bluuebunny/crossref_metadata_2025 huggingface dataset:
Supervised Training of General Surgery Residents in Carotid Endarterectomy Performed on Awake Patients under Regional Block is Safe and Desirable
Authors: Stone Melvin E. , Kunjummen Binu J. , Moran Joseph C. , Wilkerson Donald K. , Zatina Michael A.
Published: November 2022

Previous studies have documented the safety and efficacy of general surgery residents and vascular fellows performing carotid endarterectomy (CEA) under the supervision of an attending surgeon. With the proper supervision of the attending surgeon, these operations can be performed with an acceptably low perioperative stroke and mortality rate. The question remains, however, whether these desirable results can be obtained by general surgery residents when operating on awake patients under regional block (RB) anesthesia. We set out to determine whether it is prudent to promote this technique in this teaching setting. We analyzed 128 CEAs performed at a community teaching hospital training three chief residents a year. These operations were performed by residents under the direct supervision of a single attending vascular surgeon. RB was preferred and was used in 67 operations. General anesthesia (GA) was used in the remaining 61 procedures. Overall mortality was 0 per cent. Patients in the RB group were converted intraoperatively to GA in 4 of 67 (6%) procedures. There was one perioperative stroke in this series (1/128, 0.78%), occurring in a patient under RB (1/67, 1.5 %) leaving the patient with a minor sensory deficit. No strokes occurred in the GA group. There were five temporary cranial nerve deficits (3.9%). Three were in the RB group (4.5%) and two in the GA group (3.3%). General surgery residents can be trained in the performance of carotid endarterectomy using regional block anesthesia in awake patients without compromising patient safety. Suggestions to the effect that only attending physicians and/or vascular fellows can perform these procedures under regional block are without merit.
Adenocarcinoma in a Hemorrhoidectomy Specimen: Case Report and Review of the Literature
Authors: Timaran Carlos H. , Sangwan Yash P. , Solla Julio A.
Published: November 2022

Our purpose is to report a case of unexpected anal adenocarcinoma found in a hemorrhoidectomy specimen. A review of the literature, with emphasis on extramucosal anal adenocarcinoma as a pathologic entity, is included. Our patient presented with a 2-year history of grade III prolapsing internal hemorrhoids. A hemorrhoidectomy was performed and gross examination of the specimen was unremarkable. The pathologic evaluation revealed microinvasive well-differentiated adenocarcinoma at the squamocolumnar junction. There was neither an apparent connection with the overlying mucosa nor an in situ component. A metastatic workup ruled out any other site of malignancy. At follow-up 18 months after surgery, no evidence of malignancy or recurrence was observed. An unexpected extramucosal anal adenocarcinoma in a hemorrhoidectomy specimen is a very exceptional finding. Review of the literature does not support routine histopathological examination of hemorrhoidectomy specimens.
Enoxaparin Associated with Huge Abdominal Wall Hematomas: A Report of Two Cases
Authors: Antonelli Darrin , Fares Louis , Anene Charles
Published: November 2022

Enoxaparin is a low-molecular-weight heparin used for prophylaxis against deep venous thrombosis. Indications include hip and knee replacement surgery, risk of deep venous thrombosis during abdominal surgery, and prevention of ischemic complications of unstable angina and non-Q-wave myocardial infarction. Its efficacy in the prevention of the above complications has been previously studied; however, the liberal use of enoxaparin is not without incident. Complications of enoxaparin include hemorrhage, thrombocytopenia, and local reactions. Since 1993 there have been more than 40 reports of epidural or spinal hematoma formation with the concurrent use of enoxaparin and spinal/epidural anesthesia or spinal puncture. Herein reported are two cases of abdominal wall hematomas in patients receiving prophylaxis with enoxaparin. Both patients sustained an unexplained fall in the hematocrit and abdominal pain. A CT scan confirmed the diagnosis. One patient recovered uneventfully; however, the other patient, on chronic hemodialysis, became hemodynamically unstable and hyperkalemic and sustained a fatal cardiac arrhythmia. An extensive review of the literature revealed no similar cases of abdominal wall hematomas associated with enoxaparin although other complications, including spinal and epidural hematomas, psoas hematomas, and skin necrosis have been reported. The extended use of enoxaparin as an anticoagulant requires the physician to be vigilant of these rare complications. Bleeding can occur at any site during therapy with enoxaparin. An unexplained fall in the hematocrit or blood pressure should lead to a search for a bleeding site.
Surgery in the Nineties
Authors: Rigberg David , Cole Michael , Hiyama Daryl , Mcfadden David
Published: November 2022

The population of the United States is aging, and by 2020 it is estimated that 16 per cent of U.S. citizens will be over 65 years of age. Little has been published about the results of surgery in nonagenarians but mortality rates of 45 per cent are reported. Given recent improvements in perioperative care we reviewed the experience with major general surgical operative procedures in nonagenarians. We reviewed the charts of patients greater than or equal to 90 years of age who underwent general surgical procedures at UCLA Medical Center since 1986. No patients were excluded. Thirty-two patients were identified. Most (87.5%) patients had significant premorbid conditions. The most common diagnoses were cancer (12), incarcerated hernia (seven), trauma (three), colonic volvulus (two), and cholecystitis (two). Overall perioperative mortality was 9.4 per cent (3 of 32). Twenty-two surgeries (69%) were performed on an emergency basis, and all three deaths were in this group (13.6%). Overall morbidity rate was 57 per cent. Mean intensive care unit stay was 4.8 days. Most patients were discharged home. Our findings support the perioperative safety of elective general surgery in nonagenarians (0% mortality and 20% morbidity). We also found an acceptable risk (13.6% mortality and 68% morbidity) for emergency procedures despite significant comorbid conditions. Most of the patients had acceptable functional outcomes.
Endoscopic Ultrasound Does Not Accurately Assess Pathologic Stage of Esophageal Cancer after Neoadjuvant Chemoradiotherapy
Authors: Beseth Bryce D. , Bedford Rudolph , Isacoff William H. , Holmes E. Carmack , Cameron Robert B.
Published: November 2022

The accuracy of endoscopic ultrasound (EUS) for initial staging of esophageal cancer is widely accepted. There is, however, considerable variability in the reported accuracy of EUS for restaging of esophageal neoplasms after neoadjuvant therapy. From June 1995 through December 1999, we prospectively studied a series of 26 patients who underwent neoadjuvant treatment for esophageal cancer and were subsequently restaged by EUS before resection. Twenty-four patients had adenocarcinoma (92%), and two patients had squamous cell carcinoma (8%). EUS correctly predicted tumor stage in seven of 26 patients for an overall accuracy of 27 per cent. EUS overestimated the depth of tumor penetration in 18 patients (69%) and underestimated depth of penetration in one patient (4%). Lymph nodes were correctly staged in 15 of 26 patients for an overall accuracy of 58 per cent. Levels of sensitivity for detecting N0 and N1 disease were 44 per cent and 80 per cent respectively. Patients with a complete pathologic response were staged as T4N1 (one patient), T3N1 (three patients), T3N1 (one patient), and T2N1 (two patients). EUS cannot distinguish tumor involvement of the esophageal wall and lymph nodes from the postinflammatory changes that characterize effective neoadjuvant treatment. EUS is of limited utility in guiding clinical decision making after neoadjuvant therapy.
Splenectomy for Splenic Metastases: A Changing Clinical Spectrum
Authors: Lee Steven S. , Morgenstern Leon , Phillips Edward H. , Hiatt Jonathan R. , Margulies Daniel R.
Published: November 2022

Splenic metastases from solid tumors are unusual with only scattered case reports of patients treated with splenectomy before 1987. We conducted a retrospective chart review at our large tertiary-care private teaching hospital between January 1990 and September 1999 and found splenic metastases in 31 patients. In eight patients (26%), the spleen was the only site of metastatic disease. Of the 31 splenectomies for metastases, 23 were performed for ovarian neoplasms, five during primary operative procedures, and 18 during secondary cytoreductive procedures or explorations for late recurrences at an average of 3.9 years after the original operation. Nearly half of the metastases (15 of 31) appeared entirely within the splenic parenchyma, representing probable hematogenous spread, whereas seven involved both the splenic parenchyma and capsule and nine involved the capsule only. Between 1990 and 1999 we identified a statistically significant increase in use of splenectomy for treatment of metastatic tumor with a Spearman rank correlation value of 0.86 ( P < 0.05). Most of this increase was attributable to ovarian cancer cases and may be due to expansion of treatment options or improved imaging methods. We report the largest series of splenectomy for splenic metastases and the ninth case report in the world literature of splenectomy for isolated splenic metastasis due to colorectal cancer.
Laparoscopic Port Sites do not Require Fascial Closure when Nonbladed Trocars are Used
Authors: Liu Carson D. , Mcfadden David W
Published: November 2022

The development of nonbladed obturators with integrated stability sleeves allows for creation of a muscle-splitting dilated laparoscopic port site with minimal abdominal wall defects after removal of trocar sleeves. Our objective was to determine the safety of using nonbladed obturators and not closing laparoscopic fascial port sites. Seventy patients underwent various laparoscopic procedures including the following: seven laparoscopic Roux en Y gastric bypasses, 21 laparoscopic cholecystectomies, 23 laparoscopic hernia repairs, 10 laparoscopic Nissen fundoplications, two laparoscopic appendectomies, two laparoscopic liver biopsies, one laparoscopic common bile duct exploration, one laparoscopic jejunal resection, one laparoscopic low anterior resection, one laparoscopic splenectomy, and one bedside diagnostic laparoscopy. A total of 180 laparoscopic port sites did not undergo fascial closure involving 110 10- to 12-mm ports. One hundred eighty nonbladed trocars were inserted without complication during laparoscopic surgery. In all cases the nonbladed obturator did not cause bleeding or injure viscera. Upon removal of large laparoscopic ports, the fascial defect was less than 6 to 8 mm, and the muscles of the abdominal wall covered the port site defect. The anterior fascial defect did not line up with the posterior fascial defect after removal of CO2 insufflation. No patients have developed ventral incisional hernias in the postoperative period (median follow-up of 11 months). We conclude that the use of nonbladed laparoscopic trocars is a safe technique with the ability to visualize dissection through the abdominal wall layers to create the smallest port dissection without bleeding or cutting muscle fibers. The ability to split the abdominal wall musculature allows the surgeon to forego closure of the small fascial defect.
Blunt Chest Trauma in the Elderly Patient: How Cardiopulmonary Disease Affects Outcome
Authors: Alexander Jason Q. , Gutierrez Charles J. , Mariano Myron C. , Laan Thomas Vander , Gaspard Donald J. , Carpenter Catherine L. , Stain Steven C.
Published: November 2022

Blunt trauma patients with rib fractures have significant risk of morbidity and mortality. The risk of complications increases with age and cardiopulmonary disease. We reviewed our experience at a community hospital Level II trauma center over a 5-year period. A review of the trauma registry revealed 62 patients over the age of 65 with multiple rib fractures and no associated injuries. Thirty-one patients with cardiopulmonary disease (CPD+) were compared with 31 patients without cardiopulmonary disease (CPD-). Charts were reviewed for morbidity, mortality, the need to upgrade level of care (readmission to the hospital or intensive care unit), and length of hospitalization. Complications occurred in 17 of 31 CPD+ patients and in four of 31 CPD- patients ( P < 0.001). The only three deaths were in CPD+ patients. Ten CPD+ patients and four CPD- patients required an upgrade in the level of care ( P < 0.05). The CPD+ patients had longer hospitalization than the CPD- patients: 8.5 versus 4.3 days ( P < 0.05). We conclude that elderly patients with multiple rib fractures and cardiopulmonary disease are at significant risk for complications that result in readmission to the hospital and intensive care unit and prolonged length of hospitalization. Admission to the intensive care unit with attention to cardiac and pulmonary status upon transfer to the ward is warranted.
New Epidemiology for Postoperative Nosocomial Infections
Authors: Wallace William C. , Cinat Marianne E. , Nastanski Frank , Gornick Wendi B. , Wilson Samuel E.
Published: November 2022

Changes in health care delivery systems over the last decade have resulted in a major increase in outpatient surgery and a higher severity of illness for inpatients. We sought to determine the effects of this change on the epidemiology of postoperative surgical infections. Historical data on incidence and epidemiology of infection were obtained from peer-reviewed articles published between 1960 and 1999 (MEDLINE). All nosocomial infections in 5035 patients admitted to a tertiary-care university hospital surgical intensive care unit between January 1994 and December 1997 were prospectively identified and classified as wound, urinary tract, bloodstream, or pneumonia. Incidence of bacterial isolates at each site was also recorded. From these data we determined infection rates per 100 admissions. We also identified all device-related nosocomial infections and calculated infection rates. Comparisons between time periods were made. In the 1960s wound infections constituted the predominant postoperative infection at 46 per cent. This was replaced by urinary tract infection in the 1970s (44%) and 1980s (32%) and closely followed by bloodstream infections (25%). In the 1990s nosocomial pneumonia became the most common postoperative infection, comprising 43 per cent of surgical intensive care unit infections. Analysis of the bacteriology also revealed changing trends with primarily Gram-positive organisms in the 1960s followed by an increase in methicillin-resistant Staphylococcus in the 1970 to 1980s, and currently resistant Gram-negative bacteria predominate. The incidence of fungal infections has steadily increased. This survey identified a new epidemiology for postoperative surgical infections. Over the last several decades the reported wound infections have been markedly decreased and there is little change in urinary tract infection. Nosocomial pneumonia with resistant Gram-negative bacteria now predominates along with increased incidence of fungal infections. Currently, postoperative infections are now more severe, involve critical organs, and require close monitoring of the changing patterns of pathogens.
Extracorporeal Membrane Oxygenation for Cardiac Support in Pediatric Patients
Authors: Mehta Umang , Laks Hillel , Sadeghi Ali , Marelli Daniel , Odim Jonah , Alejos Juan , Kim Mina , Atkinson James B. , Bui Kim Chi
Published: November 2022

Extracorporeal membrane oxygenation (ECMO) has been used for pediatric cardiac support in settings of expected mortality due to severe myocardial dysfunction. We reviewed the records of 34 children (<18 years) placed on ECMO between March 1995 and May 1999. Demographic, cardiac, noncardiac, and outcome variables were recorded. Data were subjected to univariate analysis to define predictors of outcome. Eighteen patients were placed on ECMO after cardiac surgery (Group A); seven of 18 were weaned off ECMO, and four survived to discharge (22%). Thirteen patients were placed on ECMO as a bridge to cardiac transplantation (Group B), six of 13 received a heart transplant, one recovered spontaneously, and six survived to discharge (46%). Three patients were placed on ECMO for failed cardiac transplantation while awaiting a second transplant (Group C); one recovered graft function, two received a second heart transplant, and two of three survived (66%). The primary cause of death was multiorgan system failure (68%). Group A patients supported on ECMO for more than 6 days did not survive. Mediastinal bleeding complications and renal failure requiring dialysis were associated with nonsurvival. We conclude that ECMO as a bridge to cardiac transplant was more successful than ECMO support after cardiotomy. Mediastinal bleeding and renal failure were associated with poor outcome. Recovery of cardiac function occurred within the first week of ECMO support if at all. Longer support did not result in survival without transplantation.
Nuclear Factor κB Activation in Acute Appendicitis: A Molecular Marker for Extent of Disease?
Authors: Connie Pennington , Julie Dunn , Chauanfu Li , Tuanzhu Ha , William Browder
Published: November 2022

Nuclear factor-κB (NF-κB) has been demonstrated to regulate the transcription of target genes and stimulate inflammatory cytokine responses in a variety of inflammatory diseases. Preliminary studies have demonstrated that NF-κB is activated early in acute inflammation and sepsis and may serve as an indicator of clinical severity. The present study was designed to evaluate the degree of activation of NF-κB in patients with acute appendicitis and correlate activation with clinical extent of disease. Ten patients with acute appendicitis and five control patients (elective inguinal hernia repair) were evaluated by assaying NF-κB activity preoperatively and 12 to 18 hours postoperatively. Assaying of NF-κB was determined by binding activity for consensus probes in nuclear extracts from peripheral mixed white blood cells obtained by venous puncture. The bands of NF-κB activity from gel electrophoresis were quantified with a phosphor imager and reported as units of integrated intensity. The preoperative NF-κB activity was increased in all patients with appendicitis versus the controls [mean 151 (range 97—189) vs mean 50.3 (range 13.7—77); P < 0.0001]. The increased NF-κB activity also correlated with length of time of symptoms before operation. The patients who were symptomatic for less than 24 hours had an average NF-κB value of 103 (range 97—105) versus 171.4 (range 152–189) ( P < 0.0001) in those who were symptomatic 24 or more hours. The NF-κB activity did not correlate with the white blood cell count. Postoperative NF-κB binding activity in the appendicitis patients dropped to minimal levels (mean 50.3), even lower than the control patients’ baseline values (mean 55.6). Control patients demonstrated low baseline values preoperatively and a slight rise postoperatively [mean 50.3 (range 13.7—77) vs mean 100 (range 45–186)]. We conclude the following: (1) NF-κB binding activity is elevated in patients with acute appendicitis and correlates with symptoms longer than 24 hours. (2) This increased activity returns to baseline values within 18 hours after appendectomy. (3) Molecular indicators of inflammation may have a role in both staging surgical inflammatory conditions and predicting ultimate outcome.
Ultrasound-Guided Thrombin Injection of Iatrogenic Femoral Pseudoaneurysms: A Prospective Analysis
Authors: Wendy R. Sackett , Spence M. Taylor , Coffey Cindy B. , Viers Kelly D. , Langan Eugene M. , David L. Cull , Bruce A. Snyder , Timothy M. Sullivan
Published: November 2022

An adverse consequence of the use of the femoral artery for the endovascular evaluation and treatment of arterial disease is the increased incidence of iatrogenic femoral pseudoaneurysms. Although surgical repair has traditionally been used to treat such aneurysms, less invasive modalities have emerged. The purpose of this study is to prospectively evaluate ultrasound-guided thrombin injection (UGTI) for the treatment of iatrogenic femoral pseudoaneurysms. A treatment protocol was approved and 30 stable patients (21 female; age range 43–85 years; mean 67 years) were prospectively enrolled from December 1997 through June 1999 to undergo UGTI on 30 iatrogenic femoral pseudoaneurysms. Pseudoaneurysms occurred after cardiac intervention (n = 22, 73%), peripheral intervention (n = 7,23%), and after a femoral line placement (n = 1,3%). They ranged in size from one to 5 cm with a time interval from intervention until UGTI of one to 132 days (median 3 days). Eleven patients (37%) were systematically anticoagulated at the time of UGTI. All pseudoaneurysms were treated using sterile technique and local anesthesia with ultrasound-guided injection via a 20-gauge spinal needle of 0.1 to 2 cm3 (median 0.6 cm3) of 1000 units/cm3 topical thrombin solution administered by one of six physicians. A period of bedrest for 4 to 6 hours after injection was followed by repeat groin duplex scan at 24 hours and a clinical follow-up at 30 days. There were no procedural deaths or nonvascular complications. Twenty-seven (90%) UGTIs resulted in successful pseudoaneurysm ablation with no recurrences at 24 hours or 30 days. Two (7%) UGTIs failed and one (3%) femoral artery embolic complication occurred; all were successfully treated with surgery. Success appeared to be independent of anticoagulation status, pseudoaneurysm age, size, or operator experience. We conclude that UGTI is a safe, easy, well-tolerated and effective noninvasive method for treatment of iatrogenic femoral pseudoaneurysms and should be considered in all stable patients before operative repair.
An Unusual Case of Corneal Perforation Secondary to Pseudomonas Keratitis Complicating a Patient's Surgical/Trauma Intensive Care Unit Stay
Authors: Johnson Maj Jeffery L. , Scott G. Sagraves , Feild Carinda J. , Block Ernest F.J. , Michael L. Cheatham
Published: November 2022

We report a case of corneal perforation secondary to bacterial keratitis caused by Pseudomonas aeruginosa in a trauma patient in our intensive care unit. A 43-year-old man was involved in a motorcycle crash and suffered multiple injuries necessitating a prolonged intensive care unit (ICU) stay. Subsequently P. aeruginosa was cultured from his sputum, blood, and open abdomen. He developed a bacterial keratitis in his right eye, which also grew P. aeruginosa. This infection rapidly progressed to corneal perforation requiring a Gunderson conjunctival flap and lateral tarsorrhaphy in addition to aggressive antibiotic treatment. At the time of discharge from the hospital the patient had the return of vision to light only in his right eye. Corneal perforation is an unusual event in the ICU. Prevention or early detection of bacterial keratitis with aggressive antibiotic treatment is needed to prevent such complications. Pseudomonas is one of the more virulent organisms that can infect the cornea and early identification is paramount for a good outcome. Management of this complicated case is discussed and the limited amount of literature on nosocomial bacterial keratitis in the ICU is reviewed.
Ultrasound-Guided Percutaneous Thrombin Injection for Femoral Artery Pseudoaneurysms
Authors: Daniel Mccoy , Ben Scharfstein , William Walker , James Evans
Published: November 2022

We reviewed 13 cases of ultrasound-guided thrombin injection of femoral pseudoaneurysms. All cases occurred within a 17-month period from January 1998 through May 1999 and were complications of femoral artery puncture. Immediate total thrombosis occurred in nine of 13 patients. Twenty-four-hour follow-up ultrasound in seven patients revealed no recurrence of pseudoaneurysm. Two of 13 patients required operative repair. One pseudoaneurysm thrombosed with 15 minutes of compression after injection and one case required a second injection. No cases of arterial thrombosis were noted. Ultrasound-guided thrombin injection for femoral artery pseudoaneurysm represents a safe and effective alternative to operative repair.
Effect of Fibrin Glue on Lymphatic Drainage after Modified Radical Mastectomy: A Prospective Randomized Trial
Authors: Robert C. Dinsmore , James A. Harris , Robert J. Gustafson
Published: November 2022

Fibrin as a tissue sealant has been used since the turn of the century for hemostasis. The development of cryoprecipitate and the resultant availability of higher concentrations of fibrinogen have led to a resurgence of interest in this material. Fibrin glue has since been shown to be effective for numerous applications throughout the field of surgery. Animal studies have shown fibrin glue to be effective at reducing drain output after mastectomy. Human studies, however, have been equivocal. Our objectives were to determine whether the use of fibrin glue would decrease lymphatic drainage after modified radical mastectomy and subsequently reduce time to drain removal. A prospective randomized trial was conducted consisting of 27 women. All women received modified radical mastectomy. At the completion of the mastectomy they were randomized to receive either standard closure or the application of fibrin glue before standard closure. Patients were then monitored for daily drain output, time to drain removal, and wound complications. A total of 14 women received fibrin glue and 13 received no glue. Those patients receiving fibrin glue had a significantly higher average drain output than patients who did not receive glue (1308 vs 754 cm3; P = 0.012). Time to drain removal was also increased by 4 days, although this did not reach statistical significance. The overall complication rate was higher for the fibrin glue group, although again, this did not reach significance. The application of fibrin glue significantly increased drain total drain output after modified radical mastectomy. Time to drain removal was increased as was the complication rate. On the basis of these data fibrin glue cannot be recommended for routine use in modified radical mastectomy.
Eosinophilic Gastroenteritis Mimicking Acute Appendicitis
Authors: Tran De , Salloum Leslie , Tshibaka Cimenga , Robert Moser
Published: November 2022

Eosinophilic gastroenteritis is a rare entity that can be treated successfully with glucocorticoid therapy if the appropriate diagnosis is made. However, it may present with symptomatology mimicking acute surgical conditions. We present the case of a 26-year-old man who presented with diffuse epigastric pain, nausea, vomiting, and diarrhea. Extensive workup including upper endoscopy and imaging study revealed gastritis with ulcer and ascites. The patient developed right lower quadrant pain with localized peritonitis and leukocytosis. He underwent appendectomy and small bowel biopsy. Pathology revealed eosinophilic cellular infiltrate of both the appendiceal and small intestinal wall. The unique features of this condition are reviewed and surgical approaches are discussed.
Focused Examination of Sentinel Lymph Nodes Upstages Early Colorectal Carcinoma
Authors: Wood Thomas F. , Tsioulias George J. , Morton Donald L. , Rangel Decio , Hutchinson William , Foshag Leland J. , Turner Roderick R. , Bilchik Anton J.
Published: November 2022

Approximately 30 per cent of patients with early colorectal carcinoma (CRC) develop systemic disease. A subgroup of these patients may harbor occult micrometastatic disease and might benefit from adjuvant chemotherapy. We investigated sentinel lymph node (SLN) mapping and focused pathologic examination of the SLN as a means of detecting nodal micrometastases. Between 1996 and 2000 SLN mapping was performed in 50 consecutive patients undergoing colectomy for CRC. All lymph nodes in the resection specimen were examined via routine hematoxylin and eosin (H&E) staining. In addition multiple sections of each SLN were examined via both H&E and cytokeratin immunohistochemistry. At least one SLN was identified in 47 patients (94%). In seven patients (14%) SLN mapping identified aberrant drainage that altered the planned resection. The SLN(s) correctly predicted nodal basin status in 44 of 47 (94%) cases; there were three falsely negative SLNs. Sixteen cases had positive SLNs by conventional H&E staining. An additional 10 (20%) cases were upstaged by a focused examination of the SLNs. Micrometastases were identified in three cases by H&E staining of multiple sections of the SLN and in seven only by cytokeratin immunohistochemistry. In nine cases the SLN was the only node containing tumor cells. In this study, SLN mapping demonstrated aberrant nodal drainage patterns that altered the surgical resection in patients with CRC. Focused examination of SLNs may detect micrometastases missed by conventional techniques and thereby identify patients who might benefit from adjuvant therapy.
Multiple Ectopic Parathyroid Glands
Authors: Maxwell Robert , Carter W. Bradford , Smith Ray M. , Perry Roger R.
Published: November 2022

Parathyroid surgery to correct primary hyperparathyroidism is successful in 80 to 97 per cent of initial explorations. Failures are often linked to inability to locate ectopic parathyroid glands. Although ectopic parathyroid glands are relatively common (15%) multiple ectopic glands are rarely reported. We describe a case of multiple ectopic parathyroid glands and the intraoperative approach to their localization and review the anatomy and embryology of ectopic parathyroid glands. A 39-year-old woman presented with fatigue, lethargy, and depression. On biochemical evaluation she was noted to be hypercalcemic and hyperparathyroid. Preoperative parathyroid localization failed to identify abnormal parathyroid glands. At exploration three of four parathyroid glands, including an adenoma, were located in ectopic positions by a meticulous and systematic dissection. A careful exploration coupled with a thorough knowledge of parathyroid anatomy and embryology will produce successful surgical correction of primary hyperparathyroidism in greater than 95 per cent of patients even in the few patients with multiple ectopic parathyroid glands.
Adult Respiratory Distress Syndrome Occurring in Two Patients Undergoing Cytoreductive Surgery plus Perioperative Intraperitoneal Chemotherapy: Case Reports and a Review of the Literature
Authors: Alonso Oscar , Sugarbaker Paul H.
Published: November 2022

Cytoreductive surgery and perioperative intraperitoneal chemotherapy with mitomycin C and 5-fluorouracil may be considered as an accepted treatment for appendiceal malignancy with mucinous peritoneal carcinomatosis or for pseudomyxoma peritonei. This aggressive approach has been successfully utilized in approximately 500 patients with an acceptable mortality (1.5%) and morbidity (27%). Although pulmonary complications are frequently recorded, life-endangering acute respiratory failure in the absence of pulmonary infection or an obvious source of systemic sepsis has not been previously described. An extensive clinical review of two patients who had a clinical course compatible with acute respiratory distress syndrome without obvious cause except for the cytoreductive surgery and perioperative intraperitoneal chemotherapy itself was undertaken. These two patients developed gradually increasing respiratory distress in the postoperative period. No bacterial or fungal infections of lungs or intra-abdominal sites or sepsis were discovered. These two patients were unusual in that they had extensive cytoreduction, maximal heat with the mitomycin C chemotherapy, and perfusion of both the abdominal cavity and the right pleural space. Reoperation in both patients failed to show a septic source within the abdomen for progressive adult respiratory distress syndrome. We conclude that aggressive cytoreductive surgery plus perioperative intraperitoneal and intrapleural chemotherapy was associated with life-endangering respiratory failure in two patients. No other cause for this condition was evident from an exhaustive review of the clinical course of these two patients. It is possible that this aggressive approach to appendix malignancy with carcinomatosis is sufficiently traumatic to be considered a cause of adult respiratory distress syndrome.
Severe Necrotizing Mastopathy Caused by Calciphylaxis Alleviated by Total Parathyroidectomy
Authors: Patetsios Peter , Bernstein Michael , Kim Sanghyun , Mushnick Robert , Alfonso Antonio
Published: November 2022

Calciphylaxis is a complication caused by secondary hyperparathyroidism in patients with chronic renal failure. These patients may present with clinical findings of ischemic necrosis involving the skin and muscle resulting in subsequent gangrene and vascular calcifications. We report a rare case of necrotizing mastopathy caused by calciphylaxis in a 70-year-old female with end-stage renal disease whose symptoms resolved with a total parathyroidectomy.
Twenty-Five-Year Surgical Experience with Pheochromocytoma in Children
Authors: Reddy V. Seenu , O'Neill James A. , Holcomb George W. , Neblett Wallace W. , Pietsch John B. , Morgan Walter M. , Goldstein Richard E.
Published: November 2022

Our objective was to analyze the presentation, diagnostic localization, operative management, histology, and long-term outcome of a single center's experience with pheochromocytomas in children. A chart review was done to identify all operatively managed pheochromocytomas in patients age 18 years or younger. Open and laparoscopic cases were included. We reviewed the presentation, diagnostic imaging, localization, operative management, pathology, and postoperative outcome of these patients. Clinic visits, contact with the tumor registry, and telephone interviews were used for follow-up. From 1973 through 1999, there were 11 children (four males and seven females) with 14 pheochromocytomas. Two (18.2%) patients had bilateral adrenal lesions and one patient had both adrenal and extra-adrenal tumors. Six (54.5%) patients had extra-adrenal lesions. The average age at operation was 14.7 years (range 9–18 years). Nine (82%) patients had significant hypertension at presentation. CT was used to localize the tumor in eight patients and urine catecholamine levels were used to confirm the diagnosis. Two of the cases were associated with inherited syndromes (multiple endocrine neoplasia 2A and von Hippel-Lindau). Ten patients underwent an open operation and one patient had a laparoscopic resection. The average patient follow-up was 9.2 years (range 9 months to 25 years). There were no operative complications and all patients were alive and well at the time of last follow-up. Three patients (27.2%) had tumors with microscopic malignant features. No tumors recurred or had evidence for metastatic spread. We conclude that peak incidence of pheochromocytomas in children is in early adolescence. Resection can be carried out safely with minimal morbidity and mortality. Current best management of this entity includes establishment of a biochemical diagnosis, adequate preoperative blockade, appropriate imaging, and an individualized operative approach based on tumor location and size.
Extremes of White Blood Cell Count do not Independently Predict Outcome among Surgical Patients with Infection
Authors: Raymond Daniel P. , Crabtree Traves D. , Pelletier Shawn J. , Gleason Thomas G. , Banas Lauren E. , Patel Shefali , Pruett Timothy L. , Sawyer Robert G.
Published: November 2022

Historically patients with severely depressed or elevated white blood cell (WBC) counts during infection were felt to have worse outcomes. To test this assumption we prospectively analyzed all infections on the surgical services at the University of Virginia hospital between December 1, 1996 and April 1, 1999. Among 1737 infectious episodes 59 presented with leukopenia (WBC count ≤ 3,000 cells/μL) whereas 66 presented with leukemoid responses (WBC count ≥ 30,000 cells/μL). Compared with other infected patients leukopenic patients had higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (18 ± 0.9 vs 12 ± 0.2, P < 0.0001) and mortality (23.7% vs 11.4%, P = 0.004). Patients with leukemoid responses also had higher APACHE II scores (21 ± 1.0 vs 12 ± 0.2, P < 0.0001) and mortality (30.3% vs 11.4%, P < 0.0001). Compared with a control group randomly matched (2:1) by age and APACHE II score, however, there was no significant difference in mortality associated with leukopenia or a leukemoid response. Furthermore logistic regression did not reveal leukopenia or leukemoid responses to be independent predictors of mortality (odds ratio for death with leukopenia = 1.57, 95% confidence interval = 0.63–3.91, P = 0.33; odds ratio for death with leukemoid response = 1.19, 95% confidence interval = 0.70–2.02, P = 0.53). Although very low or very high WBC counts may represent markers of severe illness in infected surgical patients they do not appear to be significant contributors to a worsened outcome.
The Evaluation of Subatmospheric Pressure and Hyperbaric Oxygen in Ischemic Full-Thickness Wound Healing
Authors: Fabian Thaddeus S. , Kaufman Henry J. , Lett E. Dwayne , Thomas Jeffrey B. , Rawl D. Kirkland , Lewis Patricia L. , Summitt J. Blair , Merryman Joyce I. , Schaeffer Dorcas , Sargent Larry A. , Burns R. Phillip
Published: November 2022

We evaluated the efficacy of subatmospheric pressure and hyperbaric oxygen (HBO) as adjuncts in the treatment of hypoxic full-thickness wounds in a rabbit model. We hypothesized that subatmospheric pressure and HBO independently are effective in improving wound healing in the ischemic wound model and that when they are used in combination there is an increased positive effect on wound healing. Using a standard ischemic wound model four full-thickness wounds were created on each ear of 41 male New Zealand white rabbits (N = 82 ears). On each rabbit one ear was dressed with the vacuum-assisted closure (VAC) device and connected to suction; the other was dressed identically without the suction and suction tubing. Twenty rabbits were treated with HBO daily for 10 days at 2.0 atmospheres absolute for 90 minutes plus descent and ascent times. Necropsy on all rabbits was performed on postoperative day 10. Four ischemic wound treatment groups were evaluated: Group 1 (N = 21) VAC dressing alone; Group 2 (N = 20) VAC dressing plus HBO; Group 3 (N = 21) VAC dressing to suction alone; and Group 4 (N = 20) VAC dressing to suction and HBO. Using light microscopy a veterinary pathologist blinded to treatment groups quantified peak granulation tissue, granulation tissue gap, and epithelialization tissue gap. Data were analyzed by analysis of variance with significance indicated by P < 0.05. Statistical significance was found in a comparison of VAC dressing to suction and VAC dressing alone for peak granulation tissue and granulation tissue gap both with and without use of HBO. VAC device use appears to increase the rate of healing in a rabbit ischemic wound model. HBO therapy did not significantly affect the rate of healing in this model.
Anal Duct Carcinoma: Case Report and Review of the Literature
Authors: Perkowski Paul E. , Sorrells Donald L. , Evans James T. , Nopajaroonsri Charn , Johnson Lester W.
Published: November 2022

This report details the clinical course of two patients with true anal duct carcinoma. The incidence of this malignancy is low. The tissues of origination are the glands of the anal duct. The features that differentiate this tumor from the usual rectal carcinoma are prominent ductal structures, abundant mucin production with organized mucinous pools, and infiltration into the perirectal soft tissue. The clinical management of anal duct carcinoma remains a surgical challenge. The extent of surgical resection must be radical because of the infiltrative nature of the tumor. This report describes treatment of two patients with anal duct carcinoma. The first patient was a black woman with no previous history of rectal disease. Her operative procedure was an abdominoperineal resection with posterior vaginectomy. Nine months after initial surgery a local recurrence was resected. The second patient was a white man with a previous history of hemorrhoidectomy and anal fissure. He underwent an abdominoperineal resection but had positive dermal skin margins on permanent sections despite wide perirectal soft tissue resection. A secondary resection with confirmed clear margins of the skin was performed 2 weeks postoperatively. One management aspect of anal duct carcinoma that needs emphasis is the need for wide local excision of the perirectal soft tissues.
Is There a Role for Interval Appendectomy in the Management of Acute Appendicitis?
Authors: Friedell Mark L. , Perez-Izquierdo Manuel
Published: November 2022

Interval appendectomy (IA) remains a controversial subject in surgery. To determine its effectiveness we reviewed our results with this approach. From January 1990 through December 1998 a total of 73 patients underwent appendectomy, five (7%) of which were interval in nature. These IA patients had a palpable abdominal mass or delayed presentation that led to CT scan. The decision to delay surgery was determined by two factors: 1) a CT scan that showed advanced inflammatory changes (phlegmon or abscess) associated with acute appendicitis and 2) a rapid response to conservative management. All patients received antibiotics—first intravenous and then oral. Repeat CT scans were performed before surgery and showed a virtual resolution of the inflammatory process. Appendectomy was delayed from 35 to 66 days from the time of diagnosis (average 51 days). There were no preoperative complications, the operations were uneventful, and there were no significant postoperative sequelae. IA appears to convert an unfavorable surgical situation potentially fraught with complications (fistula, abscess, wound infection) to one that is essentially elective in nature. It should be considered for the patient who is found to have an extensive periappendiceal inflammatory process, is clinically stable, and responds favorably to initial nonoperative management.
Carotid Endarterectomy Based on Duplex Ultrasound in Patients with and without Hemispheric Symptoms
Authors: Thusay Manish M. , Khoury M. , Greene K.
Published: November 2022

Carotid endarterectomy is the most commonly performed vascular procedure. This retrospective study was conducted to determine the efficacy of duplex imaging as the sole diagnostic study for preoperative evaluation of symptomatic and asymptomatic patients who underwent carotid endarterectomy. We conducted a retrospective case series analysis in a community teaching hospital. From January 1994 to September 1998, 316 patients underwent carotid endarterectomy for carotid stenosis. A total of 177 patients were symptomatic and 139 patients were asymptomatic. Angiography was performed routinely in the beginning of the study but later was performed only in selected patients. Preoperative duplex ultrasound of carotid artery was performed by a laboratory accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories. Data were reviewed to obtain morbidity and mortality rates, and duplex imaging results were compared with operative findings. Cost and risk analysis of carotid angiography reviewed. This study reviewed variables of age, sex, race, diabetes, smoking, hypertension, hypercholesterolemia, coronary artery disease, and renal failure. Five patients had a lesion in the proximal portion of the carotid artery by duplex imaging criteria. Duplex ultrasound results were grossly confirmed intraoperatively in all patients except in one patient who was found to have complete occlusion of carotid artery whose duplex was read as high-grade stenosis. The duration of stay ranged from two to 30 days. This duration was influenced by patients’ comorbid conditions, postoperative complications or simultaneous coronary artery bypass graft. Four patients had a stroke within 30 days of surgery making the stroke rate of 1.26 per cent. There has been considerable debate on the use of duplex ultrasound as the only method of preoperative evaluation of carotid stenosis before carotid endarterectomy. Our study demonstrates that it is safe to perform carotid endarterectomy based on neurologic history and duplex ultrasound with good technical quality performed in an accredited vascular laboratory. This approach eliminates the cost and risk associated with angiography. Proximal carotid and intrathoracic lesions are rare and can be predicted by the duplex study. We think that carotid angiography is required only when duplex imaging is suboptimal or equivocal in the presence of atypical symptoms or uncommon vascular abnormalities.
Diaphragmatic Hernia after Ivor-Lewis Esophagectomy Manifested as Lower Gastrointestinal Bleeding
Authors: Choi Yong U. , North James H.
Published: November 2022

Diaphragmatic hernia after esophageal resection is a recognized but rare complication. Parahiatal hernias may result from manipulation and extension of the crura during surgery. This can lead to a wide array of symptoms depending on the extent and organ that is herniated. A high index of suspicion is required because there is no one symptom that is specific for herniation. This report represents the first case of a patient presenting with lower gastrointestinal bleed from a parahiatal hernia after esophageal resection.
Gingko Biloba: A Case Report of Herbal Medicine and Bleeding Postoperatively from a Laparoscopic Cholecystectomy
Authors: Fessenden John M. , Wittenborn William , Clarke Leon
Published: November 2022

An increasing variety of alternative health care products (defined as “over-the-counter,” nonprescribed herbal medicines) are taken by patients for a plethora of reasons. Unfortunately these self-prescribed remedies are seldom considered by the patient to be medications and as a result it has been noted that 70 per cent of patients do not reveal herbal use to their allopathic practitioners or hospital personnel. The rapid growth of this herbal self-therapy has important implications for the practice of surgery. A case of post-laparoscopic cholecystectomy bleeding in a patient taking Gingko biloba is reported. This preparation has been reported to cause spontaneous bleeding and may interact with anticoagulants and antiplatelet agents. Other herbal medicines have also been associated with potential increased bleeding including garlic, feverfew, ginger, and ginseng. It is vital for surgeons to be apprised of all substances ingested by patients, to be cognizant of their potential adverse effects and drug interactions, and to be familiar with their therapeutic modality, all of which will help to optimize therapeutic approaches and improve patient outcome.