6.7%), and angiomyolipoma (3.8%). Transperitoneal anterior and lateral approaches were adopted in 17 and 84 patients, respectively. Retroperitoneal approach was adopted in three patients. Mean operative time was 108 ± 39.1 minutes (range, 40–300 minutes). There was no correlation between adrenal tumor diameter and operative time. Mean intraoperative blood loss was 106 mL (range, 40–600 mL). Intraoperative complication rate and conversion rate were 4.8 per cent (5 cases). Laparoscopic adrenalectomy is a safe procedure. After a relatively short learning curve, it can be performed successfully by any surgeon with low operative morbidity and mortality. The size of the adrenal tumor should not be considered a contraindication to this procedure.
Article Commentary: Bariatric Surgery: Malpractice Risks and Risk Management Guidelines
Authors: Eagan M. Christopher
Published: June 2020

Providing appropriate medical care to bariatric surgery patients is the primary goal of every surgeon. However, with the expected growth of bariatric surgery in the future, the number of claims in this area are certain to grow. Therefore, it is important for surgeons who are engaged in the practice of bariatric surgery or who are contemplating entering the practice of bariatric surgery to consider risk management guidelines and principles very carefully. It is important to follow the available guidelines and criteria like those established by the American Society of Bariatric Surgery to help reduce the risk of liability. Despite appropriate care and treatment, unfortunately, these patients will continue to suffer complications, some of which are life-threatening. The importance of establishing and maintaining a solid physician-patient relationship by using appropriate interpersonal skills cannot be overemphasized. Indeed, a good relationship with the patient and family remains the most effective way of reducing the risk of being sued when there is an unfortunate complication, as well as increasing the chances of a successful defense in the event of suit.
Multiple Laparotomies are a Predictor of Fascial Dehiscence in the Setting of Severe Trauma
Authors: Swaroop Mamta , Williams Michael , Greene Wendy Ricketts , Sava Jack , Park Kenneth , Wang Dennis
Published: June 2020

The purpose of this study was to determine the incidence of wound dehiscence after repeat trauma laparotomy. We performed a retrospective analysis of adult trauma patients who underwent laparotomy at an urban level 1 trauma center during the past 5 years. Patients were divided into single (SL) and multiple laparotomy (ML) groups. Demographic, clinical, and outcome data were collected. Data were analyzed using χ2, t testing, and ANOVA. Overall dehiscence rate was 0.7 per cent. Multiple laparotomy patients had damage control, staged management of their injuries, or abdominal compartment syndrome as the reason for reexploration. SL and ML patients had similar age and sex. ML patients had a higher rate of intra-abdominal abscess than SL patients (13.7% vs 1.2% P < 0.0001), but intra-abdominal abscess did not predict wound dehiscence in the ML group ( P = 0.24). This was true in spite of the fact that ML patients had a significantly higher Injury Severity Score (ISS) than SL patients (21.68 vs 14.35, P < 0.0001). Interestingly, wound infection did not predict dehiscence. Patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intraabdominal abscess and ISS, but not wound infection. Surgeons should leave the skin open in the setting of repeat trauma laparotomy, which will allow serial assessment of the integrity of the fascial closure.
Leiomyosarcoma of the Inferior Vena Cava: Surgical Management and Clinical Results
Authors: Dew Jason , Hansen Kimberly , Hammon John , McCoy Thomas , Levine Edward A. , Shen Perry
Published: June 2020

Leiomyosarcoma of the inferior vena cava (IVC) is a rare lesion with less than 300 cases reported. Optimal management and long-term outcomes are not well described. From August 1984 to June 2004, eight patients with leiomyosarcoma of the IVC were treated at our institution. Clinical and pathologic data, surgical management, and outcomes were assessed. Eight cases were identified (4 males) with a median age of 52 (range 29–66). Presenting symptoms included abdominal pain (n = 5, 63%), lower extremity edema (n = 2, 25%), and palpable mass (n = 2, 25%). Tumor location was between the renal and iliac veins (low) (n = 4, 50%), between the hepatic and renal veins (middle) (n = 3, 38%), and above the hepatic veins with right atrial extension (high) (n = 1, 12%). Two patients with preoperative IVC occlusion were managed with tumor excision and IVC ligation. Three patients had primary repair of the IVC after tumor excision. A polytetrafluorothylene (PTFE) tube graft was used for IVC reconstruction in three cases. There was no postoperative mortality. Postoperative morbidity included deep venous thrombosis (DVT) (n = 1), lower extremity edema (mild n = 1; moderate n = 1), GI bleed (n = 1), and chronic renal insufficiency (n = 1). One patient is currently receiving adjuvant chemotherapy. Four patients received chemotherapy after recurrence, and one received palliative radiation therapy as well. Median survival to this point was 60 months with a median follow-up of 39 months. The 5-year overall survival and disease-free survival was 31 per cent for both (CI 0.1–1.0). The type of IVC reconstruction had no effect on survival ( P = 0.22). Recurrence was discovered in four patients (50%) at a median time of 14 months. Resection of leiomyosarcoma of the IVC should be attempted whenever feasible. The management of the IVC can be managed with primary repair, ligation, or prosthetic graft. Long-term survival is possible if complete resection can be achieved.
Blunt Trauma to the Thyroid: A Case Report
Authors: Weeks Christine , Moore Francis D. , Ferzoco Stephen J. , Gates Jonathan
Published: June 2020

Thyroid injury is a rare phenomenon in cases of blunt neck trauma. Symptoms are often subtle or not present on initial exam and can be rapidly life-threatening when airway compromise ensues. We describe the case of a 50-year-old woman who developed neck pain and swelling, dysphagia, and hoarseness after a rear-end collision in which she was the restrained driver, hitting her anterior neck against the steering wheel. Neck CT revealed fragmentation and hematoma within the right thyroid lobe. Arteriogram showed no vascular injury to the neck. The patient was observed in the ICU and was discharged home 3 days later without operative intervention. We believe that in the acute setting, a stable traumatic thyroid hematoma without airway encroachment may be safely observed. Increasing size or compromise of airway integrity should be indications for early intubation and neck exploration.
The Effect of Storage on the Survival of Cancer Cells in Blood and Efficient Elimination of Contaminating Cancer Cells by a Leukocyte Depletion Filter
Authors: Futamura Naoki , Nakanishi Hayao , Hirose Hajime , Nakamura Shigeo , Tatematsu Masae
Published: June 2020

Preoperative autologous blood pooling has been employed in patients with malignant tumor. However, it has not been reported how the survival period of tumor cells contaminating the preoperative pooled blood changes corresponding to the storage period. Intraoperative blood salvage (IBS) is used together with preoperative blood pooling. However, IBS in oncologic surgery is generally regarded as a contraindication. In the current study, using cytokeratin 19 (CK-19) mRNA reverse transcription polymerase chain reaction method, we examined the survival period of cultured cancer cells in the pooled blood and the efficacy of irradiation and leukocyte depletion filter in eliminating cancer cells in the blood. Expression of CK-19 mRNA was observed in the pooled blood stored for 21 days. The number of cancer cells decreased to about 1/10 in the blood stored for 14 days. We irradiated blood with cancer cells with doses of 25 Gy or 100 Gy. No change was observed in the amplified CK-19 signal strength immediately after and 1 day after irradiation at 100 Gy. After filtration of blood with cancer cells through the leukocyte depletion filter, no CK-19 mRNA was detected. Blood filtration with the leukocyte depletion filter was effective in eliminating cancer cells in the blood.
Carotid Endarterectomy: Update on the Gold Standard Treatment for Carotid Stenosis
Authors: Harthun Nancy L. , Baglioni A.J. , Kongable Gail L. , Meakem Timothy D. , Cherry Kenneth J.
Published: June 2020

Many prospective, randomized clinical trials evaluating the safety and efficacy of carotid endarterectomy (CEA) versus medical management in the prevention of ischemic stroke were performed in the 1990s. Clinical trials are underway that will compare CEA outcomes to carotid stenting; however, relatively few studies have examined the outcomes of modern CEA. The purpose of this report is to examine current outcomes of CEA and evaluate hospital costs and length of stay. Statewide results were collected for all hospitals, except Veterans Administration hospitals, by Virginia Health Information (VHI). Data for the years 1997–2001 were evaluated, and data were based on the All Patient Refined Diagnostic Related Group (APR-DRG; 3M Company). A total of 14,095 CEAs were performed in a 5-year period. The mortality of patients undergoing CEA was 0.5 per cent. The stroke rate was 1 per cent overall and decreased each year of the study. Mean and median lengths of hospital stay were 3 and 2 days, respectively. Length of stay decreased over the course of this study. Mean and median hospital costs were $14,331 and $11,268. Higher rates of mortality and stroke and higher costs were observed at low-volume hospitals. The need for CEA is substantial. CEA is safe and inexpensive. The data presented here demonstrates continued refinement in CEA, leading to a very low rate of perioperative adverse events, declining lengths of stay, and low hospital costs.
Tailgut Cyst (Retrorectal Cystic Hamartoma): Report of a Case and Review of the Literature
Authors: Killingsworth Christopher , Gadacz Thomas R.
Published: June 2020

Tailgut cysts are rare congenital lesions arising from remnants of normally regressing postanal primitive gut. They often present in middle-aged women with perirectal symptoms and a retrorectal multicystic mass. These cysts have occasionally shown malignant transformation. We report a case of a tailgut cyst occurring in a 25-year-old African-American female. The differential diagnosis of a retrorectal mass is briefly explored, and the etiology, diagnostic strategy, and surgical approach for tailgut cysts is examined. We also report an extensive literature review to examine clinical characteristics and surgical data for 43 cases of tailgut cysts spanning 16 years.
Metaplastic Breast Cancer: Clinical Features and Outcomes
Authors: Gibson Glen R. , Qian Dajun , Ku Joseph K. , Lai Lily L.
Published: June 2020

Metaplastic carcinoma of the breast, a neoplasm with both epithelial and mesenchymal elements, represents less than 1 per cent of all breast cancer. We reviewed the records of all patients diagnosed with localized metaplastic breast cancer from 1991 to 2003 at our institution. We identified 21 patients. Mean primary tumor size was 4.62 cm. Eight patients (38%) had axillary node involvement at presentation. All the tumors were high grade. Only two (10%) of the tumors were hormone receptor positive. Seventeen (81%) of the patients received adjuvant chemotherapy, and 12 (57%) of the patients received radiation. Ten (29%) patients suffered a local recurrence. With a mean follow-up of 46 months, the 5-year disease-free and overall survival was 42 per cent (95% CI: 20% to 65%) and 71 per cent (95% CI: 46% to 96%), respectively. Stage-specific overall survival was 100 per cent, 83 per cent, and 53 per cent for stages I, II, and III, respectively. By multivariate analysis, there was no impact on recurrence or survival with regard to size, age, menopausal status, nodal status, histologic subtype, adjuvant therapy, or extent of surgery. Metaplastic breast cancer is a unique neoplasm that tends to present at an advanced stage and has a propensity for local recurrence. When stratified by stage, however, survival appears similar to that of adenocarcinoma of the breast, and these tumors should be treated as such.
Antecolic Laparoscopic Roux-en-Y Gastric Bypass is not Associated with Higher Complication Rates
Authors: Bertucci William , Yadegar John , Takahashi Aileen , Alzahrani Ali , Frickel Deborah , Tobin Katherine , Kapur Karan , Namdari Behrouz , Dutson Erik , Gracia Carlos , Mehran Amir
Published: June 2020

Since its introduction in 1994, laparoscopic Roux- en-Y gastric bypass (LRYGB) has rapidly gained popularity for the treatment of morbid obesity. Historically, the operation is performed in a retrocolic fashion; however antecolic LRYGB has been advocated as a safe alternative. We reviewed our experience with both techniques. From January 2003 to November 2004, the new UCLA Laparoscopic Bariatric Surgery Program performed 341 LRYGBs. In March 2004, our program transitioned from a retrocolic to an antecolic approach for all gastric bypass procedures. Institutional review board approval was obtained, and the data for all patients was collected into a prospective database. The patient characteristics for the two groups were similar. The significant differences between the two groups were average body mass index and the percentage of patients with diabetes and sleep apnea. The complication profiles for the two groups were also similar. There were significant differences between the two groups in the reoperation rate, antecolic 2.0 per cent versus retrocolic 7.8 per cent, and length of stay, antecolic 2.57 versus retrocolic 2.89 days. There were no anastomotic leaks or deaths in either group. Antecolic LRYGB is safe and may be associated with fewer complications. Only long-term weight loss results and complication rates will provide a definitive answer.
The Effect of Older Blood on Mortality, Need for ICU Care, and the Length of ICU Stay after Major Trauma
Authors: Murrell Zuri , Haukoos Jason S. , Putnam Brant , Klein Stanley R.
Published: June 2020

The purpose of this study was to determine if the quantity and age of blood is an independent risk factor for in-hospital mortality, need for intensive care unit (ICU) care, and an increased length of stay in the ICU. This was a retrospective cohort study performed at a level I trauma center between 2001 and 2003. Consecutive trauma patients who received at least 1 unit of packed red blood cells (PRBCs) were included. The number of units of PRBCs transfused and the ages of each unit of PRBCs were recorded. Other variables including the patient's age, sex, Trauma-Related Injury Severity Score (TRISS), and whether the blood was leukopoor were collected. End points included in-hospital mortality, need for ICU care, and the length of stay in the ICU (in days). Multivariable logistic and Poisson regression analyses were performed to model the independent effect of the dose of aged blood (defined as the product of the average age of all units received and the total number of units received) with respect to each end point while controlling for age, TRISS, the total number of units administered, and the proportion of blood that was leukopoor. During the study period, 275 patients were studied. Patients who received older blood had a significantly longer ICU stay (RR 1.15, 95% CI: 1.11–1.20), possibly reflecting a higher level of organ dysfunction. Patients who received older blood, however, did not have a significantly higher in-hospital mortality rate (OR 1.21, 95% CI: 0.87–1.69) or a significantly higher need for ICU care (OR 1.20, 95% CI: 0.87–1.64). The quantity of aged blood is an independent risk factor for length of ICU care. This may be a proxy indicator for multiple organ failure. Further research is required to define which patients may benefit from newer blood.
Emerging Trends in Peptic Ulcer Disease and Damage Control Surgery in the H. Pylori Era
Authors: Smith Brian R. , Stabile Bruce E.
Published: June 2020

The prevalence of peptic ulcer disease (PUD) and the frequency of operation have been decreasing for decades. Immigration of patients harboring Helicobacter pylori may reverse these longstanding declines. The experience with a large public hospital population in an area of high immigration may portend future national trends. A 10-year retrospective study analyzed the changing demographics of PUD and the frequency and nature of surgical intervention. A total of 2,182 patients were diagnosed with PUD, 1,173 in the early period (1995–1999) and 1,009 in the recent period (2000–2004). The proportion of Hispanic patients increased from 39.3 per cent to 47.5 per cent ( P = 0.017). The ratio of male to female patients decreased from 1.7:1 to 1.3:1 ( P = 0.003). The PUD operation rate decreased from 6.7 per cent to 3.8 per cent ( P = 0.004). Among operated patients, the frequency of H. pylori testing increased from 41.8 per cent to 81.6 per cent ( P = 0.039). Acute perforation and bleeding necessitated the vast majority (87.2%) of operations. The use of acid-reducing operations declined from 50.6 per cent to 31.6 per cent in favor of nonacid-reducing “damage control” procedures. Contrary to historic trends, in the predominately immigrant public hospital patient population studied, 1) the incidence of PUD is decreasing only modestly, 2) male predominance is disappearing, 3) gastric ulcer (GU) is more prevalent than duodenal ulcer (DU), but DU requires operation more frequently than GU, and 4) there is a marked decrease in use of acid-reducing operations reflecting a new “damage control” surgical approach to acute PUD complications in the H. pylori era.
Negative Appendectomy Rate: Influence of CT Scans
Authors: Mcgory Marcial , Zingmond Davids , Nanayakkara Darshani , Maggard Melinda A. , Ko Clifford Y.
Published: June 2020

Negative appendectomy rate varies significantly depending on patient age and sex. However, the impact of computed tomography (CT) scans on the diagnosis of appendicitis is unknown. The goal of this study was to examine the negative appendectomy rate using a statewide database and analyze the association of receipt of CT scan. Using the California Inpatient File, all patients undergoing appendectomy in 1999–2000 were identified (n = 75,452). Demographic and clinical data were analyzed, including procedure approach (open vs laparoscopic) and appendicitis type (negative, simple, abscess, peritonitis). Patients with CT scans performed were identified to compare the negative appendectomy rate. For the entire cohort, appendicitis type was 59 per cent simple, 10 per cent with abscess, 18.7 per cent with peritonitis, and 9.3 per cent negative. Males had a lower rate of negative appendicitis than females (6.0% vs 13.4%, P < 0.0001). The use of CT scans was associated with an overall lower negative appendectomy rate for females, especially in the <5 years and >45 years age categories. Use of CT scans in males does not appear to be efficacious, as the negative appendectomy rates were similar across all age categories. In conclusion, use of CT was associated with lower rate of negative appendectomy, depending on patient age and sex.
Profound Refractory Hypocalcemia after Thyroidectomy in a Patient Receiving Chronic Oral Bisphosphonate Therapy
Authors: Richmond Bryan K.
Published: June 2020

The use of oral bisphosphonates in the primary care setting is increasing, most commonly to preserve bone density and prevent the development or progression of osteoporosis. We report a case of profound hypocalcemia occurring in a patient who underwent thyroidectomy while receiving chronic oral risedronate therapy for osteoporosis. In addition, the hypocalcemia was refractory to treatment for several days, necessitating a prolonged hospital stay. A review of the literature yielded no similar cases to date. We propose that the frequently observed transient hypocalcemia after thyroidectomy was exacerbated by the alterations in calcium homeostasis produced by bisphosphonate therapy and urge cessation of these agents for several weeks prior to surgery. A review of the relevant literature is provided.
Hashimoto Thyroiditis Coexistent with Papillary Thyroid Carcinoma
Authors: Cipolla Calogero , Sandonato Luigi , Graceffa Giuseppa , Fricano Salvatore , Torcivia Adriana , Vieni Salvatore , Latteri Stefania , Latteri Mario Adelfio
Published: June 2020

Several studies report a higher rate of papillary thyroid carcinomas (PTC) in patients with Hashimoto thyroiditis (HT), indicating a possible correlation between the two diseases. We studied a group of 89 subjects undergoing surgery for thyroid carcinomas compared with a control group of 89 subjects operated on for normofunctioning goiter, and a second group of 47 patients undergoing total thyroidectomy for HT. Association with HT was found in 19 of the 71 PTC subjects (26.7%) and in 8 goiter patients (8.9%), which was a significant difference ( P < 0.02). Thirteen of the HT patients, mostly with the nodular form, showed coexistent PTC (27.6%). HT and PTC coexisted in several morphological, immunohistochemical, and biomolecular aspects; increased incidence of PTC in HT patients might therefore indicate that HT is a precursor of thyroid cancer. Further studies are required, however, in order to confirm this hypothesis; until then, HT patients should undergo careful clinical and technical follow-up.
Is Outcome after Blunt Splenic Injury in Adults Better in High-Volume Trauma Centers?
Authors: Harbrecht Brian G. , Zenati Mazen S. , Alarcon Louis H. , Ochoa Juan B. , Puyana Juan C. , Schuchert Vaishali D. , Peitzman Andrew B.
Published: June 2020

An association between outcome and case volume has been demonstrated for selected complex operations. The relationship between trauma center volume and patient outcome has also been examined, but no clear consensus has been established. The American College of Surgeons (ACS) has published recommendations on optimal trauma center volume for level 1 designation. We examined whether this volume criteria was associated with outcome differences for the treatment of adult blunt splenic injuries. Using a state trauma database, ACS criteria were used to stratify trauma centers into high-volume centers (>240 patients with Injury Severity Score >15 per year) or low-volume centers, and outcome was evaluated. There were 1,829 patients treated at high-volume centers and 1,040 patients treated at low-volume centers. There was no difference in age, gender, emergency department pulse, emergency department systolic blood pressure, or overall mortality between high- and low-volume centers. Patients at low-volume centers were more likely to be treated operatively, but the overall success rate of nonoperative management between high-and low-volume centers was similar. These data suggest that ACS criteria for trauma centers level designation are not associated with differences in outcome in the treatment of adult blunt splenic injuries in this regional trauma system.
Endovascular Aortic Aneurysm Repair with the Zenith AAA Endovascular Graft: Does Gender Affect Procedural Success, Postoperative Morbidity, or Early Survival?
Authors: Biebl Matthias , Hakaim Albert G. , Hugl Beate , Oldenburg Warner A. , Paz-Fumagalli Ricardo , Mckinney J. Mark , Greenberg Roy , Chuter Timothy
Published: June 2020

The purpose of this study was to analyze the effect of gender on deployment, early morbidity, and survival after endovascular aortic aneurysm repair (EVAR) using the Zenith Endovascular Graft. Data were obtained from the U.S. Multicenter Zenith Endograft trial and complemented with results from the Zenith female registry, including 40 women (10.9%) and 326 men (89.1%). Data analysis included preoperative medical risk factors, aneurysm morphology, deployment, and postoperative morbidity data, and 30-day and 1-year results. Preoperatively, women more often had experienced thromboembolic events (13% vs 4.3%; P = 0.04), but less angina pectoris (24% vs 49%; P = 0.002) or myocardial infarction (18% vs 38%; P = 0.01) compared with men. Women had more angulated aneurysm necks and narrower iliac arteries compared with men. Procedural success, cardiovascular, pulmonary, renal, bowel-related, neurologic, or other adverse events were comparable, as were 30-day and 1-year survival. Females experienced more wound dehiscences (5.0% vs 0.0%; P = 0.01) and open surgical conversions in the first year (5%) compared with men (0.31%) ( P = 0.03). With more challenging aneurysm morphologies, women were found to be at a higher risk for conversion in the first year after EVAR using the Zenith endograft. This however does not translate into inferior survival or higher overall morbidity compared with men.
Laparoscopic Removal of an Intrauterine Device Perforating the Sigmoid Colon: A Case Report and Review of the Literature
Authors: Chi Esmond , Rosenfeld David , Sokol Thomas P.
Published: June 2020

We report a case of a translocated intrauterine device (IUD) embedded within the colon wall. Endoscopic tattooing and laparoscopy was used to identify the colonic site and facilitate extraction by colonic resection. A review of the literature and discussion of laparoscopic management of this complication is presented.
Colobronchial Fistula as a Rare Complication of Coloesophageal Interposition: A Unique Treatment with a Review of the Medical Literature
Authors: Zhao Xian , Sandhu Bimaljit , Kiev Jon
Published: June 2020

Colobronchial fistula after coloesophageal interposition is a rare complication that has only been reported once in the English surgical literature. We report the case of a 53-year-old man who presented with chronic respiratory complaints. He had previously undergone esophagectomy for adenocarcinoma of the gastroesophageal junction. The fistula was controlled by placement of a Polyflex esophageal stent.
Regulation of Human Vascular Smooth Muscle Cell Migration by β-Adrenergic Receptors
Authors: Johnson Richard , Webb Jerry G. , Newman Walter H. , Wang Zhongbiao
Published: June 2020

Migration and proliferation of vascular smooth muscle cells (VSMCs) are two events involved in atherosclerosis, restenosis after balloon angioplasty, and stenosis of grafted vessels. Platelet-derived growth factor (PDGF) found in stenotic vessels is known to induce migration of VSMCs. VSMCs express both α- and β-adrenergic receptors on their surface, and blood vessels are innervated by the adrenergic nervous system and exposed to circulating epinephrine. We examined the role of these receptors on PDGF-induced migration of VSMCs. VSMCs were cultured from saphenous vein segments. Migration was stimulated by PDGF. Effect of pretreatment of VSMCs with the β-agonist isoproterenol, the α-agonist phenylephrine, or forskolin on PDGF-induced migration was examined with a modified Boyden chamber. Cell migration was quantitated by spectrophotometry. Intracellular cyclic AMP was determined by radioimmunoassay. PDGF significantly induced VSMC migration. Isoproterenol (0.1 and 1.0 μM) inhibited PDGF-induced migration by 30 per cent and 50 per cent, respectively. Forskolin (10 μM) completely blocked PDGF-induced migration. The migration inhibition by isoproterenol or forskolin was associated with a significant elevation of intracellular cyclic AMP. In contrast, phenylephrine had no effect on PDGF-induced migration or on cyclic AMP. Activation of β-adrenergic receptors and the consequent rise in intracellular cyclic AMP inhibits migration of VSMCs induced by PDGF. These results are consistent with the notion that adrenergic agonists with substantial β-receptor affinity, such as isoproterenol, can inhibit smooth muscle cell migration.
Safely Increasing the Efficiency of Thyroidectomy Using a New Bipolar Electrosealing Device (LigaSure™) versus Conventional Clamp-and-Tie Technique
Authors: Franko Jan , Kish Karen J. , Pezzi Christopher M. , Pak Ho , Kukora John S.
Published: June 2020

Operative time in thyroid surgery can be safely reduced through use of a new bipolar electro-sealing device (LigaSure). We evaluated consecutive patients undergoing thyroid surgery from January 2003 through January 2005 (n = 155). During the first half of the study, hemostasis was obtained using silk ties (conventional group, n = 70). During the second half of the study period, hemostasis was obtained with a bipolar electrosealing device (LigaSure group, n = 85). The mean operative time was 130 ± 37 minutes in the conventional group and 110 ± 33 minutes (P < 0.001) in the LigaSure group. EBL in the LigaSure group was statistically significantly less (43 ± 53 vs 33 ± 33 mL; P < 0.05). Postoperative calcium level was statistically significantly higher in the Liga-Sure group (8.2 ± 0.5 vs 8.4 ± 0.6 mg/dL, P < 0.05). Hospital length of stay (LOS) did not differ significantly. One patient in each group developed neck hematoma requiring reoperation. One permanent recurrent nerve injury occurred in the conventional group and one transient bilateral recurrent nerve injury occurred in the LigaSure group. The occurrence of symptomatic hypocalcemia was similar between the two groups. The training level of the surgical resident had no significant impact on the operative time, estimated blood loss (EBL), LOS, or complication rate. LigaSure bipolar electrosealer as the primary means of hemostasis during thyroidectomy significantly reduces mean operative times. Rates of operative complications were unchanged. LigaSure use in thyroid surgery can safely increase efficiency.
Gender Differences in Outcomes after off-Pump Coronary Artery Bypass Graft Surgery
Authors: Patel Snehal , Smith J. Michael , Engel Amy M.
Published: June 2020

Our objective was to assess surgical outcomes between male and female patients undergoing off-pump coronary artery bypass grafting (CABG). The study was conducted from a 10-year hospitalization cohort (n = 11,230) in which the data were collected prospectively. Inclusion criteria included an off-pump CABG-only procedure. There were 526 men and 250 women included in the study. Fourteen potential confounding risk factors and 14 outcome variables were examined. Six potential risk factors were found to be significantly different between men and women. Men were younger (P = 0.014), had a larger body surface area (P < 0.001), a higher creatinine level (P < 0.001), required more grafts (P < 0.001), and were more likely to have a cerebrovascular history (P = 0.020) and a history of tobacco use (P ≤ 0.001). Logistic regression analysis showed that even after controlling for age, body surface area, creatinine level, number of grafts, and tobacco history, women had longer length of hospitalization (odds ratio, 1.97; 95% confidence interval, 1.28–3.04, P = 0.002) and more sternal wound complications than men (odds ratio, 1.07; 95% confidence interval, 1.01–2.11, P = 0.028) after off-pump CABG. Although not statistically different, women had lower operative mortality than men after off-pump CABG (0.8% [2 of 10] compared with 1.5% [8 of 10], respectively). Despite women requiring a longer hospitalization and having a greater incidence of sternal wound infections than men, there was no significant difference in mortality.
Prospective Evaluation of an Extubation Protocol in a Trauma Intensive Care Unit Population
Authors: Aboutanos Sharline Z. , Duane TherÈSe M. , Malhotra Ajai K. , Borchers C. Todd , Wakefield Tracey A. , Wolfe Luke , Aboutanos Michel B. , Ivatury Rao R.
Published: June 2020

Little data exists regarding extubation protocols in critically injured trauma patients. The objective of the current study was to prospectively examine the impact of implementing an extubation protocol on the outcomes of ventilated trauma patients in a surgical intensive care unit (STICU). Trauma patients admitted to the STICU over a 15-month period at a Level 1 trauma center were prospectively evaluated. The total period was divided into an education and institution period (April 2002–November 2003) and an evaluation period (December 2003–July 2003). Patient demographics, hospital course, complications, and outcomes from period I were compared with those obtained during period II. From April 8, 2002 through July 5, 2003, 69 patients intubated for greater than 24 hours were included in our analysis. Thirty-three were treated during period I and 36 were treated during period II. Both groups were well matched in terms of age, sex, Injury Severity Score, and chest Abbreviated Injury Score. Ventilation days significantly decreased from a mean of 16.3 to 8.2 days (P = 0.04). ICU length of stay also decreased, nearly meeting significance. A rigorously enforced extubation protocol significantly decreased ventilator days in STICU patients. Continued education of health care providers is key to the success of the protocol.
Acute Appendicitis: Is There a Difference between Children and Adults?
Authors: Lee Steven L. , Ho Hung S.
Published: June 2020

Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 ± 4.3 days vs 2.5 ± 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 ± 2.7 hours vs 5.7 ± 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count ≥12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 ± 3.3 days compared with nonperforated cases, 2.3 ± 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.
Accelerated Migration and Proliferation of Smooth Muscle Cells Cultured from Neointima Induced by a Vena Cava Filter
Authors: Christie D. Benjamin , Kang Jing , Ashley Dennis W. , Mix William , Lochner Frank K. , Solis Maurice M. , Newman Walter H. , Dalton Martin L. , Wang Zhongbiao
Published: June 2020

Formation of a neointima is associated with grafted artery or vein, angioplasty, and stent and inferior vena cava filter (IVCF) implantation. Contributing to the neointima is a population of vascular smooth muscle cells (SMC) that migrates from media and subsequently proliferates within intima. The purpose of this present study was to culture SMC from normal vessel wall and from neointima and to compare migration and growth of these cells. Neointima was stimulated in the vena cava of pigs by placement of an IVCF for 30 days. Tissue was taken from the thickened wall between the struts and from a normal segment of the IVCF. After removal of the endothelium and adventitia, explants were placed in culture dishes and were observed for the migration of cells. Immunoassay for smooth muscle α-actin was used to identify cell origin. Proliferation was determined by cell counting. The cell cycle regulator cyclin D1 was detected by Western blot analysis. SMC phenotype was confirmed by positive immunostaining for smooth muscle α-actin. Cells migrated from the neointimal explants (NI-SMC) more rapidly than cells from explants of normal media (NM-SMC). Proliferation of NI-SMC was also more rapid than NM-SMC with or without exogenous mitogens. NI-SMC expressed more cyclin D1 than NM-SMC. Injury to the vena cava triggered neointima formation characterized by the expansion of a population of SMC with increased migration and replication compared with SMC from normal regions of the vessel.