bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevention of Postoperative Pneumonia in Noncardiac Surgical Patients: A Prospective Study Using the National Surgical Quality Improvement Program Database
Authors: Caparelli Michael L. , Shikhman Alexander , Jalal Abdullah , Oppelt Sandra , Ogg Cari , Allamaneni Shyam
Published: June 2020

Postoperative pneumonia increases morbidity, length of stay, and hospital readmission rates. Current data support the use of perioperative chlorhexidine gluconate in elective cardiac surgery patients to prevent postoperative pneumonia. The objectives of this study were to implement a resident-driven quality improvement project and determine the efficacy of an oral care bundle in preventing postoperative pneumonia among noncardiac surgical patients. A retrospective review of postoperative pneumonia occurrences at our hospital captured by the NSQIP database from 2014 to 2016 was conducted. A pre- and postoperative pulmonary care bundle was implemented in all surgical patients undergoing general anesthesia and outcomes were tracked by NSQIP for up to 90 days postoperatively for calendar year 2017. The NSQIP-reported incidence of postoperative pneumonia at our hospital was reduced from 0.8 to 0 per cent (P = 0). The risk-adjusted smoothed rate fell from 1.17 (95% confidence interval 0.77–1.66) in 2014 to 0.33 (95% confidence interval 0.03–0.98) in 2017. We encountered multiple systematic issues while conducting this study, which led to an imbalanced compliance to the preoperative (90%) and postoperative (31%) bundle; however, there was no significant difference between these two groups. Successful implementation of a resident-driven quality project resulted in a decreased rate of postoperative pneumonia.
Intestinal Function after Early versus Late Appendectomy in Children with Perforated Appendicitis
Authors: Munoz Amanda , Hazboun Rajaie , Vannix Ian , Pepper Victoria K. , Vannix Rosemary , Tagge Edward , Moores Donald , Baerg Joanne
Published: June 2020

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3–9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.
Unplanned Returns to Care within Seven Days after Anorectal Surgery: Can they be Avoided?
Authors: Crain Nikhil , Aboulian Armen
Published: June 2020

With rates up to 50 per cent, unanticipated returns after anorectal surgery remain a major issue. A retrospective analysis was performed on 5929 anorectal operations from January 2011 to December 2015 across 14 Kaiser Permanente Southern California medical centers. Data were gathered on the cause, frequency and timing of unplanned returns to the ED and urgent care. Of all patients, 246 (4%) returned with a nonavoidable diagnosis and 243 (4%) returned with one of four avoidable diagnoses: pain, constipation, urinary retention, and nausea/vomiting. Seventy four per cent of avoidable diagnoses returns occurred within the first four postoperative days, with 48 per cent between days 2 and 4. In patients older than 50 years of age, males showed higher urinary retention (P = 0.001), whereas females had higher constipation (P < 0.001). Contrarily, pain was higher for both males (P = 0.02) and females (P < 0.001) less than 50 years old. In a separate subanalysis on anesthesia type, both constipation (P = 0.03) and urinary retention (P = 0.01) showed double the return rate in the general versus local/monitored anesthesia care group, whereas pain (P = 0.15) and nausea/vomiting (P = 0.20) showed no differences. Half of returns fall into a category that is potentially avoidable with preemptive interventions.
Review of Operative Treatment of Delayed Presentation of Acute Cholecystitis
Authors: Eubanks Ryan D. , Hassler Kenneth R. , Huish Grant , Kopelman Tammy , Goldberg Ross F.
Published: June 2020

Treatment of patients with delayed acute cholecystitis (AC) includes antibiotics and interval cholecystectomy based on proposed change at 72 hours from symptom onset to a chronic fibrotic phase with concern for increased complication rates. The purpose of our study was to compare the outcomes of patients undergoing laparoscopic cholecystectomy (LC) for AC before and after this golden 72-hour window. After institutional review board approval, a retrospective study was performed of patients presenting over two years with AC, who underwent LC during the index admission. A chart review was performed, and patients were divided into symptoms <72 hours (group A) and symptoms >72 hours (group B). Complications were defined as postoperative bleeding, return to operating room, and bile leaks. One hundred and eighty-four patients met the study criteria. Group A included 96 patients managed 5 to 71 hours after symptom onset, whereas Group B encompassed 88 patients with symptoms 72 to 336 hours. Both groups had similar baseline demographics and disease severity. No statistically significant differences were noted between the groups regarding overall complications or 30-day morbidity; however, Group B had an increased hospital stay length (P < 0.0001) and estimated blood loss (P = 0.028). LC seems safe despite duration of symptomatology and should be considered during the index admission in all AC patients.
Irreversible Electroporation as a Bridge to Liver Transplantation
Authors: Cannon Robert M. , Bolus David N. , White Jared A.
Published: June 2020

Hepatocellular carcinoma (HCC) in proximity to major hepatic vasculature poses a risk for invasion, which would contraindicate liver transplantation, yet, is difficult to treat with thermal ablation. This study was undertaken to evaluate the feasibility of irreversible electroporation (IRE) as a bridge to transplantation for high-risk tumors. All patients with HCC in proximity to major hepatic vasculature treated with laparoscopic IRE as bridge to transplantation were studied. Patient and tumor characteristics, length of stay, and treatment-related complications were recorded. Tumor response was assessed with CT and explant pathology. Five patients with a median Model for End Stage Liver Disease (MELD) of 13 (7–21) underwent IRE. The median tumor size was 2.7 cm (1.5–3.7 cm). Adjacent structures included the right portal vein, hepatic veins/inferior vena cava (IVC) and left portal vein. Length of stay was one day for all patients. One patient suffered portal vein thrombosis. The transplant occurred at a median of 142 days (47–264) after IRE. Pathologic necrosis ranged from 30 to 100 per cent, without any vascular invasion. Four patients remain alive with no evidence of disease with median follow-up of 403 (227–623) days. The remaining patients died because of transplant-related complications onpost IRE day 297. IRE shows promise as a bridge to liver transplant for high risk HCC in a preliminary series, justifying further prospective evaluation.
Single-Institution Early Experience and Learning Curve with Robotic Liver Resections
Authors: Gravetz Aviad , Sucandy Iswanto , Wilfong Chandler , Patel Nirrita , Spence Janelle , Ross Sharona , Rosemurgy Alexander
Published: June 2020

Robotic liver resection is being introduced with its potential to overcome limitations of conventional laparoscopy. This study was undertaken to document early experience and learning curve of robotic liver resection in our institution. All patients undergoing liver resection between 2013 and 2017 were prospectively followed. Patients were divided into three consecutive tertiles (cohort I–III). Thirty-three patients underwent robotic liver resection within the study period. Twenty-four per cent of patients underwent formal right or left hemihepatectomy, 21 per cent underwent sectionectomy, 6 per cent underwent central hepatectomy, and the remainder underwent non-anatomical liver resection. Formal hemihepatectomy and right posterosuperior segment resection were undertaken in two patients in cohort I, four patients in cohort II, and four patients in cohort III. Two cases were converted to “open” operation. Operative time was 172 (194.5 ± 65.1) minutes in cohort I, 222 (247.8 ± 109.8) minutes in cohort II, and 280 (302.5 ± 84.9) minutes in cohort III, reflecting increasing degree of technical complexity. Estimated blood loss decreased significantly throughout the cohorts, being 400 mL, 200 mL, and 100 mL in cohorts I to III, respectively. Major intraoperative complications were not seen. Three patients experienced postoperative complications, resulting in a single mortality. Length of hospital stay was three days, with two patients being readmitted within 30 days. Robotic technique for liver resection is feasible and safe. It offers good short-term clinical outcomes, including for patients who require major liver resection. As the proficiency developed, a notable improvement in technically ability to undertake more complex resections with decreasing blood loss and minimal morbidity was seen.
The Crossroads of Posttraumatic Stress Disorder and Physician Burnout: A National Review of United States Trauma and Nontrauma Surgeons
Authors: Jackson Theresa N. , Morgan Jake P. , Jackson Diane L. , Cook Taylor R. , McLean Kevin , Agrawal Vaidehi , Taubman Kevin E. , Truitt Michael S.
Published: June 2020

Posttraumatic stress disorder (PTSD) among trauma surgeons is three times that of the general population, and physician burnout (PBO) among surgeons is rising. Given that PTSD and PBO are both stress-based syndromes, we aim to identify the prevalence and risk factors for PTSD among trauma and nontrauma surgeons, and determine if a relationship exists. A cross-sectional survey of surgeons was conducted between September 2016 and May 2017. Respondents were screened for PTSD and PBO. Traumatic stressors were identified, and 20 potential risk factors were assessed. The respondents (n = 1026) were grouped into trauma (n = 350) and nontrauma (n = 676). Between the cohorts, there was no significant difference in prevalence of screening positive for PTSD (17% vs 15%) or PBO (30% vs 25%). A relationship was found between PTSD and PBO (P < 0.001). The most common traumatic stressor was overwhelming work responsibilities. Potential risk factors for PTSD differed, but overlapping risk factors included hospital culture, hospital support, and salary (P < 0.05). Our findings of an association between PTSD and PBO is concerning. Interventions to reduce rates of PTSD should target changing the existing culture of surgery, improving hospital support, and ensuring equitable pay.
Impact of Conversion from Laparoscopy to Open Surgery in Patients with Right Colon Cancer
Authors: Petrucciani Niccolò , Memeo Riccardo , Genova Pietro , Roy Bertrand Le , Courtot Lise , Voron Thibault , Aprodu Razvan , Tabchouri Nicolas , Saleh Nour Bou , Berger Anne , Ouaïssi Mehdi , Pezet Denis , Mutter Didier , Brunetti Francesco , De'Angelis Nicola
Published: June 2020

Conversion to open surgery is reported in up to 20 per cent of laparoscopic colectomies for cancer. This study aims to compare postoperative outcomes and survival between converted and successful laparoscopic right colectomy for cancer. Records of patients who underwent laparoscopic right colectomy for cancer between 2005 and 2015 were retrieved from the CLermontFerrand Ircad Mondor Hopital European Tours (CLIMHET) database. Perioperative, postoperative, and survival outcomes were evaluated. Multivariate analysis was performed to identify predictive factors for conversion. Overall, 445 patients underwent a successfully completed laparoscopic right colectomy and 28 (5.9%) were converted to open surgery. A higher rate of minor complications was found in the conversion group, whereas patient recovery outcomes were similar. Previous open and laparoscopic surgeries were significant predictors of conversion. No significant difference was found in overall and disease-free survival rates between converted and nonconverted procedures. In the setting of laparoscopic right colectomy for cancer, the conversion rate is low and does not have an impact on patient survival. Conversion is associated with higher rates of minor postoperative complications but recovery and survival outcomes are comparable with successful laparoscopic colectomies. The present results support the use of laparoscopy for right colon resection even in patients at risk of conversion.
Cannabis Use is Associated with Increased Mechanical Ventilation and Polysubstance Use in Trauma Patients
Authors: Banks Kian , Biswas Subarna , Wong Monica , Byerly Saskya , Clark Damon , Lam Lydia , Inaba Kenji , Demetriades Demetrios
Published: June 2020

Recent policy changes in California regarding cannabis use underscore the need to study outcomes and prevalence of this drug in trauma. Our study aims to study the prevalence of cannabis use and associations with injury types and outcomes in Los Angeles County trauma patients. Data were reviewed from 21,276 adult patients from a Los Angeles countywide database spanning five years (2012–2016), who underwent urine toxicology testing in the ED after sustaining a traumatic injury. The percentage of trauma patients using marijuana increased from 36 to 43 per cent over the five-year period. On univariate analysis, cannabis-positive patients were significantly younger and more likely male, with lower median systolic blood pressure and heart rate on arrival in the ED. A higher proportion of cannabis users had penetrating trauma, and 48 per cent of cannabis users also tested positive for amphetamines, cocaine, opioids, or Phencyclidine. On multivariate analysis, cannabis was associated with an increase in need for mechanical ventilation after adjusting for age, admission Glasgow Coma Score, gender, polysubstance use, blunt or penetrating mechanism, and Injury Severity Score, and was not associated with increases in mortality or ICU length of stay.
Penetrating Renal Trauma: Nonoperative Management is Safe in Selected Patients
Authors: Resch Thomas R. , Kufera Joseph A. , Chiu William , Scalea Thomas M.
Published: June 2020

Present literature seems to support the nonoperative management of penetrating renal trauma although data remain limited. We conducted a nine-year retrospective review of nonoperative versus operative management and mechanism of injury [stab wound (SW) versus gunshot wound (GSW)] among patients admitted with penetrating renal trauma. Of 203 patients, the median age was 24 years, with the majority being male and having GSW injuries. More than half (52.2%) were treated nonoperatively (69.9% of SW and 40% of GSW injured patients). When compared with all operative patients combined, nonoperative patients had a lower median Injury Severity Score (17 vs 26, P < 0.001), lower transfusion requirement (27.4% vs 77.3%, P < 0.001), shorter median hospital stay (4.7 vs 12.6 days, P < 0.001), and lower mortality (1.9% vs 13.4%, P = 0.002). Gunshot wound patients had a higher median Injury Severity Score (26 vs 14, P < 0.001), higher median American Association for the Surgery of Trauma-Organ Injury Score (3 vs 2, P = 0.001), greater need for transfusion (69.2% vs 29.3%, P < 0.001), longer median hospital length of stay (12.1 vs 3.9 days, P < 0.001), and greater mortality (12.5% vs 0%, P < 0.001) than SW patients. Nonoperative management of penetrating renal injury is safe in selected patients. In addition, renal GSW injuries are associated with a greater morbidity and mortality.
Lumbar Incisional Hernia Repair: Complete Reconstruction of the Deficient Myofascial Component Using Christmas Tree Bone Anchors
Authors: Baird-Gunning Eleni, B.Sc. Hons, M.B.Ch.B. , Ackermann Travis , Lim James K.
Published: June 2020

Lumbar incisional hernias are difficult to repair because one of the hernia margins is bone, namely, the iliac crest. Previous studies have described the use of orthopedic bone anchors that fix a mesh onto the iliac crest. We present a novel technique for open repair of large lumbar incisional hernias using a double-mesh technique in combination with suture-loaded bone anchors to reattach the abdominal wall musculature onto the iliac crest. The surgical technique involves creating a preperitoneal plane behind the transversus abdominus and above the iliac crest and iliacus, below the iliac crest, with application of a Prolene mesh in this layer. This is followed by the drilling of suture-loaded Christmas Tree bone anchors™ along the rim of the iliac crest. The preloaded sutures are used to attach the myofascial component on the iliac crest, followed by the placement of a second Prolene mesh in an on-lay fashion. Drains are left in the preperitoneal and subcutaneous spaces. Unlike other reported techniques in the literature which only fix mesh onto the iliac crest, our technique with the use of Christmas Tree bone anchors™ allows for complete reconstruction of the lumbar abdominal wall defect and its myofascial components.
Is the Perioperative Continuation of Antiplatelet Therapy Safe for Elective Hernia Surgery?
Authors: Hill David A. , Sleiman Mohamad , Castellano Michael R.
Published: June 2020

Antiplatelet medication use in the perioperative period for elective surgical procedures remains controversial. We hypothesized that for elective hernioplasty, the continuation of antiplatelet agents would not increase postoperative complications. A single surgeon prospectively tracked all elective hernia repairs performed. All patients were included except those on anticoagulation therapy. Patients already on antiplatelet therapy (APT) continued their regimen throughout the perioperative period, whereas those who were not remained off antiplatelet medications. All patients had postoperative visits between 7 and 10 days at which point they were evaluated with complications documented. One thousand four patients underwent open hernia repair. Two hundred sixty-seven patients were taking APT, whereas 737 were not. The mean age of the antiplatelet group was greater than those not on APT (66 vs 51 years old, P < 0.0001). Ecchymosis occurred more frequently in the APT group than in those not on APT (9.36% vs 2.71%, P = 0.0005). This was the only statistically significant difference in postoperative complications noted between these two groups. Patients taking clopidogrel alone or a combination of aspirin and clopidogrel had a significantly higher rate of ecchymosis compared with those on other antiplatelet regiments (10%, 21.6%, and 7.4%, respectively, P = 0.047). There were no postoperative hematomas, bleeding complications, urinary retention, or any patients who required cessation of antiplatelet medications. Continuation of APT in the perioperative period for elective hernia repair did not result in an increased frequency of postoperative complications except for ecchymosis development. We conclude that the continuation of antiplatelet medications throughout the perioperative period of elective hernioplasty is safe.
Management of Thoracic and Lumbar Spine Fractures: Is MRI Necessary in Patients without Neurological Deficits?
Authors: Khoury Leen , Chang Edwin , Hill David , Shams Sara , Sim Vasiliy , Panzo Melissa , vijmasi Trinka , Cohn Stephen
Published: June 2020

MRI after a CTscan for thoracolumbar spine (TLS) trauma has become commonplace because of the concerns for detection of posterior ligamentous complex injuries in the absence of substantial scientific evidence to support its use. We hypothesized that MRI scans were not necessary in the clinical management of TLS fractures. A prospective study was conducted at our Level I trauma center. A total of 39 neurologically intact patients with TLS fracture on CT were enrolled. The patients’ CT scan and neurological examination were reviewed by a senior neurosurgeon, who determined clinical management based on these data. Assessment was repeated after an MRI of the spine was performed, and a second clinical plan was devised. The two treatment schemes were then compared. MRI resulted in a change in clinical management in 15 per cent of patients. Ten per cent of patients changed from requiring a brace to no brace and merely observation alone. In no patient planned for nonoperative care was surgery deemed necessary after completion of MRI. Among five patients with initial plans for operative intervention, two avoided surgery after the MRI. MRI has little impact on the management of patients with CT-proven thoracic and lumbar spine fractures. Only when surgery is planned based on CT studies does an MRI seem to assist with determining optimal care.
Postoperative Pancreatic Swelling Predicts Pancreatic Fistula after Pancreaticoduodenectomy
Authors: Iida Hiroya , Tani Masaji , Maehira Hiromitsu , Mori Haruki , Kitamura Naomi , Miyake Toru , Kaida Sachiko , Shimizu Tomoharu
Published: June 2020

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy. However, the criteria for prompting drainage have not been clarified yet. We evaluated 80 patients who underwent pancreaticoduodenectomy between 2011 and 2016. Clinically relevant POPF (International Study Group of Postoperative Pancreatic Fistula grade B or C) was evaluated on the basis of the following parameters: changes in pancreatic thickness between preoperation and postoperative day (POD) 4 identified via enhanced CT, drain amylase level, laboratory data, and operative factors. POPF occurred in 21 patients (26.3%). The median change in pancreatic thickness before and after operation was 8.33 mm in the POPF-positive group, which was significantly larger than that in the POPF-negative group (3.79 mm, P <0.001). In addition, operation time, pancreatic texture, main pancreatic duct diameter, WBC count, C-reactive protein level, and drain amylase level demonstrated significant differences between the groups. In the multivariate analysis, operation time, C-reactive protein level on POD 3, drain amylase level on POD 1, and the change in pancreatic thickness before and after operation were independent risk factors of POPF. The drastic change in pancreatic thickness before and after operation predicted POPF in this study. This might be one of the factors that determine the requirement for drainage.
Disparities in Care: Impact of Socioeconomic Factors on Pancreatic Surgery: Exploring the National Cancer Database
Authors: Makar Michael , Worple Ericha , Dove James , Hunsinger Marie , Arora Tania , Oxenberg Jacqueline , Blansfield Joseph A.
Published: June 2020

Studies have shown high-volume institutions have decreased mortality and increased survival for pancreatectomy. However, not all patients can travel to high-volume centers. Socioeconomic factors may influence treatment decisions. The goal of this study is to examine socioeconomic factors that determine where a patient is treated and how that location affects outcome. This is a retrospective study of the National Cancer Database of patients diagnosed with pancreatic cancer from 2004 to 2014. The primary outcome was to examine socioeconomic factors that predicted where a patient underwent their pancreatectomy. Patients treated at academic programs (APs) had to travel a mean distance of 80.9 miles, whereas patients treated at community programs (CPs) had to travel 31.7 miles ( P < 0.0001). Spanish and Hispanic patients were less likely to travel to an AP (69% had surgery at an AP versus 76% of non-Hispanic patients, P < 0.001). Patients with higher comorbidities were also more likely to have care at CPs. Patients who had pancreatic cancer surgery at CPs were more likely to be Hispanic or with higher medical comorbidities. Those who had surgery at AP traveled further distances but had better perioperative outcomes and had an improvement in overall survival.
Efficacy of Enteral Nutrition by Double Elementary Diet Tube after Pylorus-Preserving Pancreatoduodenectomy
Authors: Sano Toru , Chiba Naokazu , Gunji Takahiro , Ozawa Yosuke , Hikita Kosuke , Okihara Masaaki , Tomita Koichi , Oshima Go , Takano Kiminori , Abe Yuta , Shimazu Motohide , Kawachi Shigeyuki
Published: June 2020

Nutritional support after pylorus-preserving pancreaticoduodenectomy (PpPD) is still controversial. This study aimed to evaluate the efficacy of enteral nutrition (EN) via the double elementary diet (W-ED) tube after PpPD. One hundred two patients who received EN by the W-ED tube were compared with 52 patients who received total parental nutrition (TPN) previously. Clinicopatho-logical and postoperative features were analyzed among the two groups. Patients with EN by the W-ED tube after PpPD had a lower incidence of postoperative pancreatic fistula than those with TPN. The total protein and albumin levels on discharge in the EN group were significantly higher than those in the TPN group. In the case without complication, decreasing rate of the third lumbar vertebra skeletal muscle area was significantly lower in the EN group. In the cases of soft pancreas, drainage volume by the W-ED tube until four postoperative day was significantly larger in the case without postoperative pancreatic fistula. The W-ED tube offers the advantages of reducing gastrointestinal pressure and enabling reduction of complications after PpPD surgery.
Early versus Late Tracheostomy: Is There an Outcome Difference?
Authors: Elkbuli Adel , Narvel Raed Ismail , Spano Paul J. , Polcz Valerie , Casin Astrid , Hai Shaikh , Boneva Dessy , Mckenney Mark
Published: June 2020

The effect of timing in patients requiring tracheostomy varies in the literature. The purpose of this study was to evaluate the impact of early tracheostomy on outcomes in trauma patients with and without traumatic brain injury (TBI). This study is a four-year review of trauma patients undergoing tracheostomy. Patients were divided into two groups based on TBI/non-TBI. Each group was divided into three subgroups based on tracheostomy timing: zero to three days, four to seven days, and greater than seven days postadmission. TBI patients were stratified by the Glasgow Coma Scale (GCS), and non-TBI patients were stratified by the Injury Severity Score (ISS). The primary outcome was ventilator-free days (VFDs). Significance was defined as P < 0.05. Two hundred eighty-nine trauma patients met the study criteria: 151 had TBI (55.2%) versus 138 (47.8%) non-TBI. There were no significant differences in demographics within and between groups. In TBI patients, statistically significant increases in VFDs were observed with GCS 13 to 15 for tracheostomies performed in four to seven versus greater than seven days ( P = 0.005). For GCS <8 and 8 to 12, there were significant increases in VFDs for tracheostomies performed at days 1 to 3 and 4 to 7 versus greater than seven days (P << 0.05 for both). For non-TBI tracheostomies, only ISS ≥ 25 with tracheostomies performed at zero to three days versus greater than seven days was associated with improved VFDs. Early tracheostomies in TBI patients were associated with improved VFDs. In trauma patients with no TBI, early tracheostomy was associated with improved VFDs only in patients with ISS ≥ 25. Future research studies should investigate reasons TBI and non-TBI patients may differ.
Clinicopathological Features of Remnant Gastric Cancer (RGC): Detection of RGC after Five Years of Follow-Up Was Associated with a Poor Prognosis
Authors: Kameda Chizu , Kawabata Ryohei , Koga Chikato , Matsumura Tae , Murakami Masahiro , Noura Shingo , Shimizu Junzo , Hasegawa Junichi
Published: June 2020

The purpose of this study was to evaluate the clinicopathological features and prognosis of patients who underwent surgery for remnant gastric cancer (RGC) during/after the regular five-year follow-up period after initial distal gastrectomy for gastric cancer that is recommended by the Japanese gastric cancer treatment guidelines. Between January 2007 and December 2017, 40 patients underwent surgery for RGC after distal gastrectomy. Twenty-eight of the 40 patients underwent initial gastrectomy for cancer. We divided the 28 patients into two groups: patients who were diagnosed with RGC during/after the five-year follow-up period after initial gastrectomy, and analyzed their retrospectively collected data. Among the 28 patients, 15 patients were diagnosed with RGC within five years and 13 patients were diagnosed with RGC after five years. There were significant differences in the reconstruction of the initial operation, curative resection, pathological depth of the tumor, and pathological stage of the two groups. Multivariate analyses revealed that the interval between initial gastrectomy and RGC and the pathological TNM stage were significant risk factors for shorter cancer-specific survival. Kaplan-Meier analyses demonstrated that patients with RGC after the five-year follow-up period had a significantly worse prognosis in terms of cancer-specific survival than those who developed RGC within five years. This study suggested surveillance by using the annual endoscopy might be necessary beyond the initial five-year period for patients who underwent gastrectomy for gastric cancer.
Use of Prolonged Prophylactic Antibiotics with Closed Suction Drains in Ventral Abdominal Hernia Repair
Authors: Weiss Eric , Mcclelland Paul , Krupp James , Karadsheh Murad , Brady Mary Sue
Published: June 2020

Closed suction drains (CSD) are commonly used in ventral hernia repair (VHR), with or without prolonged postoperative prophylactic antibiotics (PPA) for the duration of their use. We examine the evidence that PPA with CSD reduce surgical site infection (SSI) in patients undergoing VHR. We also examine the evidence assessing the association between SSI and CSD in VHR. A systematic review of PubMed, CIHNL, and Cochrane databases was performed to identify studies analyzing rates of SSI with CSD in patients undergoing abdominal VHR and related procedures with or without the concomitant use of PPA. The primary outcome was the rate of SSI. Five studies totaling 772 patients were identified, 525 patients were confirmed to have CSD, and 434 patients received prolonged antibiotics while drains were in place. PPA had no significant effect on SSI in two studies and were associated with decreased SSI in one study (Odds ratio 0.235, 95% confidence interval 0.090–0.617, P = 0.003). Two studies documented a higher rate of SSI in patients with CSD (79% vs 49% and 19% vs 10%) on univariate analysis. One study demonstrated a very low risk of SSI despite CSD (4.2%) and another demonstrated no increased risk with or without CSD. The use of drains is not clearly associated with an increased risk of SSI in VHR, and there is limited evidence to support antibiotic use while the drains are in place to decrease the potential risk. Prospective randomized studies are needed to more clearly assess these associations.
Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum
Authors: Khan Adeel S. , Siddiqui Imran , Affleck Arthur , Cochran Allyson , Baker Erin , Iannitti David , Vrochides Dionisios , Martinie John B.
Published: June 2020

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010–2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3–21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.
Population-Based Analysis of Firearm Injuries among Young Children in the United States, 2010–2015
Authors: Cook Alan , Hosmer David , Glance Laurent , Kalesan Bindu , Weinberg Jordan , Rogers Amelia , Schultz Cpt Susan , Gilligan Cpt Timothy , Gross Brian , Vernon Tawnya , Ward Jeanette , Osler Turner , Rogers Frederick
Published: June 2020

Firearm violence in the United States knows no age limit. This study compares the survival of children younger than five years to children and adolescents of age 5–19 years who presented to an ED for gunshot wounds (GSWs) in the United States to test the hypothesis of higher GSW mortality in very young children. A study of GSW patients aged 19 years and younger who survived to reach medical care was performed using the Nationwide ED Sample for 2010–2015. Hospital survival and incidence of fatal and nonfatal GSWs in the United States were the study outcomes. A multilevel logistic regression model estimated the strength of association among predictors of hospital mortality. The incidence of ED presentation for GSW is as high as 19 per 100,000 population per year. Children younger than five years were 2.7 times as likely to die compared with older children (15.3% vs 5.6%). Children younger than one year had the highest hospital mortality, 33.1 per cent. The mortality from GSW is highest among the youngest children compared with older children. This information may help policy makers and the public better understand the impact of gun violence on the youngest and most vulnerable Americans.
What is the Long-Term Follow-Up of Nonoperatively Treated Patients with Appendicitis?
Authors: Felber Andrew , Catalano Deven , Stafford Caitlin , Francone Todd D. , Roberts Patricia L. , Marcello Peter W. , Ricciardi Rocco
Published: June 2020

In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.
Delayed Closure is Associated with Decreased Infection Rate in Amputations after Trauma
Authors: Ali Yasmin , Halvorson Jason , Nunn Andrew , Miller Preston
Published: June 2020

Amputations associated with trauma carry significant morbidity in addition to risk of limb loss due to tissue damage, contamination, and risk of infection. The timing of formal amputation closure in this situation varies among surgeons, with some allowing the wound to remain open for some time after debridement, whereas others perform formal amputation and closure at the index operation if debridement is adequate. The presence of infection after closure of an amputation has the potential to result in a higher amputation ( i.e., a below-knee amputation to an above-knee amputation). Our goal was to examine the relationship of timing of closure to stump infection and eventual level of amputation. A review was performed of all patients admitted to a Level I trauma center over a six-year period with amputations during the initial admission after trauma. Amputations of either an arm (above or below the elbow) or a leg (above or below the knee) were included. The number of days between adequate debridement as judged by the operating surgeon and closure of the amputation and whether there was an infection after closure were evaluated. Also investigated was the relationship between infection after closure and a higher level of amputation. Between January 1, 2010, and December 31, 2015, 63 patients (ages 15–81 years, mean age 45.1 ± 18.4) underwent an amputation of a leg or an arm. Fifty-four were male, nine were female, the mean injury severity score was 20.9 ± 10.4, and the mean lactate level at admission was 3.4 ± 1.7. Of the 63 patients, 53 patients had an amputation of a leg and 10 had an amputation of an arm. The overall infection rate was 32 per cent, and the mean time until closure was 6.7 ± 11.1 days. Comparing closure times in those with and without infection after closure, the mean intervals were 3.1 ± 9.7 and 8.4 ± 11.4 days, respectively ( P = 0.01). The receiver operating characteristic curve c-statistic was 0.69 ( P = 0.04). Sensitivity of various times to closure for avoiding infection was examined and was optimized at five days with infection rates above five days of 5.3 per cent versus at or below five days to closure of 43.2 per cent ( P = 0.0029). Infection resulted in a higher level of amputation in 40 per cent of those who had an infection. Based on these data, delay in closure of an amputation even after debridement appears adequate was associated with a lower rate of infection and the presence of infection resulted in a higher amputation level in more than a third of studied patients. Delay of formal amputation closure for at least five days after adequate debridement is acheived is associated with a significantly reduced rate of infection.
Self-Inflicted Stab Wounds: A Single-Center Experience from 2010 to 2016
Authors: O'Brien Stephen , Nicolas Mark D. , Bhutiani Neal , Schucht Jessica E. , Stollo Brian , Miller Keith R. , Benns Matthew V. , Nash Nicholas A. , Franklin Glen A. , Smith Jason W. , Harbrecht Brian G. , Bozeman Matthew C.
Published: June 2020

Despite low mortality rates, self-inflicted stab wounds (SISWs) can result in significant morbidity and often reflect underlying substance abuse and mental health disorders. This study aimed to characterize demographics, comorbidities, and outcomes seen in self-inflicted stabbings and compare these metrics to those seen in assault stabbings. A Level I trauma center registry was queried for patients with stab injuries between January 2010 and December 2015. Classification was based on whether injuries were SISWs or the result of assault stab wounds (ASWs). Demographic, injury, and outcome measures were recorded. Differences between genders, ethnicities, individuals with and without psychiatric comorbidities, and SISW and ASW patients were assessed. Within the SIWS cohort, no differences were found when comparing age, gender, or race, including need for operative intervention. However, patients with psychiatric histories were less likely to have a positive toxicology test on arrival than those without psychiatric histories (22% vs. 0%, P = 0.04). When compared with 460 ASW patients, SISW were older (41 vs. 35, P < 0.001), more likely to be white (92% vs. 64%, P < 0.001), more likely to have a psychiatric history (15% vs. 4%, P < 0.001), require operative intervention (65% vs. 50%, P = 0.008), and be discharged to a psychiatric facility (47% vs. 0.2%, P < 0.001). SISW patients have higher rates of psychiatric illness and an increased likelihood to require operative intervention as compared with ASW patients. This population demonstrates an acute need for both inpatient and outpatient psychiatric care with early involvement of multidisciplinary teams for treatment and discharge planning.
Current Status of Vascularized Composite Allotransplantation
Authors: Kaufman Christina L. , Bhutiani Neal , Ramirez Allan , Tien Huey Y. , Palazzo Michelle D. , Galvis Elkin , Farner Scott , Ozyurekoglu Tuna , Jones Christopher M.
Published: June 2020

The field of vascularized composite allotransplantation (VCA) has moved from a highly experimental procedure to, at least for some patients, one of the best treatment alternatives for catastrophic tissue loss or dysfunction. Although the worldwide experience is still limited, progress has been made in translation to the clinic, and hand transplantation was recently designated standard of care and is now covered in full by the British Health System. This progress is tempered by the long-term challenges of systemic immunosuppression, and the rapidly evolving indications for VCA such as urogenital transplantation. This update will cover the state of and recent changes in the field, and an update of the Louisville VCA program as our initial recipient, the first person to receive a hand transplant in the United States celebrates the 20th anniversary of his transplant. The achievements and complications encountered over the last two decades will be reviewed. In addition, potential directions for research and collaboration as well as practical issues of how third party payers and funding are affecting growth of the field are presented.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Management of Trauma Patients: A Systematic Literature Review
Authors: Petrone Patrizio , PÉRez-JimÉNez Aida , Rodríguez-Perdomo Martín , Brathwaite Collin E. M. , Joseph D'andrea K.
Published: June 2020

Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an innovative method by which noncompressible bleeding in the torso can be mitigated until definitive treatment can be obtained. To perform a systematic review of the literature on the use of the REBOA in trauma patients. An English and Spanish literature search was performed using MEDLINE, PubMed, and Scopus, from 1948 to 2018. Keywords used were aortic balloon occlusion, resuscitative endovascular balloon, REBOA, hemorrhage, and resuscitative endovascular balloon occlusion of the aorta. The eligilibility criteria included only original and human subject articles. Nontrauma patients, nonbleeding pathology, letters, single case reports, reviews, and pediatric patients were excluded. Two hundred forty-six articles were identified, of which 17 articles were included in this review. The total number of patients was 1340; 69 per cent were men and 31 per cent women. In 465 patients, the aortic zone location was described: 83 per cent the balloon was placed in aortic zone I and 16 per cent in zone III. Systolic blood pressure increased at an average of 52 mmHg before and after aortic occlusion. Although 32 patients (2.4%) presented clinical complications derived from the procedure, no mortality was reported. The trauma-related mortality rate was 58 per cent (776/1340). REBOA is a useful resource for the management of non-compressive torso hemorrhage with promising results in systolic blood pressure and morbidity. Indications for its use include injuries in zones 1 and 3, whereas it is not clear for zone 2 injuries. Additional studies are needed to define the benefits of this procedure.
Does Neoadjuvant Chemotherapy for Breast Cancer Affect Lymph Node Harvest Rates?
Authors: White Richard L. , Palmer Pooja P. , Trufan Sally J. , Sarma Deba
Published: June 2020

Some authors report that patients receiving neoadjuvant chemotherapy have fewer lymph nodes harvested during axillary dissection and more dissections with < 10 nodes compared with patients who undergo surgery initially. We sought to determine whether there was a difference between these patient groups in terms of number of nodes harvested and number of dissections with < 10 nodes. Retrospective review of 258 patients diagnosed with breast cancer who underwent an axillary lymph node dissection between July 1,2015, and December 31, 2017 was performed. Chi-squared test was used to assess differences between patient groups. Of 258 patients undergoing dissection, 48 per cent received neoadjuvant chemotherapy; 52 per cent underwent surgery as first therapeutic intervention. Mean number of nodes resected; 14.3 + 6.3 for patients with no prior chemotherapy versus 14.9 + 6.6 for patients with neoadjuvant chemotherapy ( P = 0.48). For patients undergoing surgery as first intervention, 21 per cent had < 10 nodes harvested. For patients receiving neo-adjuvant chemotherapy, 20 per cent had < 10 nodes harvested. Patients who received neoadjuvant chemotherapy showed no statistically significant difference in the number of lymph nodes harvested during axillary dissection compared with patients undergoing surgery as first intervention. Neoadjuvant chemotherapy does not reduce the node harvest at the time of axillary dissection.