bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors Affecting the Surgical Management of Infective Endocarditis
Authors: Cassada David C. , Moniz Mark , Stevens Scott L. , Freeman Michael B. , Goldman Mitchell H. , Schuchmann George S.
Published: November 2022

Congestive heart failure and septic embolism complicate the clinical course of patients with infective endocarditis (IE). This study reviews the clinical records of patients with systemic disease secondary to IE and stratifies their disease severity according to individual risk factors and medical, and surgical interventions. The hospital records of all patients presenting to our institution from 1992 through 1997 with heart valve destruction secondary to IE were reviewed. Ten patients with hemodynamically significant valve lesions were included in this study: seven with aortic valve disease and two with mitral valve disease, and one with combined aortic and mitral valve lesions. All were diagnosed by echocardiogram. All ten patients experienced systemic septic arterial emboli: four intracranial lesions, four visceral lesions, and three extremity arterial occlusive events. Two patients required peripheral arterial repair. Cultures revealed infection secondary to Staphylococcus aureus in five, Streptococcus species in three, Coxiella species in one, and an unidentified organism in one patient. Seven patients underwent valve replacement. Three patients died from their disease processes. Statistical significance was established by Wilcoxon rank analysis with a two-tailed P < 0.05. Patients with IE secondary to staphylococcal infections suffered a more acute and virulent disease process (P = 0.04), with a 40 per cent mortality rate in the first 48 hours. There was no increased incidence of embolization associated with longer duration of symptoms (P = 0.32). Surgical repair conferred improved clinical outcome as compared with no surgical intervention (P = 0.03). Improved patient outcome was associated with nonstaphylococcal infection (P = 0.02), and a successful initial antibiotic regimen (P = 0.03). Peripheral arterial repair was successful in both cases.
Comparison of Arcuate-Legged Clipped versus Sutured Hepatic Artery, Portal Vein, and Bile Duct Anastomoses
Authors: Geevarghese Sunil K. , Bradley Anne L. , Atkinson James , Wright J. Kelly , Chapman William C. , Van Buren David H. , Blair K. Taylor , Hutchins C. H. , Jabbour Kareem , Phillips James , Williams Phillip E. , Pinson C. Wright
Published: November 2022

Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 ± 1.1 minutes and 13.3 ± 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.
The Surgical Intensive Care Unit as a Cost-Efficient Substitute for an Operating Room at a Level I Trauma Center
Authors: Porter John M. , Ivatury Rao R. , Kavarana Minoo , Verrier Ron
Published: November 2022

Critically ill patients in the surgical intensive care unit (SICU) continue to require operative procedures. Traditionally, this has meant the transport of these critically ill patients out of the safe, monitored confines of the SICU to the operating room (OR). This can be hazardous to the patient, as well as expensive. Performing the procedures in the OR can avoid both the dangers of transport and the expense of the OR. Herein is a descriptive study of 80 procedures performed on 36 patients in the SICU. We believe that these data show that the SICU can be a cost-effective alternative to the OR in a trauma center in critically ill patients. Significant cost savings may be realized without increasing the iatrogenic or infectious complications.
Management of Vascular Prosthetic Infections: Results of Long-Term Follow-up
Authors: Zeltsman David , Tzarnas Chris D. , Kerstein Morris D.
Published: November 2022

An infected vascular prosthesis is a risk to life and limb, with many of the infections insidious in nature. A retrospective analysis with a minimum 49-month follow-up identified 18 patients (mean age, 61.3 years) with culture-positive infections and exposed prosthetic grafts in the infrainguinal region. All patients were managed with muscle flaps. Mean follow-up was 59 months, with a long-term salvage of infected prosthetic grafts in 16 of 18 patients; there was no loss of life or limb. Early, aggressive reconstruction of infected prosthetic grafts using a muscle flap technique saves graft, leg, and patient.
Acute Thermal Injury to the Canine Jejunal Free Flap: Electrocautery versus Ultrasonic Dissection
Authors: Birch Daniel W. , Park Adrian , Shuhaibar Hafez
Published: November 2022

Electrocautery-induced thermal injury contributes to morbidity and mortality after laparoscopic surgery. Ultrasonic dissection is an alternative technique that may produce less thermal injury. We compared the amount of acute thermal injury caused to jejunal free flaps isolated with laparoscopic electrosurgical instruments with that caused by ultrasonic dissection (laparoscopic coagulating shears). Canine jejunal free flaps were isolated by electrocautery or laparosonic coagulating shears and remained viable on a vascular pedicle. After a period of ischemia and reperfusion, the flaps were resected to simulate harvesting and reimplantation. Thermal injury was observed at the site of dissection and was graded histologically. At the margin of the jejunal free flaps, the laparosonic coagulating shears produced less thermal injury (score, 2.2 at level 3) than the electrocautery grasping forceps (score, 3.7 at 35 W and 4.1 at 70 W). The laparosconic coagulating shears produced less thermal injury to a jejunal free flap than did electrocautery. Ultrasonic dissection is an alternative to the complications produced by electrocautery during laparoscopic dissection.
Abdominal Surgery in Chronic Hemodialysis Patients
Authors: Wind Philippe , Douard Richard , Rouzier Roman , Berger Anne , Bony Chantal , Cugnenc Paul-Henri
Published: November 2022

The number of patients with end-stage renal disease who benefit from chronic dialysis is steadily increasing. This study was designed to assess abdominal surgery in chronic hemodialysis (CHD) patients. A 7-year retrospective study was conducted including all the patients on CHD who underwent abdominal surgery in our unit. These patients were separated into an elective and an emergency surgery group. Forty-three patients underwent surgery. In the elective surgery group (18 patients), the most common diseases were colorectal cancer, symptomatic gallbladder stones, and hernia. There was no death related to surgery in this group, and only one patient developed a complication (5%). In the emergency surgery group (25 patients), the most common diseases were mesenteric ischemia and gastrointestinal bleeding from angiodysplasia. Complications occurred in 10 patients (total morbidity rate, 40%), and 6 of them died (mortality rate, 24%). Gastrointestinal elective surgery in patients on CHD can be performed with low morbidity and mortality rates. The emergency group was differentiated by the high prevalence of bleeding from angiodysplasia and mesenteric infarction, as well as its high surgical mortality rate.
Gunshot Wounds below the Popliteal Fossa: A Contemporary Review
Authors: Grossman Michael D. , Reilly Patrick , Mcmahan Damian , Kauder Donald , Schwab C.W.
Published: November 2022

The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.
Acute Acalculous Cholecystitis in Young Patients without Predisposing Factors
Authors: Parithivel Vellore S. , Gerst Paul H. , Banerjee Subhendra , Parikh Virendra , Albu Eugene
Published: November 2022

We report the atypical presentation of acute acalculous cholecystitis in four young, otherwise healthy patients. These cases emphasize the fact that the traditional concept of this disease as being associated with trauma, major surgery, or other pathology may no longer be true, and an important number of cases may appear de novo in patients without any predisposing factors.
A Clinical Comparison of Dacron Patch Closure of Small-Caliber Carotids Compared with Primary Closure of Large-Caliber Carotids after Endarterectomy
Authors: Bhattacharya Vishwanath , Ghali Rafik , El-Massry Sherif , Saad Ehab , Zammit Michael , Rodriguez Dirk , Spencer Merrill P. , Sauvage Lester R.
Published: November 2022

The objective was to study results of carotid endarterectomies performed between 1975 and 1991, comparing primary closure to Dacron patch closure. This was a retrospective study. Data from patient follow-up by physical examination, chart review, and Duplex study were used. Scan data were obtained in 92 of the primary cases, at a mean of 5 years postoperatively, and in 63 of the patch cases, at a mean of 4.1 years postoperatively. During this period, 269 endarterectomies were closed primarily and 101 were closed with a knitted Dacron patch. Twenty patients in the primary group and nine patients with patch closure were lost to follow-up, which extended for up to 12.5 years, with a mean of 4.7 ± 3.6 years. No acute closures, infections or aneurysms developed in either group. Perioperative stroke incidence was 4.1 per cent for primary closure and 3.0 per cent for the patch group (P > 0.05). Late stenosis occurred in 17.3 per cent of the primary group and 11.1 per cent of the patch closure group (P > 0.05). Five-year survival was 76.2 per cent in the primary group, compared with 79.2 per cent for patch closure. Late stroke incidence was 2.8 per cent in the primary group and 3.3 per cent in the patch closure group. Results of smaller (≤3.5 mm) carotid arteries closed with knitted Dacron patches are equivalent to those of larger carotid arteries closed primarily.
Treatment Outcomes for Female Octogenarians with Breast Cancer
Authors: Susann Phillip , Susann Philip W. , Ackerman Stewart , Gibbons Rick , Hermann Kellee , Kuhn Phyllis
Published: November 2022

Scant information is available comparing the treatment outcomes of minor surgery (lumpectomy) versus extensive treatment (radical and simple mastectomy or lumpectomy and radiation) in octogenarians with breast cancer. Medical records of women (ages 80–89) who received treatment for breast cancer from 1984 through 1994 were reviewed. All patients were stage T1 or T2, and none had palpable lymph nodes. The recurrence rate, disease-free interval, and death rate for both groups were compared. Of the 41 patients representing 43 minor surgeries, 12 per cent (5 of 41) of patients developed recurrence, all of which were related to the primary breast tumor. The mean disease-free interval was 28.6 ± 24.7 months (range, 6–65). Forty-six per cent (18 of 39) of patients died, 10 per cent (4 of 39) from recurrence and metastatic disease from breast cancer and 36 per cent (14 of 39) from other causes. Of those who underwent extensive treatment, 14.6 per cent (7 of 48) of patients experienced recurrence, all related to the primary breast tumor. The mean disease-free interval was 24.0 ± 21.9 months (range, 2–71). Forty-eight per cent (23 of 48) of patients died, 10 per cent (5 of 48) from recurrence and metastatic disease from breast cancer and 37 per cent (18 of 48) from other causes. None of the differences between the minor surgery versus extensive treatment groups were statistically significant. The recurrence rate, disease-free interval, and death rate from recurrent disease are similar for patients undergoing minor surgery compared with those undergoing extensive treatment.
Hematuria from Arteriovesical Fistula: Unusual Presentation of Ruptured Iliac Artery Aneurysm
Authors: Goff Charles D. , Davidson Jesse T. , Teague Nelson , Callis James T.
Published: November 2022

Iliac artery aneurysm rupture can be rapidly fatal if not diagnosed immediately. These aneurysms usually present in patients with other aneurysmal diseases of the aortoiliac arterial system. If not diagnosed and surgically repaired, iliac artery aneurysms can proceed to expand and ultimately rupture, usually presenting with back, flank, or abdominal pain and, possibly, signs of systemic shock. We present an unusual case report of a common iliac artery aneurysm rupture presenting as gross hematuria due to an arteriovesical fistula. Only three other cases of arteriovesical fistulae have been reported previously. Unlike the case presented, all three of these cases involved trauma or surgical instrumentation or manipulation of the bladder.
Predictive Value of Flow Cytometry for Metastatic Potential in Breast Cancer
Authors: Schmidt Hank , Wei John P. , Yeh Karen A.
Published: November 2022

Breast cancer is the leading malignancy in women in the United States. Tumor size and nodal metastases have been the most important predictors of patient outcome and determinants of treatment, but have also been used to predict metastatic potential. This study was undertaken to ascertain the predictive value of flow cytometry for lymph node or systemic metastases. From 1994 through 1997, surgical specimens from 106 women who underwent treatment for invasive breast cancer were reviewed. Epidemiological data, tumor stage, nodal metastases, and flow cytometric data were collected. Analysis of variance and Student's t test were used to determine whether the presence of nodal metastases or distant metastases correlated with high S phase values and aneuploidy. Of the 106 patients studied, the mean age was 57 years; tumor size consisted of 35 per cent T1, 48 per cent T2, 8 per cent T3, and 9 per cent T4. Node status was found in the following distribution: 56 per cent node negative, 38 per cent N1, and 6 per cent N2. Distant metastases were present in four patients. Elevated S phase (defined as >9.0%) was present in 72 per cent of the population. Fifty-six per cent of these tumors were aneuploid. Node-negative patients had an elevated S phase in 66 per cent of cases, whereas node-positive patients had an elevated S phase in 71 per cent of cases. Neither S phase (P = 0.91) nor DNA index (P = 0.99) proved to be statistically significant in determining axillary node status. Neither did S phase (P = 0.87) nor DNA index (P = 0.48) consistently predict the presence of distant metastases. There is no statistical correlation between axillary node status and flow cytometric data. Breast cancers with high S phase values and aneuploid features do not reliably have axillary nodal metastases, and this data cannot replace that information provided by axillary node dissection. Synchronous systemic metastatic disease is also not predicted by flow cytometry.
Recreational Bicycling and Injury to the External Iliac Artery
Authors: Roth John W. , Boyd Carl R.
Published: November 2022

Because the bony girdle of the pelvis protects the external iliac artery except where it enters the femoral canal, reports of blunt injury to this artery are rare. Emphasizing the importance of a thorough physical examination and judicious use of angiography, this case study discusses the diagnosis and treatment of an isolated external iliac artery injury rendered by a bicycle handlebar, a previously unreported cause of this type of injury.
Traumatic Hematuria in Patients with Polycystic Kidney Disease
Authors: Klein Andrew J. P. , Kozar Rosemary A. , Kaplan Lewis J.
Published: November 2022

Autosomal dominant polycystic kidney disease (PKD) is the most prevalent hereditary disorder in this country and a common cause of chronic renal failure. Patients frequently present with hematuria as the initial manifestation of PKD. We describe a patient with gross hematuria after blunt trauma who was found to have previously undiagnosed PKD. We review present diagnostic and treatment modalities and suggest potential management strategies for surgeons caring for patients presenting with traumatic hematuria and PKD.
Octylcyanoacrylate Tissue Adhesive in the Repair of Pediatric Extremity Lacerations
Authors: Saxena Amulya K. , Willital Günter H.
Published: November 2022

Lacerations comprise a significant number of emergency department referrals for pediatric patients. Management of lacerations with sutures involves the use of needles and the injection of local anesthetic and represents a unique challenge in the wound management of an already distressed and frightened child. Octylcyanoacrylate, a new-generation, medical-grade tissue adhesive, has been found to be an effective alternative to replace skin sutures on virtually all facial lacerations and has been employed in low-skin tension wound management. Its use, however, has generally been avoided in the management of high-skin tension lacerations. Over the last 10 months, 32 children with high-skin tension (hand, feet, and over joints) lacerations were managed at our center by octylcyanoacrylate tissue adhesives. Skin closures and splints were applied to restrict movement of the affected area to overcome the limitation of adhesive application. Octylcyanoacrylate adhesive applied with optimal immobilization was found to be an effective method of skin closure in high-skin tension lacerations. Advantages of tissue adhesives for incision and laceration include quick application, excellent cosmetic results, patient preference, and cost effectiveness.
“Blind” Placement of Long-Term Central Venous Access Devices: Report of 589 Consecutive Procedures
Authors: Kincaid Edward H. , Davis Peyton W. , Chang Michael C. , Fenstermaker Joyce M. , Pennell Timothy C.
Published: November 2022

Placement of long-term central venous access devices, such as Hickman catheters and implanted subcutaneous ports, has traditionally been performed in the operating room with fluoroscopy. This study reports our experience with percutaneous placement of these devices in the outpatient clinic setting without the use of real-time imaging. Results were generated from a prospective database of all adult patients undergoing placement of central venous access in the outpatient clinic of the Wake Forest University Baptist Medical Center. This database revealed that during the years 1996 and 1997, long-term central venous catheter placement was attempted in 589 adult patients in the outpatient clinic. Technical success was achieved in 558 patients (92%). This included 278 tunneled catheters and 280 totally implanted devices. Repositioning of the catheter tip was required in 16 patients (2.9%). The incidence of pneumothorax was 1.9 per cent. Late complications, including infection and thrombosis, occurred in 9 per cent. The average procedure-related charge for placement of a single-lumen central venous port in the outpatient clinic was $1691 versus $4559 in the operating room and $3890 in the radiology department. We conclude that routine placement of long-term central venous access devices in the outpatient clinic, without the use of real-time imaging, yields acceptable success rates and may have economic advantages over procedures performed in the operating room or radiology department.
Outpatient Laparoscopic Cholecystectomy: What Predicts the Need for Admission ?
Authors: Simpson Major Joseph P. , Savarise Major Mark T. , Moore Captain Jon
Published: November 2022

Laparoscopic cholecystectomy (LC) is commonly performed as an outpatient (OP) procedure in selected patients, either in ambulatory surgery units associated with a hospital or in freestanding facilities. To identify factors that may preclude OPLC, a retrospective analysis of all patients who underwent LC by two surgeons from August 1996 through June 1998 was performed. A total of 126 patients were divided into three groups. Group I comprised 102 patients who underwent attempted elective OPLC. Group II comprised 20 patients who underwent LC on an emergent basis. Group HI comprised 5 patients who were admitted before LC. Data were gathered regarding patient demographics, preoperative diagnoses, preoperative laboratory values, length of stay after surgery, and complications. These data were analyzed using logistic regression and univariate analysis. Age >60 and American Society of Anesthesiologists (ASA) class >2 appeared to be significant predictors of admission, but when considered together, neither was significant. The diagnosis of acute cholecystitis or biliary pancreatitis was highly predictive of admission in both groups. An ASA class >2 did predict postoperative stay of more than 12 hours. These data suggest that OPLC can be performed safely in unselected patients. However, those patients with an ASA class >2 or with a diagnosis of biliary pancreatitis or acute cholecystitis are more likely to require admission or postoperative stay over 12 hours, and these criteria should be considered relative contraindications to OPLC in free-standing facilities.
Management of Bile Duct Stones in 1572 Patients Undergoing Laparoscopic Cholecystectomy
Authors: Snow L. Lamar , Weinstein L. Steve , Hannon Jeffrey K. , Lane Daniel R.
Published: November 2022

Evidence of bile duct stones (BDSs) was identified on routine cholangiogram in 136 (8.7%) of 1572 patients undergoing laparoscopic cholecystectomy from March 1989 through March 1997. Forty-two (30.9%) were unsuspected. All patients with evidence of BDSs underwent laparoscopic bile duct exploration (LBDE). Initially, a standard choledochotomy with T-tube drainage as in the open approach was used. Later, transcystic duct exploration was added to the algorithm. The algorithm evolved into an ongoing treatment protocol study that was initiated in March 1992. Through March 1997, 100 patients underwent LBDE based on the protocol. The study is divided into two groups. Group A comprises the total 136 patients undergoing LBDE, including those in the protocol study. A subgroup, Group B, comprises only the 100 patients in the protocol study. In Group A, LBDE was successful in 114 patients (83.8%). Stones were missed in seven patients and left behind for spontaneous passage or later retrieval in six patients. Eleven patients (8.1%) were converted to open. There were 13 major complications (9.6%), including the seven missed stones and two deaths. In Group B, LBDE was successful in 94 per cent. Stones were missed in one patient and intentionally left behind in four patients. One patient was converted to open. There were seven major complications (7%), including one of the missed stones and one death. Using the protocol algorithm and the techniques described, BDSs can be effectively managed laparoscopically at the time of cholecystectomy in approximately 94 per cent of cases.
Post-treatment Dopexamine Infusions Partially Reverse Reductions in Cranial Mesenteric Blood Flow and Mucosal Oxygenation Induced by Hypoxia in Newborn Piglets
Authors: Aliabadi-Wahle S. , Choe E.U. , Flint L.M. , Ferrara John J.
Published: November 2022

A severe hypoxic insult is known to induce dramatic reductions in newborn intestinal blood flow and is, thus, considered a vector for the development of neonatal intestinal ischemic diseases. Dopexamine (DPX) is a novel synthetic agent that has potent B2-adrenoceptor and dopaminergic activity, the clinical effects of which include an increase in cardiac output and in mesenteric blood flow. Having previously shown that infusion of DPX before hypoxia (HYP) mitigated the reduction in newborn mesenteric blood flow, we sought to define its efficacy when given after an established hypoxic insult. Ultrasonic transit time blood flow probes were placed around the ascending aorta and cranial mesenteric artery of anesthetized, mechanically ventilated 0 to 2-day-old piglets. Small bowel mucosal oxygenation was observed with a tissue oxygen monitoring system. After stabilization, animals were subjected to one of the following: HYP (FIO2 = 0.12) for 60 minutes (n = 12); DPX (5 μg/kg/min) infusion begun 10 minutes after induction of HYP/DPX (n = 11). Almost no alterations in any of the monitored variables were shown in a group (n = 5) of similarly instrumented, untreated animals. In contrast, although both hypoxic piglet groups experienced significant (P < 0.05, analysis of variance) declines from baseline cardiac output, mesenteric blood flow, and mucosal oxygenation, each of these deleterious effects was significantly (P < 0.05) blunted in the DPX-treated animals. During periods of systemic hypoxemia, the reductions in neonatal mesenteric blood flow and oxygenation can be somewhat blunted by DPX. As such, this agent may prove of clinical benefit when an infant is threatened by a hypoxic episode.
Mature Presacral Teratoma in an Adult Male: A Case Report
Authors: Bull John , Yeh Karen A. , Mcdonnell Dennis , Caudell Patricia , Davis Jerry
Published: November 2022

Presacral teratomas are rare tumors derived from more than one embryonic germ layer and are usually diagnosed in infancy. It has been estimated that the incidence of presacral teratoma in children ranges from 1 in 30,000 to 1 in 43,000 live births. However, the diagnosis of these tumors in adults is extremely rare. H. Head et al. reviewed the world literature in 1975 and found only 71 reported cases. Since that time, an additional 14 cases have been reported, and only one of these was found in the United States. This study reports a case of an adult male who presented with recurrent infected pilonidal cysts that proved to be benign presacral teratoma at biopsy. The patient underwent resection by left hemisacrectomy and primary closure using a posterior approach and, since this procedure, has had no evidence of recurrence. The case is presented along with a review of the relevant literature.
Spleen-Preserving Pancreatectomy for Cystic Pancreatic Neoplasms
Authors: Lukish Jeffrey R. , Rothstein James H. , Petruzziello Mark , Kiteley Rex , Denobile John , Soballe Peter
Published: November 2022

Cystic neoplasms of the pancreas are an uncommon entity comprising fewer than 1 per cent of all pancreatic neoplasms. The guidelines for management of these tumors, specifically, the extent of resection, are unclear. Formerly, a distal pancreatectomy including the spleen was performed for tumors in the tail of the pancreas. The importance of preserving the spleen has been well documented; however, there are few reports of spleen-preserving pancreatectomy for cystic neoplasms of the distal pancreas. We report two patients who underwent spleen-preserving pancreapancreatectomy for mucinous cystic neoplasms in the tail of the pancreas. Both patients were female, ages 39 and 65 years. Preoperative preparation included administration of vaccinations and subcutaneous somatostatin. Operative technique emphasized division of the splenic artery and vein beyond the tip of the distal pancreas without mobilization of the spleen. The pancreas was transected with a vascular stapler. Fibrin glue was applied to the margin of the pancreas. The operative blood loss, duration of operation, and postoperative hospital stay were 150 and 250 mL, 150 and 180 minutes, and 7 and 9 days, respectively. The pathology revealed both lesions to be mucinous cystic neoplasms. The patients recovered and at 6-month follow-up were without complaints and in good health. Spleen-preserving pancreatectomy is rapid and associated with minimal morbidity. This procedure should be considered in the surgical management of cystic neoplasms in the tail of the pancreas.
Hemorrhagic Shock Impairs Mucosal Immunity to Gut-Derived Antigens
Authors: Saini Manmit S. , Diebel Lawrence N. , Liberati David M. , Albaran Renato G. , Dulchavsky Scott A.
Published: November 2022

Secretory immunoglobulin A (sIgA) is the principal antibody protecting against pathogens in the respiratory tract and other mucosal surfaces. Nosocomial pneumonias are frequent after injury and critical illness and are often due to enteric pathogens. The aim of this study was to assess the relative effect of hemorrhagic shock (HS) on mucosal immunity at intestinal and respiratory mucosal sites. Fisher rats were immunized intragastrically with dinitrophenylated (DNP) Pneumococcus (Pn). Three weeks later, animals were subjected to sham treatment or HS. The animals were then rechallenged with DNP-Pn 1 or 3 days later. Animals were sacrificed 7 days later, and bronchoalveolar and gastric lavage was performed. Total and anti-DNP-specific sIgA were quantitated from these secretions by enzyme-linked immunosorbent assay. There was a significant decrease in DNP-Pn-specific sIgA at 72 hours after HS, which was not present in animals at 24 hours after HS. This was most profound in bronchoalveolar lavage specimens. We conclude that impaired mucosal defense against gut-derived antigens after HS may be important mechanistically for the development of posttraumatic pneumonia and other mucosally related infectious complications.
The Role of Angiography in Periclavicular Penetrating Trauma
Authors: Gonzalez Richard P. , Falimirski Mark E.
Published: November 2022

Our objective was to evaluate whether physical examination in conjunction with chest X-ray can accurately diagnose the presence of significant vascular injury in penetrating periclavicular trauma. Results from a management protocol for penetrating periclavicular trauma were reviewed for the period January 1992 through December 1996 at an urban Level I trauma center. All patients requiring angiography for periclavicular penetrating trauma with trajectory of the injury falling between the lateral border of the manubrium and the anterior axillary line were entered into the management protocol. All patients underwent anterior-posterior chest radiography on arrival to the trauma center and 6 hours after admission. Tube thoracostomy was placed if clinically indicated on presentation or for X-ray findings. Clinical assessment was performed on all patients, with emphasis placed on the presence of “hard” signs for vascular injury. In addition to accepted hard signs for vascular injury, significant chest tube output (>1000 cc) and chest X-ray findings consistent with significant hemorrhage were also considered hard signs for vascular injury. Assuming hemodynamic stability, all patients with suspected subclavian/axillary arterial injury based on wound trajectory or clinical findings consistent with vascular injury underwent angiography. Forty-six patients were entered into the protocol with 30 left-sided injuries and 16 right sided injuries. The majority of injuries were secondary to gunshot wounds (31), with 14 stab wounds and 1 shotgun injury. Emergency room chest X-ray results revealed 32 negative chest X-rays, 7 pneumothoraces, 2 hemopneumothoraces, 2 hemothoraces, and 3 chest tubes placed before initial chest X-ray. A total of 7 injuries were diagnosed, with 1 missed injury, resulting in a sensitivity of 86 per cent for clinical assessment. The missed injury was a pseudoaneurysm of an axillary artery secondary to a self-inflicted shotgun wound. One mortality occurred in this series, which was a death in the operating room secondary to blood loss from an axillary artery injury. We conclude that clinical assessment can adequately diagnose the presence of surgically significant vascular injury in periclavicular penetrating injuries with trajectories lateral to the manubrium.
Serial pHi Measurement as a Predictor of Mortality, Organ Failure, and Hospital Stay in Surgical Patients
Authors: Robbins Mark R. , Smith R. Stephen , Helmer Stephen D.
Published: November 2022

Intestinal ischemia is a common condition in critically ill patients and has been postulated to play a role in the development of organ failure and death. This has resulted in the recent interest in monitoring gastric intramucosal pH (pHi) in critically ill patients to provide earlier evidence of inadequate resuscitation, cardiogenic dysfunction, or sepsis. Several reports have indicated that low pHi values obtained during the initial 24 to 48 hours of intensive care unit (ICU) admission were associated with the development of organ failure and death. The purpose of this study was to assess the predictive value of serial pHi measurements obtained throughout the entire ICU admission. A retrospective analysis of critically ill trauma, burn, and surgical patients who had frequent pHi determinations during ICU treatment was performed. When stratified by pHi values, there were no significant differences in length of stay, organ dysfunction, or mortality. Our findings suggest that serial pHi determinations obtained beyond the early critical care period are less reliable predictors of poor outcome.
The Advanced Breast Biopsy Instrumentation (ABBI) Experience at a Community Hospital
Authors: Sheth Dharti , Wesen Cheryl A. , Schroder Donn , Boccaccio John E. , Lloyd Larry R.
Published: November 2022

The Advanced Breast Biopsy Instrumentation (ABBI; U.S. Surgical Corp., Norwalk, CT) system is the newest technology available for the evaluation and diagnosis of nonpalpable breast lesions. It requires the breast imaging specialist, often a radiologist, to localize the suspicious lesion to x, y, and z coordinates in a digital mammogram unit The coordinates are then used by the surgeon to operate and direct the ABBI biopsy device around the lesion to obtain an excisional biopsy. Mammographic confirmation of the specimen is then immediately obtained. First introduced in the United States in April 1996, the ABBI system is aimed at rivaling the previously relied upon methods of needle-localized and core needle breast biopsies. In this study, we analyzed the first 15 months of use of the ABBI system in a community hospital to evaluate its applicability and efficacy in the diagnosis of nonpalpable breast lesions. Eighteen surgeons and three radiologists performed a total of 230 cases on 223 patients (seven patients had bilateral breast biopsies). The lesions biopsied included 114 clustered microcalcifications, 115 masses, and 1 retained guidewire from a previous needle-localized breast biopsy. The average time for the complete procedure was 65 minutes. Breast cancer was identified in 36 patients (36 of 230,15.7%) and 1 additional patient had an incidental finding of lobular carcinoma in situ. The malignancies included 20 cases of invasive ductal carcinoma, 12 cases of ductal carcinoma in situ, and four cases of invasive lobular carcinoma. Overall, 84 per cent of the patients had a definitive benign diagnosis and required no further surgical treatment of their mammographic finding. There have been no known missed lesions after use of the ABBI procedure. In conclusion, our experience has shown the ABBI system to be a valuable option in the management of selected patients with nonpalpable breast lesions.
Spectrum of Mammographically Detected Breast Cancers
Authors: Sener Stephen F. , Winchester David J. , Winchester David P. , Kurek Raffael , Motykie Gary , Martz Carole H. , Rabbitt Sarah
Published: November 2022

Mammographic screening of women at both ends of the age spectrum presents a number of challenges. The purpose of this study was to characterize experience with mammographic detection of breast cancer. The two goals were 1) to establish the cancer detection rate of screening mammography and 2) to compare the tumor size of cancers found by mammography, physical examination, or both modalities. From January 1994 through June 1997, data on 609 consecutive female primary breast cancer patients were collected concurrent with definitive surgical therapy. The method of detection was determined by the surgeon, after reviewing mammogram and physical examination. Screening ultrasound was not used. For the 184 patients under 50 years of age, 53 (29%) cancers were detected by mammography only and 48 (26%) by physical examination only. Women under 50 years of age had fewer cancers detected by mammography only (P < 0.001) and more cancers detected by physical examination only (P = 0.0014) than those over 50. With increasing age, the proportion of women with ductal carcinoma in situ decreased (P = 0.004), and the proportion with T1c or T2 tumors increased (P = 0.006). We conclude that 1) when examining women under 50 years of age, the surgeon must be clearly focused on the double-edged sword of screening mammography in this age group, and 2) community cancer programs should encourage annual screening of women over 40 years of age but focus on those over 70, without an arbitrary upper age limit.
Predictors of Axillary Lymph Node Metastasis in T1 Breast Carcinoma
Authors: Shoup Margo , Malinzak Lauren , Weisenberger Julia , Aranha Gerard V.
Published: November 2022

This study was designed to determine the predictors of axillary lymph node metastasis in T1a (≤0.5 cm), T1b (>0.5 cm and ≤1.0 cm), and T1c (>1.0 cm and ≤2.0 cm) breast cancers. The charts of 204 patients who underwent axillary lymph node dissections for T1 breast carcinomas at our institution were reviewed. Of these, 23 (11%) patients had T1a cancers, 55 (27%) patients had T1b cancers, and 126 (62%) patients were diagnosed with T1c lesions. Fifty patients (24.5%) had axillary node metastases. Of those with T1a lesions, one (4.3%) patient had axillary node involvement, compared with 9 (16.4%) patients with T1b and 40 (31.7%) patients with T1c lesions. Nodal involvement was significantly increased in T1c cancer compared with either T1a (odds ratio = 8.24; P < 0.05) or T1b (odds ratio = 2.73; P < 0.05). Similar results were found in tumors with grade 3 nuclear pleomorphism (odds ratio = 10.45 versus grade 1 and 3.46 versus grade 2; P < 0.05). The presence of lymphovascular invasion was also associated with an increased likelihood of nodal involvement (odds ratio = 3.15; P < 0.05). Predictors of axillary lymph node metastasis in T1 breast carcinomas include increasing tumor size, grade 3 nuclear pleomorphism, and the presence of lymphovascular invasion. These predictors may have a role in stratifying patients with T1 breast carcinomas into subgroups that may benefit from less invasive methods of evaluating axillary lymph node status.
The Utility of Physical Examination in Proximity Penetrating Extremity Trauma
Authors: Gonzalez Richard P. , Falimirski Mark E.
Published: November 2022

This study assessed the efficacy of physical examination as a screening modality for the diagnosis of surgically significant arterial injury in proximity penetrating extremity trauma (PPET). All cases of PPET were assessed and admitted per established protocol over a 30-month period from January 1, 1993, to June 30, 1995. No patients were excluded if other body regions were also injured. Landmarks defining upper extremity injuries were the deltopectoral groove to the wrist and for lower extremities from the inguinal ligament to the ankle. Patients admitted with PPET fell into one of three categories: 1) no hard signs of vascular injury present—admitted for 24-hour observation; 2) presence of at least one hard sign of vascular injury—taken immediately to the operating room; 3) positive sign of arterial injury that requires angiography (i.e., diminished but appreciable pulse by physical examination or doppler, large nonexpanding hematoma, bilateral pulse deficit, no appreciable pulse with unreconstructable trajectory). Four hundred six patients with 489 injured extremities secondary to PPET were admitted over a 30-month period. Sixty-two extremities suffered multiple injuries. Of the extremities injured, 83 per cent were secondary to gunshot wounds, 12 per cent were attributed to stabs/lacerations, and 5 per cent were due to shotgun injuries. Four hundred twenty-one extremities with PPET fell into Group 1. There were four missed injuries (specificity, 99%) in this group (one ulnar artery, one radial artery, one posterior tibial artery, and one anterior tibial artery). Two of these injuries were considered surgically significant. None of the patients suffered limb or functional loss as a consequence of their missed arterial injury. Thirty-nine extremities were entered into Group 2, with two patients found to have no arterial injury. Twenty-nine extremities were placed into Group 3 with 10 (35%) found to have surgically significant injury on angiogram. The overall sensitivity and specificity for physical examination was 92 per cent and 95 per cent, respectively, for surgically significant injury. Physical examination is a highly sensitive and specific screening modality for the identification of surgically significant arterial injury in PPET. Patients who present with diminished, but appreciable, pulses by physical examination or doppler, large nonexpanding hematomas as the only sign, bilateral pulse deficits and nonappreciable pulses with unreconstructable trajectory benefit from further investigation with angiography.
The Chest Radiograph in Critically Ill Surgical Patients is Inaccurate in Predicting Ventilator-Associated Pneumonia
Authors: Butler Karyn L. , Sinclair Karlene E. , Henderson Vernon J. , Mckinney Gerald , Mesidor Dominique A. , Katon-Benitez Iva , Weaver William Lynn
Published: November 2022

Chest radiographs (CXRs) are frequently obtained in surgical intensive care unit (SICU) patients when a diagnosis of ventilator-associated pneumonia (VAP) is suspected. The purpose of this study was to determine if the interpretation of the CXR correlated with a diagnosis of VAP in SICU patients. Prospective evaluation of 20 SICU patients clinically suspected of VAP was performed from July 1997 through December 1998. All patients required mechanical ventilation for at least 48 hours, and antibiotic use was discontinued 24 hours before entry into the study. Bronchoscopy with protected specimen brush (PSB) sampling of secretions from the right and left lung was performed. A positive PSB was present if quantitative analysis yielded ≥104 colony-forming units/mL of bacteria. VAP was diagnosed if either the right or left PSB was positive and ruled-out if both the right and left PSB yielded <104 colony-forming units/mL. Twelve of 20 patients (60%) were diagnosed to have VAP by PSB criteria. Eight of 20 patients (40%) had CXRs interpreted as negative for infiltrates; four patients had VAP by PSB criteria. There were four patients with focal infiltrates; two patients had VAP. The remaining eight patients had radiographs interpreted as bilateral infiltrates (one) or pulmonary edema (seven); of these, six patients (75%) had VAP. The sensitivity of the CXR in determining the presence of VAP was 25 per cent, the specificity was 75 per cent, and the accuracy was 0.45. The CXR does not improve the clinician's ability to diagnose VAP: a normal CXR does not exclude the presence of VAP and the finding of a focal infiltrate does not confirm the diagnosis of VAP.
Acute Pancreatitis after Cardiac Transplantation and Other Cardiac Procedures: Case-Control Analysis in 24,631 Patients
Authors: Herline A.J. , Pinson C.W. , Wright J.K. , Debelak J. , Shyr Y. , Harley D. , Merrill W. , Starkey T. , Pierson R. , Chapman William C.
Published: November 2022

Previous series have identified an increased risk of developing acute postoperative pancreatitis in heart transplant recipients and other cardiac surgical patients, and some suggest that mortality is significantly increased when pancreatitis occurs in the transplant setting. We conducted a retrospective case-control analysis of adult patients undergoing orthotopic heart transplant or other cardiac procedures from April 1985 through June 1996 at our medical center. Specific risk factors for outcome were assessed including low cardiac output, intra-aortic balloon pump usage, exogenous calcium repletion, immunosuppression, cytomegalovirus infection, cholelithiasis, prior pancreatitis, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. There was a 30-fold increase in the incidence of pancreatitis in the heart transplant group [12 of 394 (3%) vs 27 of 24,237 (0.1%); P < 0.01]. Compared with the nontransplant cardiopulmonary bypass patients, the transplant patients experienced a statistically significant increased incidence of immunosuppression and three or more risk factors. Transplant patients with pancreatitis demonstrated a significant increase in APACHE II scores and the incidence of three or more risk factors compared with their transplant control group. Patients undergoing nontransplant cardiac procedures and developing pancreatitis had significantly increased cross-clamp times, incidence of low cardiac output, APACHE II scores, and incidence of three or more risk factors compared with their nontransplant cohort. In conclusion, there is a significant increase in the incidence of pancreatitis after orthotopic heart transplant compared with other cardiac procedures. Analysis demonstrates the additive effect of multiple individual risk factors. Immunosuppression confers significant additional risk for pancreatitis in the orthotopic heart transplant patient.