bluuebunny/crossref_metadata_2025 huggingface dataset:
“Successful Outcome” after Below-Knee Amputation: An Objective Definition and Influence of Clinical Variables
Authors: Taylor Spence M. , Kalbaugh Corey A. , Cass Anna L. , Buzzell Nicole M. , Daly Charles A. , Cull David L. , Youkey Jerry R.
Published: June 2020

Functional success after below-knee amputation (BKA) has been poorly studied. The purpose of this study was to establish a consistent definition of “successful outcome” after BKA and to identify clinical variables influencing that definition. Three hundred nine consecutive patients undergoing BKA were evaluated postoperatively using the following definition for “successful outcome”: 1) wound healing of the BKA without need for revision to a higher level; 2) maintenance of ambulation with a prosthesis for at least 1 year or until death; and 3) survival for at least 6 months. Independent clinical predictors influencing outcome were determined using bivariate and multivariable logistic regression analyses. For the cohort, median survival and maintenance of ambulation were 44 months and 60 months, respectively. Although 86.4 per cent of patients healed without the need for revision to a higher level, 63.4 per cent maintained ambulation with a prosthesis for 1 year and 86.1 per cent survived for 6 months, successful outcome as defined by attaining all three components of the definitions occurred in only 51.1 per cent (n = 158) of patients. Of 19 clinical variables examined, six were identified in bivariate analysis as significantly associated with outcome. However, only three were found to be independent predictors of outcome using logistic regression modeling. The presence of coronary artery disease [odds ratio (OR), 0.465; 95% CI, 0.289–0.747], cerebrovascular disease (OR, 0.389; 95% CI, 0.154–0.980), and impaired ambulatory ability before BKA (OR, 0.310; 95% CI, 0.154–0.623) were each associated with a decreased odds for successful outcome. Patients who presented with impaired ambulatory ability in combination with another independent predictor had only a 20 per cent to 23 per cent probability of successful outcome and patients who presented with all three had a 10.4 per cent probability of success. In contrast, patients who had none of the independent predictors at presentation had a 67.5 per cent probability of successful outcome after BKA. A standardized definition of success after BKA capable of predicting outcomes is feasible and can be a useful tool to determine rehabilitation potential. When judged by our definition, patients without predictors of failure possess a high potential for rehabilitation, whereas patients with multiple predictors rarely rehabilitate, should probably receive palliative above-knee amputation, and forgo the expense of futile prosthetic training.
Isolated Lymphoplasmacytic Sclerosing Pancreatitis Involving the Pancreatic Tail
Authors: Kim Tad , Grobmyer Stephen R. , Dixon Lisa R. , Hochwald Steven N.
Published: June 2020

We present an interesting case of a 62-year-old woman with a 3-month history of vague, left-sided abdominal pain. CT imaging revealed a hypodense lesion in the tail of the pancreas. The patient had no history of pancreatitis or autoimmune diseases. Laboratory testing revealed a normal CA19-9 (33 U/mL) and an elevated IgG4 (133 mg/dL). Due to concerns of pancreatic malignancy, she underwent operation. We found a dense, inflammatory mass in the tail of the pancreas, which was removed via an open distal pancreatectomy with splenectomy. Histologic analysis revealed a pancreas with sclerotic ducts and surrounding lymphoplasmacytic inflammation most consistent with lymphoplasmacytic sclerosing pancreatitis (LPSP). LPSP, also termed autoimmune pancreatitis, is a benign disease of the pancreas, which can mimic pancreatic adenocarcinoma. It is the most common benign finding diagnosed on pathology after pancreatic resection for presumed malignancy. LPSP most commonly involves the head and, more uncommonly, the tail of the pancreas. It can be successfully treated with steroids obviating the need for resection. IgG4 levels may assist in recognition of this disease. As our experience with utilization of IgG4 testing and knowledge of the systemic nature of LPSP increase, patients with this disease may be spared unnecessary resection.
Endometrial Stromal Sarcoma Development after Hysterectomy and Tamoxifen Therapy
Authors: Christie D. Benjamin , Day J. Daniel , Moore Amy B. , Chapman Jason R. , Nakayama Don K. , Conforti Arnold M.
Published: June 2020

Tamoxifen therapy is well known for its success in adjuvant therapy for breast carcinoma; however, despite its benefits, the agents’ estrogenic influence on the uterus, and subsequent endometrial cell proliferation may result in development of invasive uterine tumors. It has been estimated that tamoxifen may increase the risk of endometrial-based cancer two- to threefold, but uterine sarcomas remain relatively rare, accounting for 2 to 5 per cent of all uterine malignancies. We report the case of a 72-year-old woman having received tamoxifen for a breast carcinoma and having a hysterectomy nearly 30 years prior who presented with an intra-abdominal, omentum-based mass that on excision was identified as an endometrial stromal sarcoma.
Blunt Liver Injury in Children and Adults: Is There Really a Difference?
Authors: Klapheke W. Patrick , Franklin Glen A. , Foley David S. , Casos Steven R. , Harbrecht Brian G. , Richardson J. David
Published: June 2020

Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (≥18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.
Endoscopy-Assisted Laparoscopic Resection of Gastric Heterotopic Pancreas
Authors: Margolin Daniel J.
Published: June 2020

This is a case report of a 51-year-old white female who underwent an endoscopy-assisted laparoscopic resection of a submucosal mass in the prepyloric region of the stomach, which turned out to be heterotopic pancreas. She presented with vague upper gastrointestinal complaints of pain, early satiety, nausea, vomiting, and an 8 pound weight loss. Her only diagnostic workup was an upper endoscopy, which revealed this submucosal umbilicated mass. This manuscript provides a detailed description of the operation and a discussion and review of the literature about gastric heterotopic pancreas.
Acquired Jejunoileal Diverticulosis and Its Complications: A Review of the Literature
Authors: Woods Kevin , Williams Eric , Melvin Willie , Sharp Kenneth
Published: June 2020

Jejunoileal diverticulosis is a rare entity. Jejunoileal diverticulosis is not a disease that surgeons see often in clinical practice; however, it should remain on the differential diagnosis for any patient with an acute abdomen or gastrointestinal bleeding of unknown origin. It can present with a wide range of clinical scenarios and when patients experience chronic symptoms such as bloating, abdominal pain, nausea, bacterial overgrowth, or malabsorption, medical therapy is successful in most patients. However, when patients present with acute symptoms of bleeding, inflammation, perforation, or obstruction, surgical resection and primary anastomosis is often the treatment of choice. If patients are asymptomatic, they are better left alone, even when discovered incidentally in the operating room. In closing, the possibility of a patient having jejunal diverticular disease should be suspected whenever the symptoms of obscure abdominal pain, anemia, dilated jejunal loops on abdominal radiographs, a history of colonic diverticuli, and a history of acute appendicitis.
A Prospective Look at the Current State of Open Abdomens
Authors: Teixeira Pedro G.R. , Salim Ali , Inaba Kenji , Brown Carlos , Browder Timothy , Margulies Daniel , Demetriades Demetrios
Published: June 2020

The present study examines the current management, closure rate, and complications of open abdomens in trauma patients admitted to an Academic Level I trauma center between May 2004 and April 2007. Variables examined include mechanism, injuries, use of antibiotics and paralytics, type of abdominal closure, days to closure, complications, ICU and hospital length of stay, and mortality. Stepwise logistic regression was performed to identify independent predictors of failed abdominal closure. Of 900 laparotomies, 93 (10%) were left open. Eighty-five (91%) patients survived for closure opportunity. Definitive fascial closure was achieved in 72 (85%) at 3.9 ± 3.7 days (range 1–21 days). Of the remaining 13 patients, seven were closed with biologic material, five by skin grafting, and one had skin-only closure. Entero-atmospheric fistulas occurred in 14 (15%) patients. Two independent risk factors associated with failed abdominal closure were the presence of deep surgical site infection [odds ratio (OR) 17.4; 95% confidence interval (CI) 2.6–115.8, P = 0.003] and intra-abdominal abscess (OR 7.4; 95% CI 1.1–51.0, P = 0.04). In conclusion, open abdomens are commonly necessary after trauma laparotomies. Definitive fascial closure can be achieved in 85 per cent of cases. In conjunction with biologics, closure can be achieved in 93 per cent of cases. Failure to primarily close the abdomen is associated with a significantly higher risk for entero-atmospheric fistula occurrence.
100 Robotic-Assisted Laparoscopic Gastric Bypasses at a Community Hospital
Authors: Deng Joseph Y. , LouriÉ David J.
Published: June 2020

Laparoscopic Roux-en-Y gastric bypass (LGB) is one of the most popular surgeries for morbid obesity. Robotic use is also on the rise. Data concerning outcomes is limited, hence the need for more information. The first 100 robotic-assisted bypasses by one surgeon in one institution were studied. Data obtained from clinic notes and hospital records included all who underwent the procedure. There were 79 females and 21 males. Mean age and body mass index were 42 years and 48 kg/m2, respectively. Comorbidities included diabetes, 22 per cent; hypertension, 47 per cent, gastroesophageal reflux disease, 40 per cent; obstructive sleep apnea, 53 per cent; dyslipidemia, 17 per cent; and heart disease, 8 per cent. Prior surgeries included cesarean -section, 26 per cent; cholecystectomy, 17 per cent; hysterectomy, 3 per cent; hernia, 1 per cent, and other abdominal surgery, 27 per cent. Intraoperatively procedures included adhesiolysis, 22 per cent; cholecystectomy, 16 per cent; and herniorrhaphy, 3 per cent. Average time was 177.7 minutes. Mean stay was 1.51 days. Thirty-day mortality was 0. Emergency department re-evaluations included 13. Most were minor problems. There was one gastrojejunal leak. Early complications included leak, thrombosis, and bleeding requiring transfusion in four patients. There were four strictures. Overall follow up was greater than 90 per cent. Average weight loss was 21.2 per cent of excess body weight by Month 1, 33.8 per cent by Month 3, and 50.7 per cent by Month 6. Learning curves for time and major complications were 30 and 50 cases, respectively (P = 0.03, 0.04). Robotic use in bariatrics is possible in community hospitals. Although technologies are still in their infancy, complication rates and weight loss are comparable to nonrobotic procedures.
Blunt Thoracic Aortic Injury
Authors: Benjamin Elizabeth R. , Tillou Areti , Hiatt Jonathan R. , Cryer H. Gill
Published: June 2020

Blunt thoracic aortic injury (BAI) is a rare but often fatal injury that occurs with severe polytrauma. Immediate diagnosis and treatment of BAI are essential for a successful outcome. We reviewed our experience with 20 patients with BAI treated at a Level I trauma center between 1995 and 2006. The mean Injury Severity Score was 38 ± 14 and 14 patients had an abnormal Glasgow Coma Score; associated injuries included abdomen in 13 patients, extremity in 12, and head in six. Chest x-ray (CXR) findings were suggestive of aortic injury in 15 patients, equivocal in three, and showed no evidence of aortic injury in two. Diagnosis was made by CT angiography (CTA) in 17 patients, transesophageal echocardiography (TEE) in two, and formal angiography in one. Sixteen patients underwent operative repair of BAI. Of these, eight also underwent laparotomy, six had operative repair of extremity fractures, and three had pelvic embolization. Five patients died, three of whom were treated nonoperatively, and length of hospitalization in survivors was 32 ± 20 days. BAI is rare and often associated with multiple life-threatening injuries complicating diagnosis and treatment. Our data support the aggressive use of CTA even when classic CXR findings are not present. When CT must be delayed for abdominal exploration, intraoperative TEE is useful.
Intracranial Pressure Monitoring in Severe Isolated Pediatric Blunt Head Trauma
Authors: Salim Ali , Hannon Matthew , Brown Carlos , Hadjizacharia Pantelis , Backhus Leah , Teixeira Pedro G.R. , Chan Linda S. , Ford Henri
Published: June 2020

Very little research regarding standard treatments for pediatric traumatic brain injury (PTBI) exists. The objective of this study was to examine the use of intracranial pressure (ICP) monitoring devices in PTBI and to determine if its use was associated with any outcome benefit. Data were collected from the Trauma Registry over an 11-year period (1996–2006) on all blunt trauma pediatric patients (age < 14 years) with an initial Glasgow Coma Scale score ≤ 8. Data collected included: demographics, admission Glasgow Coma Scale score, mechanism of injury, Injury Severity Score, Abbreviated Injury Score, and use of an ICP monitor. Outcome measures included: mortality, complications, discharge location, and capacity. Thirty-three (25%) of 129 blunt PTBI patients had ICP monitors placed. Patients with monitors were more severely injured overall (Injury Severity Score: 25 vs 18, P = 0.001) and had more severe head injury (81% head Abbreviated Injury Score > 3 vs 55%, P = 0.01) than patients without monitors. However, there was no difference in mortality (28% vs 35%, P = 0.52), discharge location (P = 0.10), and discharge capacity (P = 0.84). After multivariable analysis to adjust for the differences between the two study groups, the use of ICP monitor provided no survival benefit (adjusted odds ratio: 1.1; 95% confidence interval [CI]: 0.3–4.1; adjusted P value = 0.85). The use of ICP monitor was, however, independently associated with a higher risk of developing extracranial complications (adjusted odds ratio: 4.3; 95% CI: 1.2–16.4; adjusted P value = 0.025). In conclusion, the use of ICP monitors in pediatric patients with severe isolated head injury provided no survival benefit and was associated with an increased risk of complications.
Pancreatic Trauma: Demographics, Diagnosis, and Management
Authors: Peter Stawicki Stanislaw , Schwab C. William
Published: June 2020

Pancreatic injuries are rare, with penetrating mechanisms being causative in majority of cases. They can create major diagnostic and therapeutic challenges and require multiple diagnostic modalities, including multislice high-definition computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, ultrasonography, and at times, surgery and direct visualization of the pancreas. Pancreatic trauma is frequently associated with duodenal and other severe vascular and visceral injuries. Mortality is high and usually related to the concomitant vascular injury. Surgical management of pancreatic and pancreatic-duodenal trauma is challenging, and multiple surgical approaches and techniques have been described, up to and including pancreatic damage control and later resection and reconstruction. Wide surgical drainage is a key to any surgical trauma technique and access for enteral nutrition, or occasionally parenteral nutrition, are important adjuncts. Morbidity associated with pancreatic trauma is high and can be quite severe. Treatment of pancreatic trauma-related complications often requires a combination of interventional, endoscopic, and surgical approaches.
Does Fever at the Time of Discharge Have Any Impact on the Incidence of Readmission?
Authors: Barone James E.
Published: June 2020

Most physicians believe that patients who have fever within 24 hours of the planned date of discharge should be kept in the hospital until the fever resolves. A search of the literature revealed very few articles addressing this topic. The object of this study was to review a number of patient discharges from the surgical service and to document the presence or absence of fever within 24 hours of the time of discharge. The primary end point of the study was to determine the rate of readmission for both patients discharged with fever and those discharged without fever. Secondary end points were to determine whether the readmission was related to the original discharge diagnosis or the presence of fever at the time of discharge. The records of all adult patients with a hospital length of stay of ≥5 days discharged from the surgical and gynecology services from April through July of 2007 were reviewed. Deaths were excluded. The following data elements were recorded: primary discharge diagnosis; age; highest recorded temperature within 24 hours of discharge; date time and cause of readmission within 30 days; and outcome. Fever was defined as a temperature of ≥100° F. Data were entered into an Excel (Microsoft, Redmond, WA) spreadsheet, and statistical analysis was performed using χ2 and Fisher's exact tests using Primer of Biostatistics© (McGraw-Hill, New York, NY). The records of 300 consecutive patients were reviewed. Follow-up was available for 86.7 per cent of the patients, 84.4 per cent of the febrile patients, and 87.1 per cent of the nonfebrile patients. A fever of ≥100° within 24 hours of discharge was noted in 45 (15.0%) patients. The mean fever was 100.5°, with a range of 100° to 102.1°. There were 38 readmissions. Of the 45 patients with fever, seven (15.6%) were readmitted. Of those seven, four readmissions were related to the previous admitting diagnosis. Of the patients who were discharged without fever, 31 (12.2%) were readmitted with 24 of those read-missions for diagnoses related to the first admission. The rate of readmission for fever and nonfever patients was not statistically significantly different (P = 0.697). Similarly, the rate of related versus nonrelated diagnoses in both the fever and nonfever groups was not statistically significantly different (P = 0.351). The presence or absence of fever within 24 hours of patient discharge seems to have no impact on the rate of readmission within 30 days.
Endovascular Aortic Crossclamp: A Novel Way to Reduce Warm Ischemia Time in DCD Donors
Authors: Grandas Oscar H. , Amortegui Jose D. , Goldman Mitchell H.
Published: June 2020

Strategies like donation after cardiac death (DCD) have become more widely accepted to increase potential organ supply and decrease waiting list time. Warm ischemia time (WIT) is a key prognostic factor for organ function. Any process that can decrease WIT could decrease the number of discarded organs as well as improve graft and patient survival. A novel endovascular aortic crossclamping technique in DCD donors is described. Six kidneys and two livers were recovered from three donors. Mean WIT from extubation to aortic crossclamp was 25 ± 8 minutes. Time from initial glidewire placement to crossclamp was less than 2 minutes. All the organs were adequately flushed; back table examination confirmed clean venous effluent and no signs of thrombosis. Four kidneys were transplanted. Two kidneys were discarded after DCD was prolonged and WIT was 60 minutes. The two livers were not allocated. The WIT can be manipulated after cardiac activity has stopped. The endovascular crossclamp is a novel and feasible technique that can decrease WIT after cardiac death by reducing the surgical time to aortic crossclamp.
23-Hour Stay Outcomes for Laparoscopic Roux-en-Y Gastric Bypass in a Small, Teaching Community Hospital
Authors: Fares Louis G. , Reeder Rachel C. , Bock John , Batezel Valerie
Published: June 2020

The goal of every surgery is a successful outcome with the shortest hospital stay. Morbidly obese patients with their myriad of comorbidities have confounded surgeons over the years, usually leading to an increased length of hospital stays after complicated surgeries. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has proven to be an effective treatment for the morbidly obese with a usual length of stay of 3 days. The purpose of this article is to review our experience with 23-hour stays for LRYGB over a 13-month period and to apply a recently published risk score to these patients. A single surgeon performed 173 bariatric surgeries of which 96 were LRYGB, the study group. The demographics of this group found the overwhelming majority were female, white, slightly older than the men but with a somewhat smaller body mass index (BMI). The ethnic breakdown was 67.7 per cent white, 22.9 per cent black, and 9.4 per cent Hispanic. The average for all patients was 41.7 years and the BMI was 49.25 kg/m2. Using the Obesity Surgery Mortality Risk Score, 62.5 per cent of our patients were low risk or Class A, 37.5 per cent intermediate risk or Class B, and none of our patients qualified as high risk or Class C. Our average patient score was 1.3. In terms of length of stay, 91 of the 96 patients (94.8%) were discharged within 23 hours of surgery without mortality or 30-day readmission. The remaining five patients (5.2%) had unexplained, sustained tachycardia and were re-explored on the first postoperative day laparoscopically. Three of these patients had negative explorations. One had a jejunojejunostomy revision and the other was found to have a small bowel injury, which was laparoscopically repaired. All five patients were discharged within the next 23 hours. All patients were discharged on a clear liquid diet and advanced to a regular diet over the next month. No diet intolerance was noted nor were any patients converted to an open operation. In conclusion, we have demonstrated that a comprehensive bariatric program in a small teaching community hospital can successfully perform LRYGB and discharge a high percentage of patients within 23 hours with a very low complication rate. We also believe the Obesity Surgery Mortality Risk Score will help bariatric programs to risk-stratify their patients preoperatively. This will contribute to decision-making and further inform patients of their risk as part of their education preoperatively.
Variations in Interferon Gamma Receptor Gene Expression during Liver Regeneration after Partial Hepatectomy in Rats
Authors: Lai Hong-Shiee , Lin Wen-Hsi , Hsu Wen-Ming , Chen Chiung-Nien , Chang King-Jen , Lee Po-Huang
Published: June 2020

Cell-mediated immunity, which includes interferon gamma (IFN-γ) expression, is activated during the process of liver regeneration; however, the genetic pathway of this activation is still unclear. The present study evaluated variations in the interferon gamma receptor (IFN-γR) gene and its mRNA expression during liver regeneration after partial hepatectomy (PH). Male Wistar rats weighing approximately 200 g were subjected to PH (70 or 40%). IFN-γR gene expression in the remnant liver was measured by cDNA microarray, and mRNA expression was verified by real-time quantitative reverse transcription-polymerase chain reaction (Q-PCR) preoperatively and at 2, 4, 6,12, 24, and 72 hours and 7 days postoperatively. The ratio of remnant liver weight to body weight increased markedly after 70 per cent PH and more gradually after 40 per cent PH. It reached near 90 per cent of the preoperative level at 72 hours after PH in both groups. The scanned spots of the genomic survey on the cDNA microarray chips were uneven and increased irregularly in number and density after PH. IFN-γR gene expression increased markedly in a single peak pattern, up to more than double the preoperative level, at 6 hours after 70 per cent PH. The curve in the 40 per cent PH group was flat and peaked at only 1.6 times the preoperative level. The variations in IFN-γR-related mRNA expression were verified by Q-PCR. Elevations in IFN-γR gene and mRNA expression were shown during the early stage of liver regeneration after PH. The genetic pathway of IFN-γ/IFN-γR expression is activated during liver regeneration.
Article Commentary: Complications of Bariatric Surgery: Implications for the Covering Physician
Authors: Tanner Benjamin D. , Allen Jeffrey W.
Published: June 2020

Bariatric surgery is the only effective option for sustained weight loss for morbidly obese patients. The increasing prevalence of obesity in America and the application of a laparoscopic approach to bariatric surgery have combined to dramatically increase the number of patients undergoing these types of operations. The number of bariatric surgeons and centers devoted to surgery of the morbidly obese is also rising. These facts lead to the assumption that there will be more patients with complications specific to bariatric surgery that must be cared for by general surgeons in the immediate future. Covering surgeons and those without expertise in bariatric surgery need to know how to diagnose and manage these potential complications in emergent and outpatient settings. This paper reviews some of the more common bariatric operations, complications, and conservative treatment options.
Laparoscopic Gastrojejunostomy in Patients with Obstruction of the Gastric Outlet Secondary to Advanced Malignancies
Authors: Guzman Eduardo A. , Dagis Andy , Bening Lisa , Pigazzi Alessio
Published: June 2020

Surgical palliation is an important therapeutic goal in patients with gastric outlet obstruction from cancer. The use of laparoscopic approaches for this condition has not been well studied. Our objective is to compare surgical outcomes of laparoscopic and open gastrojejunostomies in patients with gastric outlet obstruction secondary to advanced malignancies. We did a retrospective review of 20 patients who underwent a palliative gastrojejunostomy as their primary surgical procedure. There were 10 patients in the laparoscopic group and 10 patients in the open one. We identified no significant difference between groups in mean surgery time (116 vs 116 minutes) ( P = 0.99), blood loss (23 vs 142 mL) ( P = 0.19), or length of stay (8 vs 14 days) ( P = 0.14). We also identified no difference in median time to tolerate a regular diet (7 vs 8 days) ( P = 0.49) and median survival (11.2 vs 9.0 months) ( P = 0.83). Delayed gastric emptying was the most common complication occurring in four patients. There is no detectable difference in surgical outcomes between laparoscopic and open gastrojejunostomies in the management of patients with obstruction of the gastric outlet secondary to cancer. Laparoscopic gastrojejunostomy is a safe and feasible operation in this setting
Is Survival Reduced for Patients with Anal Cancer Requiring Surgery after Failure of Radiation? Analysis from a Population Study over Two Decades
Authors: Kiran Ravi P. , Pokala Naveen , Rottoli Matteo , Fazio Victor W.
Published: June 2020

Chemoradiotherapy is the standard treatment for anal cancer. Surgery is reserved for failure of therapy, but there are limited data examining outcomes after surgery. From a prospective population-based database on radiation and surgical therapy, we compare outcomes for patients with anal cancer undergoing rectal resection after radiation with patients undergoing radiation alone. Patients undergoing surgical resection of the rectum after initial radiation (SRT) for squamous cell carcinoma of the anus, anal canal, cloacogenic zone, and overlapping lesions of the rectum and anal canal from 1983 to 2002 were identified from the Surveillance, Epidemiology and End Results database. Patient and tumor characteristics of SRT were compared with those of patients who underwent radiation alone (RT). Survival was calculated by the Kaplan-Meier test. There were 1202 patients undergoing RT and 48 patients undergoing SRT. RT and SRT had similar median age, gender, and grade of tumor. SRT had more patients with regional stage of disease (66.7 vs 42.4%, P = 0.001). Mean survival for SRT was, however, similar to RT (103 vs 96 months, P = 0.8). For patients with localized stage, survival for SRT and RT was similar (105 vs 98 months, P = 0.7). For patients with regional stage, survival for SRT and RT was similar (95 vs 83 months, P = 0.6). The presence of regional disease appears to be associated with surgical resection after radiotherapy. Mean survival for such patients is comparable to that of patients undergoing radiation alone. Because radiation is combined with chemotherapy, this suggests that salvage surgery after failure of therapy results in outcomes comparable to combination therapy alone.
Sturgeons versus Surgeons: Leaping Fish Injuries at a Level I Trauma Center
Authors: Wilson Jason P. , Burgess George , Winfield Robert D. , Lottenberg Lawrence
Published: June 2020

We have recently noted an increase in patients injured by an unusual mechanism and source: leaping sturgeon. We present our experience with eight cases of sturgeon related injuries. Between January 2006 and June 2007, there were eight patients evaluated at our Level I trauma center for sturgeon related injuries. Injuries included isolated fractures, liver lacerations, severe facial trauma, and a closed head injury. The overall length of stay was 6 days (range 0-20) and 50 per cent of patients required an intensive care unit stay. For comparative purposes, injuries were classified as primary sturgeon injuries (injuries where the sturgeon directly impacted the patient) and secondary sturgeon injuries (injuries related to the sturgeon but not resultant from direct impact). There were five primary injuries and three secondary injuries in our series. Patients with secondary injuries had a longer length of stay (12 days vs 3 days) and a higher intensive care unit utilization (100 % vs 20%) when compared with patients having primary injuries. This is the first report of sturgeon-related injuries in the medical literature. These peculiar insults seem to have increased in recent years. Public awareness and proper boat safety are vital in reducing the number and severity of these incidents.
Diagnostic and Therapeutic Dilemmas of Hypercortisolemia during Pregnancy: A Case Report
Authors: Terhune Kyla P. , Jagasia Shubhada , Blevins Lewis S. , Phay John E.
Published: June 2020

Pregnancy and Cushing's syndrome rarely coexist. When they do, it is generally the result of the presence of an adrenal adenoma. Because of significantly increased morbidity and mortality in both the mother and fetus when hypercortisolism is present, it is imperative that it be treated when recognized. This treatment can take the form of definitive surgical treatment or temporary medical treatment until after delivery, both of which carry risks and benefits. Complicating the evaluation, however, it is well known that pregnancy itself can induce many of the symptoms and laboratory abnormalities associated with hypercortisolism. We present the case of a 35-year-old woman who was noted to have an adrenal mass before pregnancy, but then during evaluation became pregnant. Her case is particularly intriguing because she had only vague clinical symptoms and mild laboratory abnormalities but also had a complicating pituitary mass noted on MRI. We outline the evaluation process and eventual laparoscopic adrenalectomy during the second trimester in this unique and difficult case, and discuss risks and benefits of different treatment options for hypercortisolism during pregnancy
First Three Sentinel Lymph Nodes Accurately Stage the Axilla in Breast Cancer
Authors: Kidd Sabrina A. , Keto Jessica L. , Tran Huynh , Fitzgerald Timothy L.
Published: June 2020

Sentinel lymph node (SLN) biopsy is the preferred method of assessing lymph nodes in breast cancer. Recent literature suggests increasing morbidity with increased number of SLN removed. However, controversy exists regarding the number of SLN that should be removed. A retrospective review of patients undergoing SLN biopsy for breast cancer from 2003 to 2005 was performed. Data analyzed included the number of SLNs, nodes per specimen, and pathology. The order of SLN removal was documented and the first positive lymph node noted. Three hundred fifty-three patients underwent successful SLN biopsy. On average, only one surgical SLN was identified. However, the average number of pathologically identified SLN was 1.3. Nodal disease was identified in 79 patients (22.4%). The first SLN was positive in 70 of those patients (88.6%). Six additional patients were diagnosed by the second SLN (76 of 79 [96.2%]), and all 79 patients were identified within the first three nodes. All patients with nodal disease were identified within three SLNs. These data support the concept that surgeons do not need to remove all identifiable sentinel nodes. Moreover, surgeons could consider limiting the number of excised SLNs to three.
Elderly Patients with Pelvic Fracture: Interventions and Outcomes
Authors: Dechert Tracey A. , Duane Therèse M. , Frykberg Brett P. , Aboutanos Michel B. , Malhotra Ajai K. , Ivatury Rao R.
Published: June 2020

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.
Transfusion, Not Just Injury Severity, Leads to Posttrauma Infection: A Matched Cohort Study
Authors: Sadjadi Javid , Cureton Elizabeth L. , Twomey Patrick , Victorino Gregory P.
Published: June 2020

Blood transfusion has been associated with infection; however, the collinearity of injury severity has not been clearly addressed to show a direct relationship. Using more rigorous analysis, we aimed to untangle the effect of injury severity from transfusion leading to sepsis. We hypothesized that blood transfusion independently increases infection in massively transfused versus nontransfused patients with matched Injury Severity Scores (ISSs). We performed a matched cohort study measuring infection rates in trauma patients receiving massive transfusion. Control subjects were contemporaneous patients with matched ISS receiving no blood. Infection was defined as intraperitoneal or intrathoracic abscesses, pneumonia, urinary tract infection, or bacteremia. Multivariate logistic and univariate analysis was completed. Infection rate was 61 per cent in 44 transfused patients versus 20 per cent in 44 control subjects ( P = 0.001). Odds of infection were eightfold greater in transfused patients (OR, 7.97; 95% CI, 2.3 to 27.5; P < 0.001) independent of ISS, Glasgow Coma Scale, mechanism, and age. Infection was most associated with transfusion of packed red blood cells (PRBCs), although transfusion of other blood products had strong collinearity with PRBCs. Transfused patients had eight times the risk of infection independent of ISS; this appears to be the result of PRBC transfusion. Modifying the ratio of components in transfusion protocols favoring plasma may cause less infection after injury
Impact of Hollow Viscus Injuries on Outcome of Abdominal Gunshot Wounds
Authors: Harris Brady T. , Franklin Glen A. , Harbrecht Brian G. , Richardson J. David
Published: June 2020

Abdominal gunshot wounds (GSW) are a source of morbidity and mortality. Limited data are available on the effect of hollow viscus injuries (HVI) secondary to gunshot wounds. GSW sustained in the Louisville area from 2004 to 2007 were reviewed. Attention was given to the impact of HVI from abdominal GSW. Statistical significance was determined. One-hundred ten patients sustained GSW with peritoneal violation. Eighty-six had HVI. Eighteen died after laparotomy with 15 having an HVI. Patients undergoing damage control (DC) have a significant increase in mortality compared with those not requiring DC. Exsanguination was the major cause of mortality (67%). Mortality directly related to HVI was found in 11 per cent. Twenty patients underwent DC with 11 deaths. Isolated HVI did not show a significantly increased mortality compared with other injury patterns involving solid organ or major vascular structures. Various methods of repair showed no significant survival advantage. Recognition and repair of HVI in abdominal GSW is crucial to patient salvage. Definitive repair of HVI at the initial operation should be considered. Primary repair of HVI is preferred although no survival disadvantage is seen in other forms of repair in marginally stable patients. Definitive repair at the initial operation decreases complications.
Dual Mechanism for Type-2 Diabetes Resolution after Roux-en-Y Gastric Bypass
Authors: Lin Edward , Davis S. Scott , Srinivasan Jahnavi , Sweeney John F. , Ziegler Thomas R. , Phillips Lawrence S. , Gletsu-Miller Nana
Published: June 2020

Resolution of Type-2 diabetes mellitus (DM) after weight loss surgery is well documented, but the mechanism is elusive. We evaluated the glucose-insulin metabolism of patients undergoing a Roux-en-Y gastric bypass (RYGB) using the intravenous glucose tolerance test (IVGTT) and compared it with patients who underwent laparoscopic adjustable gastric band (AB) placement. Thirty-one female patients (age range, 20 to 50 years; body mass index, 47.2 kg/m2) underwent RYGB. Nine female patients underwent AB placement and served as control subjects. All patients underwent IVGTT at baseline and 1 month and 6 months after surgery. Thirteen patients undergoing RYGB and one patient undergoing AB exhibited impaired glucose tolerance or DM defined by the American Diabetes Association. By 6 months post surgery, diabetes was resolved in all but one patient undergoing RYGB but not in the patient undergoing AB. Patients with diabetes undergoing RYGB demonstrated increased insulin secretion and β-cell responsiveness 1 month after surgery and continued this trend up to 6 months, whereas none of the patients undergoing AB had changes in β-cell function. Both patients undergoing RYGB and those undergoing AB demonstrated significant weight loss (34.6 and 35.0 kg/m2, respectively) and improved insulin sensitivity at 6 months. RYGB ameliorates DM resolution in two phases: 1) early augmentation of beta cell function at 1 month; and 2) attenuation of peripheral insulin resistance at 6 months. Patients undergoing AB only exhibited reduction in peripheral insulin resistance at 6 months but no changes in insulin secretion.
Surgical Therapy for Familial Hyperparathyroidism
Authors: Sharma Jyotirmay , Weber Collin J.
Published: June 2020

Isolated familial hyperparathyroidism (FHPT) not associated with multiple endocrine neoplasia is a rare and aggressive form of primary hyperparathyroidism. The traditional management of FHPT is a bilateral neck exploration with an increased rate of multigland hyperplasia, supernumerary glands, and recurrence. A prospective database was queried, which included 1383 consecutive parathyroidectomies between 1992 and 2008, and 28 patients with FHPT were identified. Patient demographics, pathology, intraoperative parathyroid hormone (IOPTH) kinetics, recurrence patterns, and accuracy of localization studies were analyzed. Twenty-one patients underwent bilateral neck explorations as an initial surgery, and seven patients had nine unilateral neck explorations for recurrent hyperparathyroidism. Overall cure rate was 89.2 per cent with a mean follow-up of 2.9 years (range: 6 months to 9.2 years); 64.3 per cent of patients had multigland disease. IOPTH helped identify supernumerary glands in three (12.5%) patients and accurately lateralized recurrent disease in eight of nine surgeries (88.8%). Tc-99m-Sestamibi failed to identify multigland disease in 11 patients (52.3%). FHPT has a greater prevalence of multigland disease, decreased utility of sestamibi scanning, and a higher recurrence rate than sporadic primary hyperparathyroidism. In FHPT, IOPTH is a useful adjunct in identifying additional tumors and in select cases may play a role in tumor localization.
Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes
Authors: Finan Kelly R. , Cannon Emily E. , Kim Eugenia J. , Wesley Mary M. , Arnoletti Pablo J. , Heslin Martin J. , Christein John D.
Published: June 2020

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.
Incidental Finding of Colorectal Cancer in Screening Colonoscopy and Its Cost Effectiveness
Authors: Berhane Chichi , Denning David
Published: June 2020

The objective of this study is to measure the risk of colorectal cancer and adenoma with screening colonoscopy and its cost effectiveness. We reviewed the procedure and pathology results of approximately 11,000 asymptomatic patients age 50 to 90 that underwent screening colonoscopy Among those 11,808 screening colonoscopies performed, advance neoplasm (adenocarcinoma) was detected in 272 (2.3%) patients; age 50 to 90, with mean age of 64-years-old. Fourteen per cent had hyperplastic polyps, 15 per cent had tubular adenoma, and 8.6 per cent villous adenoma. Adenoma with high grade dysplasia was found in 6.6 per cent, and 5.5 per cent had nonadenomatous lesions. Sixty-five of 272 (24%) neoplasms were found proximally Forty-five of 207 distal neoplasms were found through sigmoidoscopy, nine of 45 (20%) had proximal involvement. Rate of complication during colonoscopy was 0.06 per cent and no patients died. All patients underwent complete colonoscopy, 99.8 per cent were men. Rate of adenocarcinoma from 2000 to 2006 was (24/470, 29/520, 33/891,37/961,46/2889,49/2977, and 54/3100). Screening colonoscopy can detect advanced colorectal neoplasm in asymptomatic adults. The more screening colonoscopy was preformed the earlier the neoplasm was discovered and with better prognosis. Twenty per cent of the patients with distal neoplasms found on sigmoidoscopy had proximal lesions when complete colonoscopies were performed. These findings warrant refinement of the screening recommendations for colorectal cancer.
The Ventriculo-Gallbladder Shunt in the Treatment of Refractory Hydrocephalus: A Review of the Current Literature
Authors: Girotti Micah E. , Singh R. Ramesh , Rodgers Bradley M.
Published: June 2020

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) –shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.