bluuebunny/crossref_metadata_2025 huggingface dataset:
Relevance of Group Milleri Streptococci in Thoracic Surgery: A Clinical Update
Authors: Stelzmueller I. , Biebl M. , Berger N. , Eller M. , Mendez J. , Fille M. , Angerer K. , Schmid T. , Lorenz I. , Margreiter R. , Bonatti H.
Published: June 2020

Group Milleri streptococci (GMS), a heterogeneous group of streptococci, are associated with purulent infections. This study was a retrospective analysis of all consecutive thoracic infections of GMS between 2001 and 2004. Of 246 surgical GMS infections, thoracic infections accounted for 4.5 per cent, including 10 pleural infections (eight empyemas and two infected pleural effusions) and one mediastinal infection. The etiology of pleural infection was parapneumonic (7), second to esophageal perforation (1), liver transplantation (1), and liver resection (1). Polymicrobial infections were present in 64 per cent. All patients underwent removal of the infected masses, including drainage (3), thoracoscopic decortication (5), thoracotomy with debridement (2), and incision with drainage (1). The case fatality rate was 9 per cent (there was one patient with congestive heart disease unfit to undergo surgical empyema evacuation) and the recurrence rate was 27.3 per cent (three patients). Combined antibiotic/surgical treatment was successful in all other cases. GMS isolates were susceptible to clindamycin and all β-lactam antibiotics except ceftazidime, but were resistant to aminoglycosides. If found intrathoracically, GMS frequently progress to severe empyema. Therefore, timely removal of pleural collection by percutaneous drainage or surgical intervention seems indicated. If surgery is required, thoracoscopic decortication may be the preferred approach.
Captive Tiger Attack: Case Report and Review of the Literature
Authors: Schiller Henry J. , Cullinane Daniel C. , Sawyer Mark D. , Zietlow Scott P.
Published: June 2020

Tigers, as well as other large predators, are being held in private settings with increasing frequency. Unregulated private “zoos” are cropping up in many rural and suburban settings across the country. The number of attacks from captive predators also is on the rise. This case highlights the potentially violent and aggressive nature of wild animals held in captivity. Treatment principals and wounding patterns of large cat attacks are emphasized.
Carotid Angioplasty and Stenting is a Safe and Durable Procedure in a Community Hospital
Authors: Friedell Mark L. , Sandler Bryan J. , Andriole Joseph G. , Martin Samuel P. , Cohen Michael J. , Horowitz John D.
Published: June 2020

Carotid angioplasty and stenting (CAS) has been touted as a reasonable alternative to carotid endarterectomy (CEA) for high-risk surgical candidates. Several published CAS series, primarily from academic centers, show immediate results approaching those of CEA. However, very little is known about long-term results with CAS, particularly in the community hospital setting. Therefore, we retrospectively reviewed our CAS experience. From February 1999 to July 2003, 44 consecutive patients underwent placement of 46 stents. The mean patient age was 73 years, and 57 per cent were men. Most patients were asymptomatic (74%). High-risk categories included prior CEA (71%), other anatomic risks (13%), and/or significant medical comorbidities (16%). Technical success was achieved in all 46 cases. At 30 days, there were no deaths and one stroke, giving a combined stroke/mortality of 2 per cent. Clinical follow-up was obtained on all 44 patients at a mean follow-up of 42 months. Duplex scans performed on 44 stents (96%), at a mean follow-up of 40 months, demonstrated four 60 per cent to 79 per cent recurrent stenoses. CAS in a community hospital can have a 30-day stroke/mortality equivalent to CEA. The procedure is durable, with no critical (80%–99%) carotid restenoses and no stroke or transient ischemic attacks referable to a stented carotid artery in long-term follow-up.
Initial Chest CT Obviates the Need for Repeat Chest Radiograph after Penetrating Thoracic Trauma
Authors: Magnotti Louis J. , Weinberg Jordan A. , Schroeppel Thomas J. , Savage Stephanie A. , Fischer Peter E. , Bee Tiffany K. , Maish George O. , Minard Gayle , Zarzaur Ben L. , Croce Martin A. , Fabian Timothy C.
Published: June 2020

The use of serial chest radiographs (CXRs) to evaluate patients with penetrating thoracic trauma is common practice. However, the time interval between these studies and the duration of observation remains uncertain. The purpose of this study was to evaluate whether a noncontrast chest CT is as reliable as a 6-hour CXR for detecting delayed pneumothorax (PTX) after penetrating thoracic trauma. Hemodynamically stable patients with isolated penetrating thoracic trauma were prospectively evaluated with a CXR and a noncontrast chest CT. If there was no PTX or hemothorax, or a finding that did not require immediate intervention, a 6-hour CXR was obtained. Findings were treated as clinically indicated and patients were discharged if all three studies were negative. One hundred eighteen patients were evaluated (89 stab wounds and 29 gunshot wounds). All initial CXRs were negative. CT identified six PTXs and one hemothorax. Two patients required operative intervention. There were no delayed findings on CXR provided the CT was negative. The mean time to CT and before disposition was 19 minutes and 8 hours, respectively, with a potential decrease in charges of $313.32 per patient. The use of serial CXRs provided no additional information that was not available on the initial chest CT, allowing for expedited discharge, decompressing overcrowded emergency areas, and reducing the number of patients leaving before completion of their work-up.
Operative Fixation of Chest Wall Fractures: An Underused Procedure?
Authors: Richardson J. David , Franklin Glen A. , Heffley Susan , Seligson David
Published: June 2020

Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously without specific treatment. However, a small subset of patients have fractures that produce overlying bone fragments that may produce severe pain, respiratory compromise, and, if untreated mechanically, result in nonunion. We performed open reduction and internal fixation on seven patients with multiple rib fractures—five in the initial hospitalization and two delayed—as well as 35 sternal fractures (19 immediate fixation and 16 delayed). Operative fixation was accomplished using titanium plates and screws in both groups of patients. All patients with rib fractures did well; there were no major complications or infections, and no plates required removal. Clinical results were excellent. There was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with no complications occurring in this group. Three patients had their plates removed after boney union was achieved. No evidence of infection or nonunion occurred. The excellent results achieved in the subset of patients with severe chest wall deformities treated initially at our institution and those referred from outside suggest that operative fixation is a useful modality that is likely underused.
Prevention of Bile Peritonitis by Laparoscopic Evacuation and Lavage after Nonoperative Treatment of Liver Injuries
Authors: Franklin Glen A. , Richardson J. David , Brown Aaron L. , Christmas A. Britton , Miller Frank B. , Harbrecht Brian G. , Carrillo Eddy H.
Published: June 2020

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2–18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.
Mechanical Abrasion Improves Early Incorporation of Small Intestinal Submucosa
Authors: Rauth Thomas P. , Poulose B.K. , Davidson J.M. , Nanney L.B. , Holzman M.D.
Published: June 2020

It has been shown that gross incorporation of porcine-derived small intestinal submucosa (SiS) is limited at 2 weeks. This study evaluates a technique for improving the early incorporation of implanted eight-ply SiS. Six pigs underwent implantation of SiS on the peritoneal surface using three techniques: suture fixation of stock-perforated SiS, suture fixation of manually perforated SiS, and suture fixation of stock-perforated SiS to mechanically abraded peritoneum. Gross incorporation was evaluated and random samples harvested for tensiometric analysis 2 weeks after implantation. SiS placed onto mechanically abraded peritoneum demonstrated significantly greater gross incorporation than both stock-perforated SiS (100% versus 42%, P = 0.015) and manually perforated SiS (100% versus 50%, P = 0.042). There was no difference in gross incorporation between stock and manually perforated SiS. Using tensiometric analysis, the force required to separate the peritoneum from the SiS implant was significantly greater for the SiS placed onto mechanically abraded peritoneum (4.4 ± 1.7 kg · f/cm2) than for both the stock-perforated SiS samples (1.0 ± 0.5 kg · f/cm2) and the needle-perforated SiS samples (1.4 ± 0.9 kg · f/cm2; P < 0.001). There was no difference between stock and manually perforated SiS at 2 weeks. Mechanical abrasion of the peritoneum before SiS onlay leads to improved gross incorporation 2 weeks after implantation in a porcine model of herniorrhaphy. Long-term studies and histologic analysis are needed to validate this method as a means for improving early incorporation of SiS.
Central Line Simulation: A New Training Algorithm
Authors: Britt Rebecca C. , Reed Scott F. , Britt L.D.
Published: June 2020

Recent development of a partial task simulator for central line placement has altered the training algorithm from one of supervised learning on patients to mannequin-based practice to proficiency before patient interaction. There are little data published on the efficacy of this type of simulator. We reviewed our initial resident experience with central line simulation. Education to proficiency using the CentralLine Man simulator is completed by all interns during orientation. At the completion of training, te residents were asked to complete a voluntary, anonymous questionnaire with a 5-point Likert scale as well as open-ended questions. Additionally, the residents were asked to maintain a log of the initial 10 central lines placed. Retrospective review of the questionnaire and logs were done with analysis of simulator experience as well as initial line experience. Seventeen trainees completed the central line simulation course and returned the initial survey. Before the course, the trainees had placed an average of 0.4 internal jugular (IJ) and 1 subclavian (SC) line. On the simulator, an average of 3 SC attempts and 2.5 IJ attempts led to resident comfort with the procedure. On the first attempt, the vessel was accessed after an average of 1.5 SC and 1.9 IJ needlesticks, which improved to 1 SC and 1.3 IJ by the fifth simulated attempt. A total of 4 pneumothorax and 5 carotid sticks were done. Overall, the residents were highly satisfied with the course with an average score of 4.8 for didactics, 4.8 for equipment, 4.5 for the mannequin, and 4.8 for practice opportunity. Nine of the 11 residents who completed logs felt the simulation improved performance on the patient. On the first patient attempt, an average of 1.8 needlesticks was done with an average of 1.3 by the tenth line. For the first patient line documented in the logs, comfort with the anatomy was rated 3.8 with comfort with the procedure rated 2.8. Central line simulation before actual performance on patients is useful and well regarded by the trainees, suggestive of a transference effect. Prospective evaluation is needed to further determine the impact of simulation on resident performance as well as patient outcomes.
Severe Sepsis Attributable to Community-Associated Methicillin-Resistant Staphylococcus aureus: An Emerging Fatal Problem
Authors: Castaldo Eric T. , Yang Edmund Y.
Published: June 2020

We observed a number of cases of sepsis from bacteremia in children from community-associated methicillin-resistant Staphylococcus aureus (MRSA), which led us to study its patterns of infection and outcome. A retrospective review identifying children admitted to our institution with blood culture-proven community-associated MRSA sepsis over a 2-year period was performed. The inclusion criteria were younger than 19 years old, two or more blood cultures for MRSA within 48 hours of admission, evidence of systemic inflammatory response syndrome, and no prior hospital admissions within 6 months. Eight patients were included; seven required mechanical ventilation. Vasopressors were required in seven patients. Four patients required extra-corporeal membrane oxygenation. Four patients had culture-proven septic arthritis or thrombophlebitis and three of these patients developed bilateral necrotizing pneumonia. Bilateral necrotizing pneumonia was identified in the other four patients, but the primary source of infection was never identified. The overall intact neurologic survival was 50 per cent. Children with severe community-associated MRSA sepsis can rapidly progress to cardiorespiratory failure. Mortality appears to be high, and children may benefit from a search of their soft tissues and joints to identify the source of infection to prevent embolic dissemination.
Reproduction of Postprandial Symptoms with Cholecystokinin Injection: An Indication for Cholecystectomy without the Presence of Gallstones or an Abnormal Ejection Fraction on Quantitative Cholescintigraphy?
Authors: Cofer Joseph B. , Dart B.W.
Published: June 2020

Quantitative cholescintigraphy with cholecystokinin injection is commonly used to assess patients without evidence of cholelithiasis but with functional biliary pain. However, normal results may not always exclude the possibility of pathologic biliary disease. Retrospective review of prospectively collected data on eight patients with biliary colic, no evidence of cholelithiasis, a normal quantitative cholescintigraphy ejection fraction but with reproduction of their specific symptoms on cholecystokinin injection was performed. The mean ejection fraction was 66.2 per cent. All of these patients underwent cholecystectomy with complete resolution of their symptoms. Pathology was abnormal in all cases. Patients with symptoms suggestive of biliary disease with reproduction of these symptoms on cholecystokinin injection may benefit from cholecystectomy even in the absence of abnormally low ejection fraction on quantitative cholescintigraphy.
Hand Injuries as an Indicator of Other Associated Severe Injuries
Authors: Vossoughi Faranak , Krantz Brent , Fann Stephen
Published: June 2020

The purpose of this study was to investigate the incidence of disabling or life-threatening injuries in patients with hand injuries. Retrospective data were collected from a level 1 trauma center registry. A total of 472 patients with hand injuries were admitted to the trauma unit between January 2000 and March 2004. Forty-four per cent of patients with hand injuries had life-threatening injuries. Fifty-one per cent of them had motor vehicle crash-related injuries. Motorcycle crashes were the next most common cause followed by explosions, falls, gunshots, machinery, stabs, bites, crushes, and so on. Frequency of associated injuries was as follows: head injuries, 31 per cent, including skull fractures, 22 per cent; spine injuries, 18 per cent, including spine fractures 18 per cent; chest injuries, 36 per cent, including rib fractures, 15 per cent; and abdominal injuries, 13 per cent. The authors focused on the incidence of disabling or life-threatening injuries in patients with hand injuries. Motor vehicle crashes were most common cause of hand injuries. The most common organs to be injured were chest and head. The most common head injury was skull fracture. Other injuries in decreasing order were spine and rib fractures. These data may be helpful in assessing ambulatory patients in the emergency room, in those hand injuries maybe indicative of other simultaneous life-threatening or disabling injuries.
Total Abdominal Colectomy: Patient Satisfaction and Outcomes
Authors: Payne Jason A. , Snyder David C. , Olivier Jacob , Salameh Jihad R.
Published: June 2020

Total abdominal colectomy is required for many colonic diseases. The authors studied the outcomes of this operation and the quality of life based on the decision to perform an ileostomy or an anastomosis. Patients who underwent total abdominal colectomy (excluding those with inflammatory bowel disease and chronic constipation) had either ileoproctostomy or ileostomy and were compared. Patients were surveyed to assess satisfaction. Thirty-seven patients with ileo-proctostomy and 23 patients with ileostomy were identified. There were no significant differences between groups with regard to urgency of operation, preoperative and total blood units received, and preoperative hospital stay. Morbidity and mortality were higher in the ileostomy group (38 vs 57% and 5 vs 17%), with odds ratios of 2.14 and 3.68 respectively; this was not, however, statistically significant ( P = 0.157 and 0.132, power = 20% and 6%). All (14 of 14) surveyed ileostomy patients were at least satisfied versus 90 per cent (19 of 21) of ileoproctostomy patients. Of the latter, only 15 of 20 patients were continent, with 6.85 average daily bowel movements. Total abdominal colectomy has high morbidity and mortality rates. Performing an ileoproctostomy does not influence outcome but may lead to a high frequency of bowel movements and incontinence in some patients.
Thyroid Abscess: Case Report and Review of the Literature
Authors: Herndon Mark D. , Christie D. Benjamin , Ayoub Macram M. , Duggan A. Daniel
Published: June 2020

A thyroid abscess is an infrequently encountered condition with a rarity that is attributable to anatomic and physiologic characteristics of the gland that impart a unique quality of infection resistance. The differential diagnoses for a painful thyroid is limited, with subacute and chronic thyroiditis being the most often-encountered processes. Acute suppurative thyroiditis with abscess formation, although rare, is a formidable clinical scenario with morbid complications. Because the diagnosis of a thyroid abscess is often delayed in lieu of investigating other more common etiologies of thyroiditis, this disease entity may portend to a dismal clinical outcome. The authors report the case of a 53-year-old woman with a thyroid abscess yielding a single microbial isolate believed to be resultant from a urinary tract bacteremia. They also review the literature for discussion of abscess etiologies, presentations, and management strategies.
The Impact of Mild Renal Dysfunction on Postoperative Mortality in the Surgical Intensive Care Unit
Authors: Brandt Mary-Margaret , Falvo Anthony , Horst H. Mathilda
Published: June 2020

The negative impact of mild to moderate renal dysfunction on patient outcome is often underestimated. Any amount of renal dysfunction is deleterious in the surgical intensive care unit (SICU). We evaluated all surgery patients admitted to our SICU. We identified two groups of patients: no renal failure and acute renal failure. A total of 5152 patients were included in this study. There were 1259 patients in the acute renal failure group. The average number of ventilator days increased by 2.2 for every increase of creatinine by 1.0. Patients who required dialysis stayed an average of 11 days longer than patients who did not have any renal failure. For every increase of creatinine by 1.0, average cost increased by $23,048. Only 7 per cent of the patients with acute renal failure required dialysis (n = 85). The odds ratio for mortality compared with those patients without renal failure was 7.06 (confidence interval, 3.91–12.76) regardless of the definition of renal failure. This study demonstrates that even mild to moderate renal failure increases mortality. Moreover, we demonstrated that even a mild decline in renal function increases length of stay, ventilator days, and cost in patients in the SICU. Aggressive vigilance in the prevention of any loss of renal function is warranted in the SICU.
Superior Mesenteric Artery Syndrome in the Modern Trauma Patient
Authors: Adams John B. , Hawkins Michael L. , Ferdinand Coville H. , Medeiros Regina S.
Published: June 2020

In 1861, von Rokitansky described obstruction of the third part of the duodenum by external compression of the duodenum by the superior mesenteric artery (SMA). In 1926, this entity was furthermore described by Wilke in his presentation of 75 patients with “chronic duodenal compression”. In 1968, Mansberger used angiography to define anatomical measurements as the diagnostic criteria for this condition. Current modalities of diagnosis of SMA syndrome include esophagogastroduodenoscopy, computerized tomography angiogram, fluoroscopy, transabdominal ultrasound, and endoscopic ultrasound. The SMA syndrome has been associated with prolonged confinement in the supine position, loss of weight, loss of abdominal wall muscle tone, application of a body cast, and severe burns. With current surgical techniques allowing early ambulation, patients are able to avoid prolonged bed rest. The use of parenteral and enteral nutritional support has limited the loss of weight associated with trauma and burn patients, making this syndrome uncommon in this patient population. Recent reports of SMA syndrome focus on the association with corrective surgical procedures for scoliosis and obesity.
Ascending Colon Cancer in a Patient with Situs Inversus
Authors: Greene Quincy J. , Cheadle William G.
Published: June 2020

Presented during Poster Grand Rounds at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Savannah, GA, February 10–13, 2007.
Morbidity-Associated Factors after Gastrojejunostomy for Malignant Gastric Outlet Obstruction
Authors: Medina-Franco Heriberto , Abarca-Pérez Leonardo , España-Gómez Nayví , Salgado-Nesme Noel , Ortiz-López Laura J. , García-Alvarez Miriam N.
Published: June 2020

Palliative care of malignant gastric outlet obstruction symptoms is critical for improved quality of life. We reviewed 66 consecutive patients with malignant gastric outlet obstruction who underwent palliative gastrointestinal bypass. The objective was to analyze morbidity and mortality-associated factors of this surgical procedure. Surgical morbidity and mortality were 39 per cent and 31 per cent, respectively. Reintervention was necessary in 16.6 per cent of cases. The only variable associated with surgical mortality was a Karnofsky score less than 80 (P = 0.02). Median survival of patients was 4 months (range, 2.11–5.9 months). Variables associated with shorter survival rates were an advanced stage of the disease and a Karnofsky score less than 80. Nine of 45 (20%) patients who survived after the gastrointestinal bypass surgery were unable to tolerate a normal diet. Palliative gastrojejunostomy in patients with malignant gastric outlet obstruction is associated with high morbidity and mortality; it is necessary to improve nonsurgical options such as endoscopic stenting.
Eikenella Corrodens Causing Necrotizing Fasciitis after an Elective Inguinal Hernia Repair in an Adult: A Case Report and Literature Review
Authors: Miller Aaron T. , Byrn John C. , Divino Celia M. , Weber Kaare J.
Published: June 2020

We report an unusual case of necrotizing fasciitis in a 43-year-old man after elective inguinal hernia repair. The patient presented to the emergency department 9 days postoperatively with high fevers, tachycardia, and crepitus along his abdominal wall. He was treated with broad-spectrum antibiotics and underwent a diagnostic laparoscopy as well as a wide debridement of all necrotic tissue. Cultures grew out Eikenella corrodens, which, to our knowledge, has only been reported in one other case as a cause of necrotizing fasciitis. Patients can develop necrotizing fasciitis after elective, clean procedures and should be adequately resuscitated, undergo immediate surgical debridement, and receive antibiotics. Laparoscopy can be useful in determining if intraabdominal pathology is the cause of the infection and a wound vacuum-assisted device is a cost-effective way to decrease healing times.
A Giant Peritoneal Loose Body: Report of a Case
Authors: Mohri Tomomi , Kato Toshio , Suzuki Hiroshi
Published: June 2020

Peritoneal loose bodies are usually small, 0.5 to 2.5 cm in diameter, and rarely cause symptoms. However, “giant” peritoneal loose bodies, larger than 5 cm in diameter, presenting with various symptoms have been also reported. We report here a case of a “giant” peritoneal loose body found in a 73-year-old man. In this case, the peritoneal loose body was 9.5 cm in diameter, comparable to the largest one reported in the literature. The patient refused any treatment at his first visit but accepted surgical removal of the peritoneal loose body 5 years later. The size of the peritoneal loose body has increased from 7.3 cm to 9.5 cm in diameter during this observation period.
Glenohumeral Joint Ganglion Cyst and Other Rare Cysts of the Axilla
Authors: Fogelson Marc H. , Craig William D. , Mcphee Joseph R. , Lenert Jeffrey T. , Henry Leonard R.
Published: June 2020

Although ganglion cysts have been reported to arise from almost any joint, those arising from the glenohumeral joint producing an axillary mass are extremely rare. We report what we believe to be the eighth such case and describe its management. The unusual differential diagnosis and aids to diagnosis of axillary cysts are reviewed. Specific issues regarding axillary space ganglions are emphasized.
Antibiotic Therapy and Interval Appendectomy for Perforated Appendicitis in Children: A Selective Approach
Authors: Emil Sherif , Duong Son
Published: June 2020

The role of initial nonoperative treatment in pediatric perforated appendicitis remains controversial. We examined our outcomes after using this approach in a selective manner. Children with perforated appendicitis treated during a 28-month period were retrospectively reviewed. Antibiotics and delayed appendectomy were used if there were more than 3 days of symptoms, absence of bowel obstruction, absence of diffuse peritonitis, and an appendiceal mass. Of 221 patients with perforated appendicitis, 32 (14%) were treated with this approach. Average age was 7.4 ± 4.2 years. Twenty-eight patients (88%) were successfully managed and 26 (81%) underwent appendectomy 8.6 ± 4.2 weeks after first presentation. Two patients did not respond completely, and underwent appendectomy during the same admission. Two patients initially responded, but had recurrent symptoms necessitating earlier appendectomy. There were no complications. Average total hospital stay was 7.2 ± 3.0 days. Initial nonoperative treatment is highly successful in selected children who meet specific criteria. Failure is not associated with increased morbidity.
Esophagogastro-Roux-en-Y Jejunostomy: A Surgical Option in Recurrent Achalasia? Case Report and Review of the Literature
Authors: Roa Paul E. , Sesto Mark E.
Published: June 2020

Recurrent obstructive symptoms after cardiomyotomy for achalasia occur in approximately 10 per cent to 15 per cent of patients, but only some require reoperation. Reoperative procedures for achalasia vary, and in general, have less success in relieving symptoms than the initial procedure. We present the case of a 37-year-old male with a 15-year history of recurrent achalasia, with symptoms of heartburn and progressive dysphagia after meals. He underwent several esophageal dilatations, botox injections, and two transthoracic Heller myotomies before the transabdominal esophagogastro-Roux-en-Y jejunostomy was performed. This case represents another surgical option for management of the challenging problem of recurrent achalasia.
Completely Laparoscopic Nonanatomic Hepatic Resection Using Saline-Cooled Cautery and Hydrodissection
Authors: Nissen Nicholas N. , Grewal Navanjun , Lee Joseph , Nawabi Atta , Korman Jeremy
Published: June 2020

The technical aspects of laparoscopic hepatic resection have evolved rapidly. The key to any approach is establishing a reliable method to prevent or control hemorrhage during parenchymal transection. Although combining a hand-assist technique with laparoscopy allows improved control of bleeding risk, this requires the addition of a hand-port incision. The development of novel devices that can be used to safely divide liver parenchyma laparoscopically may lessen the need for hand-assist. Here, we report a series of laparoscopic hepatic resections that were attempted without the use of hand-assistance (completely laparoscopic). Resections were performed using saline-cooled cautery (Tissue-Link Endohook) and/or hydrodissection (Erbe Helix Hydrojet). Fifteen laparoscopic hepatic resections were attempted by a single surgeon from 2002 to 2006. In each case, a nonanatomic, completely laparoscopic approach was attempted. Patients with lesions at the hepatic dome or those requiring lobectomy or hilar dissection were excluded. Fourteen of 15 cases (93%) were accomplished completely laparoscopically, while one patient required placement of a hand port. Resected tumors averaged 3.9 cm diameter. There were no bile leaks and no patient required transfusion. Average length of stay was 4.1 days (range 1–5). Complications included ileus (1) and atrial fibrillation (1). In six patients with malignancies, margins were negative and there have been no local or port recurrences. This report demonstrates the feasibility of completely laparoscopic hepatic resection using novel devices for parenchymal transaction. Hand-assist techniques remain useful as a salvage strategy or for larger resections.
The Prevalence of Obesity and Postoperative Complications in a Veterans Affairs Medical Center General Surgery Population
Authors: Herrera Fernando A. , Yanagawa Jane , Johnson Amanda , Limmer Karl , Jackson Nancy , Savu Michelle K.
Published: June 2020

Patients who are obese are believed to be at greater risk of developing intraoperative and postoperative complications than their nonobese counterparts. Many studies have shown that there is a higher prevalence of obesity among the Veterans Affairs patient population. We performed a retrospective review of 941 patients presenting to a single Veterans Affairs Medical Center. We aimed to determine the incidence of obesity among the Veterans Affairs Medical Center general surgery patient population as well to compare the frequency of postoperative complications between patients who are obese and nonobese patients undergoing elective general surgery. Body mass index was calculated for all patients; of the 941 patients seen in the clinic, 547 underwent elective surgery. Thirty-three per cent of all clinic patients had a body mass index greater than 30 kg/m2. Twenty-eight per cent of patients who underwent surgery had a body mass index greater than 30 kg/m2. Postoperative complications developed among 5.5 per cent of all surgical patients; 23.3 per cent were obese and 76.7 per cent were nonobese. There was no statistically significant difference between these two groups ( P = 0.54). This study illustrates the increased prevalence of obesity among the Veterans Affairs Medical Center general surgery patient population. In addition, our study suggests that obesity is not an independent risk factor for postoperative complications in patients undergoing elective general surgery.
Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury
Authors: Salim Ali , Ottochian Marcus , Gertz Ryan J. , Brown Carlos , Inaba Kenji , Teixeira Pedro G.R. , Rhee Peter , Demetriades Demetrios
Published: June 2020

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.
Complications of Implanted Central Venous Catheters in Neutropenic Children
Authors: Elihu Arvand , Gollin Gerald
Published: June 2020

Although neutropenia is recognized as a risk factor for infection and compromised wound healing, there are little data regarding the specific impact of neutropenia on morbidity and mortality after placement of implanted central venous catheters (CVC). We conducted a retrospective review of children with a diagnosis of acute lymphocytic leukemia or aplastic anemia who received a CVC over a 5-year period. The absolute neutrophil count immediately before catheter placement was recorded. Three hundred eight catheters were placed in 195 patients with acute lymphocytic leukemia and 15 with aplastic anemia. Absolute neutrophil count was less than 0.5 x 109/L in 105 cases (Group 1). The incidence of CVC removal for all causes and for infection within 100 days in Group 1 was 17.1 per cent and 11.4 per cent, respectively, compared with 7.9 per cent ( P = 0.01) and 1.5 per cent ( P < 0.0001) with absolute neutrophil count 0.5 x 109/L or greater (Group 2). Infections included two cases of mucormycosis with one death. Ports were more likely than Hickman catheters (C. R. Bard Inc., Murray Hill, NJ) to be removed for all causes ( P = 0.01) and for infection ( P = 0.04). The placement of implanted central venous catheters in neutropenic children was associated with substantial infectious morbidity and one death. When possible, CVC, particularly ports, should be avoided in the presence of neutropenia.
Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: Experience in a Community Hospital
Authors: Davit Flavia E. , Cole Theresa , Helling Thomas , Tretter James
Published: June 2020

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66–82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multi-center study may eventually show this method to be helpful in patients who require repair of RAAA.
The Effect of Postoperative Aspirin on Random Pattern Flaps in Rats
Authors: Shalom Avshalom , Friedman Tal , Westreich Melvyn
Published: June 2020

Our laboratory has been studying the effect of aspirin, given alone or in combination with other medications, on random pattern skin flaps. We have consistently found that preoperative aspirin in high doses (200 mg/kg) increases flap survival, apparently as a result of its ability to modify the inflammatory reaction and/or direct vasodilatation, and not as a consequence of antiaggregation of platelets. In an effort to further elucidate how this effect is modulated, we designed this experiment in which we gave aspirin after the operative procedure to simulate an acute clinical surgical problem such as a failing or ischemic flap. Our results failed to show any difference between the rats that received postoperative aspirin and the untreated control group. It would appear that aspirin given postoperatively is not able to counteract the noxious elements that affect flap survival. This work indicates an important relationship between the timing of administration and the beneficial effects of aspirin. By investigating fully the mechanism whereby aspirin is able to improve flap survival, we hope to isolate this mechanism so an alternative pharmacological agent, safer than aspirin, can be found for clinical use.
Spontaneous Hepatic Hemorrhage in Older Women
Authors: Broughan Thomas A. , Walser Eric M.
Published: June 2020

Spontaneous liver hemorrhage in older women is not well described. We report an experience with five postmenopausal women who spontaneously bled from the liver. All five patients presented with acute bleeding. Four were treated nonoperatively. No tumor was identified in any patient. Four patients acutely were discharged alive and well, but one died after operation to control bleeding. Spontaneous liver hemorrhage can occur in a variety of clinical settings, but an association with older women taking hormone replacement and anticoagulation has not been reported.
Can Acute Appendicitis be Treated by Antibiotics Alone?
Authors: Liu Katherine , Ahanchi Sadie , Pisaneschi Mark , Lin Irene , Walter Robert
Published: June 2020

Emergency appendectomy at presentation has been the standard of care for acute appendicitis. We examined the use of antibiotics as an alternative treatment. From September 2002 to August 2003, 170 consecutive patients diagnosed with acute appendicitis without abscess were reviewed retrospectively. Patients were divided into two groups: Group I (n = 151) underwent emergency appendectomy and Group II (n = 19) received antibiotics alone. The mode of treatment was at the attending surgeon's discretion. The overall complication rate was eight per cent for Group I and 10 per cent for Group II patients ( P = 0.22). Group II patients suffered no complications during antibiotic treatment, and any complications that did occur developed after subsequent appendectomy. One Group II patient had recurrent appendicitis (5%). The length of stay was 2.61 ± 0.21 days for Group I and 2.95 ± 0.38 days for Group II patients ( P = 0.57). Patients with acute appendicitis may be treated safely with antibiotics alone without emergency appendectomy.
Anatomical Basis of Liver Hanging Maneuver: A Clinical and Anatomical in Vivo Study
Authors: Maria Ettorre Giuseppe , Douard Richard , Corazza Valerio , Santoro Roberto , Vennarecci Giovanni , Santoro Eugenio
Published: June 2020

Liver Hanging Maneuver (LHM) provides better exposure of the deeper section plane together with Inferior Vena Cava (IVC) protection during right hepatectomies without primary liver mobilization. This study assessed the feasibility and complication rates of LHM focusing on the anatomical distribution of the accessory hepatic veins in the retrohepatic portion of the IVC. From January 2002 to December 2005, LHM was planned in 49 consecutive major hepatectomies. The IVC retrohepatic portion was studied during the anhepatic phase in 17 liver transplantations with IVC preservation. The diameter and location of the vein openings were recorded after IVC division into nine portions. LHM was achieved in 47/49 patients (96%). Bleeding occurred in only one patient (2%) and did not entail procedure interruption. The anatomical study revealed a total of 86 veins present in 17 cases (5.18 ± 4 per patient) and classified them according to diameter (<3, 3 to 6, and >6 mm), as small (n = 40), medium (n = 29), and large (n = 17), respectively. Nine openings were found in the avascular channel for 6/17 (35%) patients (small n = 6, medium n = 3, large n = 0). LHM is a highly feasible procedure with minor bleeding risks due to the lower density and small diameter of short hepatic veins and caudate veins present in the avascular channel.
Article Commentary: Diagnosis and Management of Extremity Compartment Syndromes: An Orthopaedic Perspective
Authors: Konstantakos Emmanuel K. , Dalstrom David J. , Nelles Meghann E. , Laughlin Richard T. , Prayson Michael J.
Published: June 2020

More than 200,000 people in the United States are diagnosed annually with compartment syndrome. This condition is commonly established based on clinical parameters. Determining its presence, however, can be challenging in obtunded patients or those with an altered mental status. A delay in diagnosis and treatment of these injuries can result in significant morbidity. Surgical release of the enveloping fascia remains the acceptable standard treatment for compartment syndrome. This article reviews the evaluation and treatment of compartment syndrome.
Two-Stage Surgical Treatment of Unresectable Obstructive Rectal Cancer with Synchronous Hepatic Metastases
Authors: Tsimogiannis Konstantinos E. , Pappas-Gogos George K. , Nikas Konstantinos , Stefanaki-Nikou Stella , Gossios Konstantinos , Tsimoyiannis Evangelos C.
Published: June 2020

Unresectable obstructing rectal cancer with synchronous hepatic metastases is usually a fatal disease. This prospective study was scheduled to treat this difficult condition using a multimodal curative strategy combined with a two-stage surgical treatment. Patients with T4N2 or N3M1 rectal cancer and hepatic metastases underwent a two-stage surgical treatment; in the first stage, a decompressing colostomy plus radiofrequency ablation (RFA) in liver metastases. In the second stage, a colectomy was done with stoma closing and resection of superficial necrotic hepatic tumors, plus repetition of RFA in recurrent or new hepatic tumors. Four patients were included, with 1 to 8 (total 20) hepatic metastases, each <5 cm in diameter. In the first stage, two patients were operated on by open approach and two laparoscopically. All hepatic tumors were treated by RFA to produce at least a 1-cm tumor-free margin. After chemoradiation of the rectal tumor, the second stage of surgical treatment was successful in colectomies and stoma closing. Three had complete necrosis of hepatic tumors and one a recurrent tumor plus two new metastases treated by RFA. Two patients died 14 and 42 months after the first stage of surgical treatment, and the other two patients are alive. One of them is disease-free 54 months after the first stage and the other with new recurrence 52 months after the first stage of the procedure. The multimodal curative strategy for the treatment of unresectable obstructing rectal cancer with synchronous hepatic metastases, containing a two-stage surgical treatment with RFA of hepatic metastases and chemoradiation of the rectal tumor between the two stages of the procedure, is a promising method. A larger number of patients with long-term follow-up is necessary to confirm these findings.
Venous Thromboembolic Events in Hospitalized Trauma Patients
Authors: Azu Michelle C. , Mccormack Jane E. , Huang Emily C. , Lee Thomas K. , Shapiro Marc J.
Published: June 2020

Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolus and is a significant cause of morbidity and mortality in injured patients. Absolute risk factors for VTE development are poorly defined. This study aimed to elucidate and evaluate risk factors in a large, population-based trauma registry. The trauma registry for a 10-year period of a single county was examined. VTE risk factors in 10,150 adult patients treated in the county's five trauma centers and seven nontrauma centers were identified. χ2 and Student's t tests were used for statistical analysis. The incidence of VTE was low at 0.493 per cent. The rate was 0.096 per cent at nontrauma centers. Injury severity score (ISS), operative intervention, spinal cord injury, lower extremity fracture, and certain thoracic injuries were significant in VTE development. There were no differences in VTE rate by age, gender, injury mechanism, or admitting service. Hospital length of stay was doubled by VTE. The VTE rate at trauma centers was higher, which was expected, given the complexity of patients treated and higher ISS. Patients with ISS greater than 15, need for operation, spinal cord injuries, lower extremity fractures, and certain thoracic injuries are at risk for VTE.
Amyand Hernia: What Lies Beneath–A Proposed Classification Scheme to Determine Management
Authors: Losanoff Julian E. , Basson Marc D.
Published: June 2020

Acute appendicitis in a hernia sac occurs exceptionally. An 80-year-old male patient underwent emergency surgery for an incarcerated right inguinal hernia found to contain a gangrenous appendix. His brief improvement after an emergency herniotomy with appendectomy was followed by intestinal obstruction caused by advanced colon cancer. The unique features and individualized management of the four published types of Amyand hernia are reviewed. Rather than simply being an anatomical curiosity, Amyand hernias require individualized attention to decide how to manage both the appendix and the hernia. Clinical scrutiny, a high index of suspicion for surgical comorbidities, and a common sense approach may improve outcomes.