bluuebunny/crossref_metadata_2025 huggingface dataset:
The Surgical Safety Checklist: Lessons Learned During Implementation
Authors: Calland James Forrest , Turrentine Florence E. , Guerlain Stephanie , Bovbjerg Viktor , Poole Garrett R. , Lebeau Kelsey , Peugh James , Adams Reid B.
Published: June 2020

Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases performed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants.
Standard Computed Tomography of the Chest, Abdomen, and Pelvis Is Sensitive and Cost-Effective for the Detection of Fractures of the Shoulder Girdle
Authors: Adams John M. , Bilaniuk Jaroslaw W. , Difazio Louis T. , Siegel Brian K. , Durling-Grover Renay , Mccarthy Denise , Grob Patricio , Bobbin Mark D. , Skerker Robert S. , NÉMeth ZoltÁN H.
Published: June 2020

Computed tomography of the chest, abdomen, and pelvis (CTCAP) has become the mainstay of diagnosis in stable blunt trauma patients. The purpose of this study was to investigate whether standard CTCAP has adequate sensitivity to identify fractures of the scapula, clavicle, and humeral head to replace routine radiographs of the shoulder. A retrospective chart review was carried out from January 1, 2004, to December 31, 2007, at Morristown Memorial Hospital. Inclusion criteria were all shoulder fracture patients in our trauma registry who underwent both a CTCAP and plain radiographs of the injured shoulder. Data were collected for patient age, sex, Injury Severity Score, mechanism of injury, and fracture location. Sensitivity was calculated for each diagnostic modality as well as hospital costs and radiation dose of plain radiographs. A total of 374 charts were reviewed and 98 patients were included in the study with a total of 117 fractures. The sensitivity of trauma CTCAP for scapula fractures was 100 per cent, clavicle fractures 98 per cent, and humeral head fractures 100 per cent. The sensitivity of the shoulder series for scapula fractures was 60 per cent, clavicle fractures 85 per cent, and humeral head fractures 100 per cent. The plain radiographs added $298 in hospital charges and 0.191 mSv of radiation per patient. CTCAP is a sensitive tool for identifying fractures in the shoulder girdle. Therefore, CTCAP can replace the routine radiographs of the shoulder resulting in less total radiation exposure of the trauma patients. This also would lead to lower healthcare cost and better diagnostic workflow.
Evaluation of Hemostatic Factors in Patients Undergoing Major Hepatic Resection and Other Major Abdominal Surgeries
Authors: Tapper Elliot B. , Tanaka Ken A. , Sarmiento Juan M.
Published: June 2020

The aim of this study was to evaluate the role for additional testing of coagulation in perioperative management of patients undergoing major hepatic resection. Major outcome measures were perioperative measurements of hemostatic factors (activated partial prothrombin time [aPTT], prothrombin time/international normalized ratio, fibrinogen, antithrombin-III). We conducted a prospective, single-blind study comparing hemostatic factors in patients undergoing major hepatectomy, Whipple procedures, and other gastrointestinal operations. Ninety-five consecutive patients were enrolled. No values differed significantly at baseline. Immediately postoperative, only international normalized ratio was significantly lower comparing major hepatectomy with Whipple ( P < 0.005) and other procedures ( P < 0.0032). Twenty-four hours postoperative, antithrombin-III was lower for major hepatectomy than Whipple ( P < 0.028) and others ( P < 0.0001); fibrinogen was lower compared with Whipple ( P < 0.014) and others ( P < 0.0009); international normalized ratio was lower to compared with Whipple ( P < 0.0001) and others ( P < 0.0001). aPTT measurements never differed significantly between groups at any time. Antithrombin-III and fibrinogen only correlated with international normalized ratio and aPTT for the other procedures. Additional hemostatic values beyond the standard evaluations of aPTT and international normalized ratio are needed to better assess patients undergoing major hepatic surgery.
Proteinuria as a Predictor of Renal Dysfunction in Trauma Patients Receiving Intravenous Contrast
Authors: Clark Justin J. , Wong Linda L. , Lurie Fedor , Kamitaki Brad K.
Published: June 2020

Trauma patients have unknown comorbidities, multiple injuries, and incomplete laboratory testing, yet require contrast-enhanced imaging to identify potentially life-threatening problems. Our goal was to characterize contrast-induced nephropathy (CIN) in this population. We retrospectively reviewed characteristics of 402 patients who presented to a Level II trauma center and received contrast-enhanced imaging. CIN was defined as creatinine rise of 0.5 mg/dL or greater or 25 per cent or greater from baseline within 48 hours. CIN occurred in 7.7 per cent and four patients required hemodialysis. Patients with CIN were older, had lower admission hemoglobin, higher Injury Severity Score, and received more blood products. Factors that predicted CIN included: male sex, age older than 46 years, body mass index less than 27 kg/m2, glomerular filtration rate less than 109 mL/min/1.73 m2, hemoglobin less than 12 mg/dL, hematocrit less than 36 per cent, proteinuria, 2 units or more of fresh-frozen plasma in 48 hours, and alcohol use. Odds ratio for developing CIN with two, five, or six of these factors was 3.39, 6.54, and 8.38, respectively. A match-controlled analysis for Injury Severity Score and age in patients with CIN versus non-CIN patients revealed the strongest predictor of CIN was proteinuria (relative risk, 2.5; confidence interval, 1.1 to 5.8). Although it is difficult to truly differentiate CIN from renal dysfunction related to injury severity in trauma patients, proteinuria may be an important factor in identifying nephropathy in this population.
D2 Lymph Node Dissection Improves Staging in Patients with Gastric Adenocarcinoma
Authors: Putchakayala Krishna , Difronzo L. Andrew
Published: June 2020

Debate continues over the recommended extent of routine lymphadenectomy for gastric cancer. Although evidence of improved locoregional control with extended dissection accumulates, understaging and stage migration continue to confound the issue. Our objective was to determine whether D2 lymph node dissection improves staging compared with D1 in patients with gastric adenocarcinoma. We performed a retrospective study of 79 consecutive patients who underwent resection of gastric adenocarcinoma at a single institution. The American Joint Committee on Cancer (AJCC) 7th edition (2010) was used for TNM staging. Twenty-seven patients (34%) underwent D2 lymphadenectomy; 52 underwent D1 lymphadenectomy. There was no significant difference in age, gender, or operation. Significantly more lymph nodes were removed with a D2 than a D1 lymphadenectomy (mean, 26 vs 9; P < 0.0001). Significantly more patients had at least 15 nodes removed in the D2 cohort (85 vs 17%, P < 0.001). Within the D2 cohort, nine patients (39%) demonstrated additional lymph node metastases on extended dissection. This altered nodal status in five patients (20%) and altered TNM stage in four patients (16%). There was no significant difference in perioperative morbidity. D2 lymphadenectomy significantly increases node retrieval and AJCC compliance for gastric adenocarcinoma, resulting in improved staging.
Mortality Risk Stratification in Elderly Trauma Patients Based on Initial Arterial Lactate and Base Deficit Levels
Authors: Neville Angela L. , Nemtsev Denis , Manasrah Raed , Bricker Scott D. , Putnam Brant A.
Published: June 2020

Elderly trauma patients have worse outcomes than their younger counterparts. Early risk stratification remains difficult, particularly because traditional vital signs are less reliable. We hypothesized that arrival lactate and base deficit (BD) could be used to predict mortality in elderly trauma patients with a normal admission blood pressure. We retrospectively evaluated the prospectively collected trauma registry at our urban Level I trauma center between 2003 and 2009. Patients sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group. Primary outcomes were in-hospital and 24-hour mortality. There were 364 patients with a lactate and 324 with a BD drawn. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI, 1.6 to 8.2; P = 0.0018). The OR for mortality was 5.2 (95% CI, 2.5 to 11.2; P < 0.0001) in patients with a BD -4 or less. Elevated lactate and BD were even stronger predictors of early mortality (within first 24 hours). After increasing the hypotension threshold to a systolic blood pressure 110 mmHg or greater, lactate and BD remained highly predictive of in-hospital and 24-hour mortality.
Are There Racial Disparities in the Use of Restraints and Outcomes after Motor Vehicle Collisions in Los Angeles County?
Authors: Yaghoubian Arezou , De Virgilio Christian , Kaji Amy H. , Putnam Brant , Neville Angela L. , Bricker Scott , Lee Steven L.
Published: June 2020

Motor vehicle collisions (MVCs) continue to be a leading cause of traumatic death, yet there is a paucity of data regarding racial/ethnic differences in injury severity, use of restraints, and outcomes. This study determines whether racial/ethnic disparities exist in adult MVC victims. A retrospective review of patients (age older than 18 years) involved in MVC in Los Angeles County from 2004 to 2009 was performed. Main outcome measures were hospital length of stay, mortality, and complication rate. Independent variables evaluated included race/ethnicity, use of restraints, age, gender, Injury Severity Score (ISS), and Glasgow Coma Scale. During the 5-year study period, 22,444 patients were involved in an MVC in Los Angeles County. Overall restraint use was 69 per cent, lowest in blacks (67%) and Hispanics (68%). Mortality and morbidity rates were both 3 per cent for all racial/ethnic groups. On multivariable analysis, higher ISS, older age, male gender, not wearing a seatbelt, and being Asian increased the risk of death. In conclusion, our study demonstrated racial/ethnic differences in MVC victims, particularly identifying that Hispanics and blacks were less likely to be restrained and thus could be the target of future injury prevention programs.
Utilization and Outcomes of Laparoscopic Versus Open Paraesophageal Hernia Repair
Authors: Nguyen Ninh T. , Christie Catherine , Masoomi Hossein , Matin Taraneh , Laugenour Kelly , Hohmann Samuel
Published: June 2020

The optimal operative approach for repair of diaphragmatic hernia remains debated. The aim of this study was to examine the utilization of laparoscopy and compare the outcomes of laparoscopic versus open paraesophageal hernia repair performed at academic centers. Data was obtained from the University HealthSystem Consortium database on 2726 patients who underwent a laparoscopic (n = 2069) or open (n = 657) paraesophageal hernia repair between 2007 and 2010. The data were reviewed for demographics, length of stay, 30-day readmission, morbidity, in-hospital mortality, and costs. For elective procedures, utilization of laparoscopic repair was 81 per cent and was associated with a shorter hospital stay (3.7 vs 8.3 days, P < 0.01), less requirement for intensive care unit care (13% vs 35%, P < 0.01), and lower overall complications (2.7% vs 8.4%, P < 0.01), 30-day readmissions (1.4% vs 3.4%, P < 0.01) and costs ($15,227 vs $24,263, P < 0.01). The in-hospital mortality was 0.4 per cent for laparoscopic repair versus 0.0 per cent for open repair. In patients presenting with obstruction or gangrene, utilization of laparoscopic repair was 57 per cent and was similarly associated with improved outcomes compared with open repair. Within the context of academic centers, the current practice of paraesophageal hernia repair is mostly laparoscopy. Compared with open repair, laparoscopic repair was associated with superior perioperative outcomes even in cases presenting with obstruction or gangrene.
Excisional Biopsy of Borderline Lesions after Large Bore Vacuum-Assisted Core Needle Biopsy- Is It Necessary?
Authors: Green Sari , Khalkhali Iraj , Azizollahi Elliot , Venegas Rose , Jalil Yasmin , Dauphine Christine
Published: June 2020

The current recommendation for borderline breast lesions after core needle biopsy is for surgical excision due to a high rate of pathologic underestimation. With the use of vacuum-assisted core needle (VACN) biopsy devices, upgrade rates have improved, but still average 20 per cent. We routinely use larger bore VACNs (7- and 8-gauge) than previously reported (9 to 11-gauge). The aim of this study is to evaluate the upgrade rate to malignancy in patients undergoing VACN using larger bore needles. VACN biopsies were performed in 902 patients. Of those, 87 were recommended excisional biopsy for borderline or noncorrelating lesions and 66 underwent the procedure. Two patients were upgraded to cancer, for an overall upstage rate of 3 per cent. Both of these underestimations were in patients that initially had atypical ductal hyperplasia. In the patients not excised, no patient developed further cancer. A 7- or 8-gauge needle was used in 57 per cent of patients, greater than 90 per cent removal of the initial lesion was accomplished in 53 per cent of cases, and there were no bleeding complications. This study suggests that upgrade rates decline with larger bore biopsy needles with near complete excision of the initial lesion, and that some borderline lesions may potentially be managed nonoperatively.
Medical Student Mentorship in a University Setting as a Strategy for a Career in Surgery
Authors: Barry Parul N. , Fallat Mary E.
Published: June 2020

Gender balance in surgery is a respectable and necessary goal. At the University of Louisville (UL) School of Medicine, we have compared percentages of UL medical student applicants to general surgery or surgical subspecialty residency programs, surgical residents, and surgical faculty with the rest of the nation. Although UL has at times paralleled or exceeded the nation in many of these categories, there is room for improvement and the comparison data allow for strategic planning initiatives. To promote gender balance among future generations of surgeons at UL, we recently implemented a mentoring program that pairs medical students with residents and faculty in surgery. We plan to track the success over time and correct any shortcomings of this program. Virginia Commonwealth University's commitment to gender balance in surgery is exemplary. As part of a more comprehensive vision to create a mentorship program for female medical students at the UL School of Medicine, we have recently recruited female surgical residents and faculty, whom we hope will provide the type of inspiration and guidance that will increase the number of women from UL who decide to train in general surgery and the surgical specialties. To understand why women across the nation are not generally at numerical parity in these fields, it is important to consider the length and intensity of the surgical residency programs in the context of the other goals and objectives that a woman might have for her future. This article does not address this broad topic but provides a perspective of how a medical school can evaluate and perhaps intervene to mentor medical students more effectively about the satisfaction derived from a career in surgery. As part of this project, we have evaluated each step of the path through medical school and a surgical residency by comparing data for our students, residency programs, and faculty with national data.
Prognostic Factors after Pancreatoduodenectomy for Distal Bile Duct Cancer
Authors: Qiao Qi-Lu , Zhang Tai-Ping , Guo Jun-Chao , Zhan Han-Xiang , Zhao Jian-Xun , Liu Yu-Cun , Wan Yuan-Lian , Leng Xi-Sheng , Zhao Yu-Pei
Published: June 2020

Prognostic factors influencing long-term survival after radical resection for distal bile duct cancer have not been well established because of the rarity of this malignancy. The goal of this study was to identify main prognostic factors in patients undergoing pancreatoduodenectomy for distal bile duct carcinoma. A retrospective study consisting of 122 patients with distal bile duct cancer who underwent pancreatoduodenectomy in three major university hospitals was performed to identify the main prognostic factors. Major surgical complications occurred in 40 patients (32.8%), of whom eight died (6.6%) in the hospital. Overall actuarial survival (excluding hospital deaths) at 1-, 3-, and 5-year follow-up was 82.9, 49.4, and 32.7 per cent, respectively, with a median survival of 36 months. Univariate analysis showed that papillary tumor ( P = 0.045), negative surgical margin (R0 resection, P = 0.005), earlier pT ( P = 0.005), pTNM stage ( P < 0.001), and absence of lymph node involvement ( P < 0.0001) were significant predictors of survival. On multivariate analysis, only lymph node metastasis was shown to be an independent prognostic factor of survival ( P = 0.036). Lymph node involvement was the most important survival predictor after a Whipple resection in patients with distal cholangiocarcinoma.
Colorectal Cancer Surgery in Patients Older than 80 Years of Age: Experience at One Nonteaching Hospital in Japan
Authors: Maeda Hiromichi , Okabayashi Takehiro , Ichikawa Kengo , Miyazaki Jyunichi , Hanazaki Kazuhiro , Kobayashi Michiya
Published: June 2020

The safety and efficacy of surgical treatment for colorectal cancer in patients older than 80 years of age are seldom assessed. The aim of the present study was to compare short- and long-term outcomes after surgery between younger and elderly patients at a single nonteaching hospital. In all, 342 consecutive patients who underwent surgical resection for invasive primary colorectal cancer between April 1999 and April 2007 were included in the study. Patients were divided into two groups according to their age at the time of surgery, those younger than 79 years of age (n = 283) and those older than 80 years of age (n = 59). A greater proportion of elderly patients had concurrent disease before surgery, right-sided colon cancer, and postoperative complications. Cox proportional hazards model (multivariate analysis) identified three independent risk factors for a poor outcome after surgery (excluding death by other causes): 1) the presence of preoperative symptoms; 2) noncurative resection for colorectal cancer; and 3) the presence of lymph node metastases. Age older than 80 years was not a risk factor for a poor postoperative prognosis. At our nonteaching hospital, surgical resection appears to be a safe and beneficial treatment option for elderly patients (older than 80 years of age) who have colorectal cancer.
Effect of Glycemic State on Hospital Mortality in Critically Ill Surgical Patients
Authors: Chi Albert , Lissauer Matthew E. , Kirchoffner Jill , Scalea Thomas M. , Johnson Steven B.
Published: June 2020

Intensive insulin therapy can reduce mortality. Hypoglycemia related to intensive therapy may worsen outcomes. This study compared risk adjusted mortality for different glycemic states. A retrospective review of patients admitted to a surgical intensive care unit over 4 years was performed. Patients were divided into glycemic groups: HYPER (≥1 episode > 180 mg/dL, any <60), HYPO (≥1 episode < 60 mg/dL, any >180), BOTH (≥1 episode < 60 and ≥1 episode > 180 mg/dL), NORMO (all episodes 60-180 mg/dL), HYPER-Only (≥1 episode > 180, none <60 mg/dL), and HYPO-Only (≥1 episode < 60, none >180 mg/dL). Observed to expected Acute Physiology and Chronic Health Evaluation (APACHE) III mortality ratios (O/E) were studied. Number of adverse glycemic events was compared with mortality. Hypoglycemia and hyperglycemia occurred in 18 per cent and 50 per cent of patients. Mortality was 12.4 per cent (O/E = 0.88). BOTH had the highest O/E ratio (1.43) with HYPO the second highest (1.30). Groups excluding hypoglycemia (NORMO and HYPER-only) had the lowest O/E ratios: 0.56 and 0.88. Increasing number of hypoglycemic events were associated with increasing O/E ratio: 0.69 O/E for no events, 1.19 for 1-3 events, 1.35 for 4-6 events, 1.9 for 7-9 events, and 3.13 for ≥ 10 events. Ten or more hyperglycemic events were needed to significantly associate with worse mortality (O/E 1.53). Hyper- and hypoglycemia increase mortality compared with APACHE III expected mortality, with highest mortality risk if both are present. Hypoglycemia is associated with worse risk. Glucose control may need to be loosened to prevent hypoglycemia and reduce glucose variability.
Minor Hepatic Resection for Hepatocellular Carcinoma in Cirrhotic Patients: Kelly Clamp Crushing Resection Versus Heat Coagulative Necrosis with Bipolar Radiofrequency Device
Authors: Sandonato Luigi , Soresi Maurizio , Cipolla Calogero , Bartolotta Tommaso V. , Giannitrapani Lydia , Antonucci Michela , Galia Massimo , Latteri Mario A.
Published: June 2020

Hemorrhage and postoperative liver insufficiency are frequent and serious complications of hepatic resection in cirrhotic patients. The aim of this study was to assess retrospectively whether the surgical techniques using Kelly clamp crushing resection or heat coagulative necrosis with a bipolar radiofrequency device can reduce the incidence of the above complications and an eventual recurrence of neoplasia on the liver slice. We retrospectively reviewed the results of 35 patients who had undergone resection for monofocal hepatocellular carcinoma at our center. Thirteen patients (Group A) had undergone liver resection with Kelly clamp crushing resection, 22 patients (Group B) had had liver resection assisted with a bipolar radiofrequency device. Radiofrequency-assisted liver resection was associated with diminished blood loss ( P < 0.0001), a lower blood transfusion rate ( P < 0.005), reduced operative time ( P < 0.0001), and better postoperative serum albumin levels ( P < 0.03). This nonrandomized retrospective study suggests that radiofrequency-assisted liver resection is associated with better results than the Kelly clamp crushing resection technique in cirrhotic patients with focal hepatocellular carcinoma and preserved liver function. These results should now be assessed prospectively in a randomized clinical trial.
Incidental Findings on Computed Tomography Scans for Acute Appendicitis: Prevalence, Costs, and Outcome
Authors: Ozao-Choy Junko , Kim Unsup , Vieux Ulrich , Menes Tehillah S.
Published: June 2020

CT scan is increasingly being used to diagnose appendicitis due to its specificity and literature suggesting its cost-effectiveness. CT scans are associated with incidental findings. We sought to investigate the rates of incidental findings identified on CT scans, the follow-up of these findings, and the added cost associated with this follow-up. A retrospective review of patients who underwent appendectomies for acute appendicitis between 2003 and 2005 was completed at Elmhurst Hospital Center (Elmhurst, NY). Incidental findings were grouped into low and high significance, based on workup or follow-up needed. The diagnostic workup and cost of each incidental finding was ascertained. For patients who did not receive a workup due to lack of follow-up, an estimate of the minimum workup was calculated. Of 1142 patients with acute appendicitis, 876 (77%) had a CT scan. This rate increased over time (from 66% in 2003 to 85% in 2005, P < 0.01) and with age (70% in patients under 20 and 98% in patients over 50, P < 0.001). Incidental findings were common and increased with age (23% in the youngest group vs 78% in patients older than 50, P < 0.001). The cost associated with workup of these incidental findings increased with age as well. The increased use of CT scans is associated with a high rate of incidental findings. These findings are usually of low clinical significance but may require further workup and follow-up. Physicians need to be aware of the high rate of incidental findings, the need for further workup, and the associated costs.
Total Laparoscopic Distal Pancreatectomy: Beyond Selected Patients
Authors: Boutros Cherif , Ryan Kristin , Katz Steven , Espat N. Joseph , Somasundar Ponnandai
Published: June 2020

Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP. Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS ( P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14 patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP. Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.
A Single-Institution Approach to Total Pelvic Exenteration
Authors: Chokshi Ravi J. , Fowler Jeffrey , Cohn David , Bahnson Robert , Lumbley Joshua , Martin Edward W.
Published: June 2020

The objective of this study was to describe in detail the technique of total pelvic exenteration. Total pelvic exenteration (TPE) was first described in 1948 by Brunschwig. Since its description, complications of the procedure and surgical innovations have changed the approach to this radical surgery. We have described our institutional approach and outcomes of TPE. Fifty-four patients underwent TPE between 2004 and 2010 by the Division of Surgical Oncology at the Ohio State University Medical Center. Fifty-three patients have complete medical records available for review. Outcomes are described and have shaped these techniques. Patients were divided into various groups based on their histology: colorectal (n = 36), gynecologic (n = 6), urologic (n = 5), squamous cell (n = 2), sarcomatous disease (n = 3), and severe infections (n = 1). These were divided into two groups—colorectal (n = 36) and noncolorectal (n = 17)—for analysis. Demographics, operative time, length of stay, and complication rates were similar between the two groups. The median survival was 21.4 months for the colorectal group and 6.9 months for the noncolorectal group. Total pelvic exenteration for colorectal tumors has improved survival when compared with patients undergoing exenteration for pelvic malignancies of other origins. Total pelvic exenteration continues to be associated with high morbidity; however, with appropriate patient selection and proper operative technique, a perioperative mortality of 0 per cent can be achieved.
Breast Cancer Reconstruction in the Elderly
Authors: Howard-Mcnatt Marissa , Forsberg Clay , Levine Edward A. , Defranzo Anthony , Marks Malcolm , David Lisa
Published: June 2020

Mastectomy is a surgical choice for breast cancer, yet breast reconstruction is underused in women older than age 60 years. Because of a paucity of information examining breast cancer reconstruction in the elderly, we sought to review our experience. By retrospective chart review, we evaluated 89 women older than 60 years having mastectomy and reconstruction from January 1998 to June 2008. Mean patient age was 65 years (range, 60 to 74 years). The majority (41%) had Stage 1 disease or Stage 2 (30%). Ductal carcinoma in situ comprised 25 per cent and Stage 3 totaled 2 per cent. Mastectomy for ipsilateral breast tumor recurrence after radiation therapy and lumpectomy comprised 11 per cent. Most underwent immediate breast reconstruction (89%). Reconstructive techniques included two-stage implant (58%), transverse rectus abdominus musculocutaneous (TRAM) flap (10%), latissimus dorsi musculocutaneous flap with implant (2%), or deep inferior epigastric perforator flap (1%). Complications included a 12 per cent infection rate, removal of two expanders resulting from exposure, one TRAM failure, and one TRAM required debriding. Four patients undergoing mastectomy with tissue expander had radiation resulting in one expander being removed. One local skin recurrence was treated with removal of implant and skin resection. Two patients have died from metastatic disease. Age should not be a contraindication for breast reconstruction in elderly women.
A Retrospective Study of 12 Cases of Pyoderma Gangrenosum: Why We Should Avoid Surgical Intervention and What Therapy to Apply
Authors: Barańska-Rybak Wioletta , Kakol Monika , Naesstrom Matilda , Komorowska Olivia , Sokolowska-Wojdyło Małgorzata , Roszkiewicz Jadwiga
Published: June 2020

Lesions of skin are ubiquitous in the medical field. The varying etiopathologies with similar presentation can pose a misleading picture, especially when faced with less common skin diseases. Furthermore, the misdiagnosis can cause detrimental effects on the patient's morbidity and mortality, which was seen in the case series study we performed on pyoderma gangrenosum. The history of 12 patients were analyzed in reference to the course of the disease, accompanying diseases, clinical picture, histopathological examination, surgical intervention before diagnosis, and treatment. Within this group of 12 patients, five were exposed to surgical interventions before diagnosis of pyoderma gangrenosum. The 5 patients were all exposed to prolonged aggravation of the disease process, followed by remission after proper diagnosis and treatment therapy. This study was done to improve the knowledge of surgeons about pyoderma gangrenosum considering the frequency of skin lesion cases in the surgical practice. Knowledge of the disease is essential to diagnose pyoderma gangrenosum in early stages to avoid interventions that may prolong or worsen the outcome. Surgical interventions in these patients should be avoided before proper diagnosis. The key to a better prognosis of pyoderma gangrenosum patients is often in the hands of surgeons.
Cavity Margin Status Is an Independent Risk Factor for Local-Regional Recurrence in Breast Cancer Patients Treated with Neoadjuvant Chemotherapy Before Breast-Conserving Surgery
Authors: Chen Kai , Jia Weijuan , Li Shunrong , He Jianrong , Zeng Yunjie , Yang Hua , Jin Liang , Wu Xiayi , Su Fengxi
Published: June 2020

The objection of this study is to investigate whether the cavity margin (CM) status has different predictive efficacy for local-regional recurrence (LRR) in patients who have received or have not received neoadjuvant chemotherapy (NAC) before breast-conserving surgery. We identified 61 patients who received NAC before breast-conserving surgery. A nonrandomized unmatched cohort of 295 patients without history of receiving NAC were also included in this study. Clinicopathological features and follow-up data were abstracted and analyzed. Patients in the NAC-treated group had more advanced diseases when compared with patients in the non NAC-treated group. With a median follow-up of 42 months, the LRR-free survival rate of patients with positive CMs was significantly lower than that of patients with negative CMs in the NAC-treated group. This distinction was not observed in the nonNAC-treated group. Univariate and multivariate analysis revealed that positive CM was the only independent predictive factor for LRR in the NAC-treated group but not in nonNAC-treated patients. CM status had different predictive efficacy for LRR in different settings. Association between CM status and LRR was observed in NAC-treated patients rather than nonNAC-treated patients. More extensive surgical treatment might be needed in NAC-treated patients when their CMs are positive.
The University of Florida Department of Surgery: Building a Stronger Tomorrow on Yesterday's Foundation
Authors: Behrns Kevin E. , Copeland Edward M. , Howard Richard J.
Published: June 2020

Established in 1957, the University of Florida Department of Surgery has a solid foundation on which current faculty are driven to build a stronger tomorrow. The department is focused on promoting patient-centered care, expanding its research portfolio to improve techniques and outcomes, and training the surgical leaders of tomorrow. It fosters an environment where faculty, residents, students, and staff challenge long-held traditions with the goal of improving the health of our patients, the quality of our care, and the vitality of our work environment.
A Systematic Review of Prognosis and Therapy of Anal Malignant Melanoma: A Plea for More Precise Reporting of Location and Thickness
Authors: Kanaan Ziad , Mulhall Aaron , Mahid Suhal , Torres Marla L. , McCafferty Michael , McMasters Kelly M. , Hornung Carlton , Galandiuk Susan
Published: June 2020

Anal malignant melanoma (AMM) is a rare tumor with poor prognosis. We performed a systematic review of reports on wide local excision (WLE) and abdominoperineal resection (APR) for treatment of AMM in an attempt to define a precise set of reporting measures for outcomes of treatment of AMM. A systematic review of the literature was performed. Demographic data, surgical treatment, pathology, and survival rates were recorded. We compared WLE versus APR in terms of the overall survival time, the disease-free survival, and overall survival at 60 months. Twenty-one reports met the inclusion criteria. Notably, of these, 10 did not specify thickness of the primary melanoma. Interestingly, groin lymph node status was described in 19 of 21 reports, whereas location was specified in only 12 papers and thickness (depth in mm) in only 11. The median survival times of patients undergoing WLE (n = 324) and those undergoing APR (n = 369) are comparable (20 and 21 months, respectively). The mean median survival at 60 months was 15 per cent for WLE and 14 per cent for APR. The mean disease-free survival at 60 months was found to be 10 per cent for WLE and 6 per cent for APR. Patient selection for such a rare neoplasm yields very similar outcomes for both conservative and radical treatments. There is a wide variation in the reporting of both clinical and treatment outcomes. More uniformity of reporting of pathologic features and node status is essential before rational assessment of results can be done.
Lactate Levels in the Detection of Preoperative Bowel Strangulation
Authors: Tanaka Keiichiro , Hanyu Nobuyoshi , Iida Tomonori , Watanabe Atsushi , Kawano Susumu , Usuba Teruyuki , Iino Toshio , Mizuno Ryoji
Published: June 2020

The aim of this retrospective study was to examine whether various laboratory parameters could predict viability of strangulation in patients with bowel obstruction. Forty patients diagnosed with bowel strangulation were included. We performed operations for all patients within 72 hours of the start of symptoms. Blood samples were obtained from all patients immediately before operation. Arterial blood was examined for pH and lactate levels using a blood gas analyzer. We also evaluated white blood cell count and serum levels of creatine phosphokinase, lactic dehydrogenase, amylase, and C-reactive protein. At surgery, 18 patients had viable strangulation and did not undergo resection, whereas 22 had nonviable strangulation and underwent resection of the necrotic bowel. None of the patients died. Bowel strangulation was caused most commonly by adhesions. In terms of diagnostic efficiency, lactate level was the only laboratory parameter significantly associated with viability ( P < 0.01, Mann-Whitney test). Other laboratory data did not show statistically significant associations. These results suggest that arterial blood lactate level (2.0 mmol/L or greater) is a useful predictor of nonviable bowel strangulation.
Laparoscopic Cholecystectomy under Epidural Anesthesia: A Retrospective Comparison of 100 Patients
Authors: Zhang Hong-Wei , Chen Ya-Jin , Cao Ming-Hui , Ji Feng-Tao
Published: June 2020

There are limited data about laparoscopic cholecystectomy (LC) under epidural anesthesia. This retrospective comparative study aimed to evaluate on the feasibility and advantages of LC under epidural anesthesia. In this retrospective comparative study, 100 patients (46 men and 54 women) with symptomatic cholelithiasis undergoing laparoscopic cholecystectomy using epidural anesthesia (EA) were compared with 100 patients undergoing laparoscopic cholecystectomy using general anesthesia (GA). Both groups were evaluated with regard to intraoperative mean arterial pressure, heart rate, operation time, duration of stay in the recovery room, and hospital cost. Laparoscopic operation was performed for 200 patients. Mean age of patients was 46.4 ± 6.9 years and 45.3 ± 6.8 years in EA and GA, respectively. Forty-six and 50 per cent of subjects were male in EA and GA, respectively. The mean operation time was 24 minutes and 25.58 minutes for EA and GA, respectively ( P = 0.652). The duration of stay in the recovery room was significantly shorter in EA than that in GA (19.56 ± 2.55 minutes vs 56.27 ± 6.85 minutes, respectively; P = 0.0001). In the EA group, 23 patients (23%) had severe shoulder pain during surgery. After receiving pethidine intravenously, all these patients could subsequently undergo surgery smoothly. There were no complications or mortality in either group. Most of the patients regarded EA as a comfortable procedure. The mean hospital cost for the EA group was only three-fourths that of the GA group. LC under EA is feasible and safe in selected patients.
Cholangiocarcinoma: Aggressive Surgical Intervention Remains Justified
Authors: Boland Brendan , Kim Amanda , Nissen Nicholas , Colquhoun Steve
Published: June 2020

Cholangiocarcinoma (CCA) continues to be a difficult disease to both diagnose and treat. Optimal treatment includes resection to histologically negative margins. In recent years, advanced imaging, including magnetic resonance cholangiography and endoscopic ultrasound, has presumably improved the accuracy of determining resectability. From 2004 to 2009, a total of 61 patients with cholangiocarcinoma were evaluated for resection. The majority were men (37) and ages ranged from 29 to 87 years (mean, 67 years). Only 31 per cent were found to be obviously unresectable based on imaging alone. The remaining 69 per cent underwent exploration, at which time resection was found unfeasible in an additional 25 per cent (overall 56% unresectable). Although all resection specimens had grossly negative margins, 37 per cent were ultimately found to be microscopically positive. The overall 5-year actuarial survival for patients undergoing resection was 39.2 per cent with no survival difference between those with positive and negative margins. Despite advances in diagnostic imaging, more than half of patients with CCA presenting for surgical evaluation are ultimately found to be unresectable. However, the final determination can still only be made at the time of exploration. Even in the presence of microscopic residual disease, surgical intervention results in improved survival. An aggressive stance toward surgical intervention in patients with CCA remains justified.
Is Muscular Atrophy a Contraindication in Laparoscopic Abdominal Wall Defect Repair? A Prospective Study
Authors: Moreno-Egea Alfredo , Sanchez-Elduayen Maite , Parlorio De Andres Elena , Carrillo-Alcaraz Andres
Published: June 2020

Laparoscopic surgery for abdominal wall hernias improves short-term results as compared with open hernia surgery. However, no evidence exists to recommend this approach for pseudohernias, which are abdominal wall defects postsurgery caused by denervation and muscular atrophy. The purpose of this study is to analyze whether the laparoscopic approach benefits patients with a pseudohernia. A prospective nonrandomized, single-center clinical study was conducted of 24 patients operated on for pseudohernia. This study was designed with the basic principle of one unit, one surgeon, one mesh, and two techniques (laparoscopic or open double prosthetic repair). The primary end point was assessment of the abdominal wall according to: 1) abdominal perimeter; 2) computed tomography scan; and 3) degree of satisfaction. The secondary end points were intraoperative parameters and comorbidity. Laparoscopy offered no benefits in patients with pseudohernias. Open surgery offered no significant differences in intra- and postoperative morbidity, but if the initial weakness improved with a decrease in abdominal perimeter and visceral content, then there was more than 90 per cent satisfaction ( P < 0.05). The laparoscopic approach does not improve the bulge caused by abdominal muscle atrophy. The option of a muscular and prosthetic reconstruction provides better clinical and cosmetic results.
The Use of Neural Networks in Identifying Risk Factors for Lymph Node Metastasis and Recommending Management of T1b Esophageal Cancer
Authors: Sgourakis George , Gockel Ines , Lyros Orestis , Lanitis Sophocles , Dedemadi Georgia , Polotzek Ursula , Karaliotas Constantine , Lang Hauke
Published: June 2020

The objective of this study was to establish a prediction model of lymph node status in T1b esophageal carcinoma and define the best squamous and adenocarcinoma predictors. The literature lacks a satisfactory level of evidence of T1b esophageal cancer management. We performed an analysis pooling the effects of outcomes of 2098 patients enrolled into 37 retrospective studies using “neural networks” as data mining techniques. The percentages for lymph node, lymphatic (L1), and vascular (V1) invasion in Sm1 esophageal cancers were 24, 46, and 20 per cent, respectively. The same parameters apply to Sm2 with 34, 63, and 38 per cent as opposed to Sm3 with 51, 69, and 47 per cent. The respective number of patients with well, moderate, and poor histologic differentiation totaled 267, 752, and 582. The rank order of the predictors of lymph node positivity was, respectively: Grade III, (L1), (V1), Sm3 invasion, Sm2 invasion, and Sm1 invasion. Histologic-type squamous and adenocarcinoma (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were sm3 invasion and (V1). As concerns ADC, the most important predictor was (L1). Submucosal esophageal cancer should be managed with surgical resection. However, this is subject to the histologic type and presence of specific predictors that could well alter the perspective of multimodality management.
Preoperative Functional Health Status Impacts Outcomes after Ventral Hernia Repair
Authors: Albright Emily L. , Davenport Daniel L. , Roth J. Scott
Published: June 2020

Associated with the aging population is an increase in comorbidities and a decrease in the ability to perform basic daily activities. This is tracked within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) as a patient's preoperative functional health status. Our goal was to evaluate the impact of preoperative functional status upon outcomes after ventral hernia repair. We reviewed all cases of patients that underwent ventral hernia repair from 2005 to 2010 in the ACS-NSQIP database. Patients were identified based on selected Current Procedural Terminology codes and grouped based on functional status as listed in the ACS-NSQIP database—independent, partially dependent, and totally dependent. Preoperative and operative variables were recorded for all patients. Clinical risk factors and short-term outcomes between groups were compared. Multivariable logistic regression was used to adjust for age, wound class, American Society of Anesthesiologists class, and case relative value units. A total of 76,397 patients were identified: 74,785 were independent (97.9%), 1,317 partially dependent (1.7%), and 295 totally dependent (0.4%). Totally dependent patients had an increased risk for all short-term outcomes after ventral hernia repair: wound occurrence, pneumonia, pulmonary embolism, urinary tract infection, myocardial infarction, deep venous thrombosis, sepsis, return to the operating room, and death ( P < 0.001 for all).