bluuebunny/crossref_metadata_2025 huggingface dataset:
Prospective Evaluation of Early versus Delayed Laparoscopic Cholecystectomy for Treatment of Acute Cholecystitis
Authors: Chandler Charles F. , Lane John S. , Ferguson Peggy , Thompson Jesse E. , Ashley Stanley W.
Published: November 2022

Although laparoscopic cholecystectomy (LC) is known to be safe in the treatment of acute cholecystitis (AC), the optimal timing of laparoscopic intervention remains controversial. The objective of this study is to prospectively compare the safety and cost effectiveness of early versus delayed LC in AC. Our study population consisted of 43 patients presenting with AC (localized tenderness, white blood cell count >10.0 or temperature >38.0° C, and ultrasound confirmation) who were prospectively randomized to early versus delayed LC during their first admission. Exclusion criteria included a history of peptic ulcer disease or evidence of gallbladder perforation. All patients were treated with bowel rest and antibiotics (piperacillin 2 g intravenous piggyback every 6 hours). Early treatment patients underwent LC as soon as the operating schedule allowed. Delayed treatment patients received anti-inflammatory medication (indomethacin 50 mg per rectum every 12 hours) in addition to bowel rest and antibiotics and underwent operation after resolution of symptoms or within 5 days if symptoms failed to resolve. Early LC was performed in 21 patients, whereas 22 patients underwent delayed LC. There was no difference in age, temperature, or white blood cell count on admission between groups. Early LC slightly reduced operative time and conversion rate. There was no difference in complications. Estimated blood loss was significantly lower in those receiving early LC. There was also a significant reduction in total hospital stay and hospital charges with early LC. We conclude that delay in operation combined with anti-inflammatory medication showed no advantage with regard to operative time, conversion, or complication rate. Furthermore, early laparoscopic intervention significantly reduced operative blood loss, hospital days, and hospital charges.
The Utility of Transesophageal Echocardiography in Determining the Source of Arterial Embolization
Authors: Mariano Myron C. , Gutierrez Charles J. , Alexander Jason , Roth Fernando , Katz Steven , Kohl Roy D.
Published: November 2022

Arterial embolism is frequently of a cardiac source. Arterial-arterial and paradoxical embolization also occurs. Failure to identify the origin may subject the patient to an important series of events. Herein we describe seven cases in which transesophageal echocardiography (TEE) was uniquely valuable in identifying the source or mechanism and in which conventional echocardiography and aortography were nondiagnostic. We conducted a chart review of patients with arterial emboli definitively diagnosed after undergoing TEE. Seven patients (mean age 68 years) were included in the study. Peripheral embolization occurred in four patients, visceral embolization occurred in one, and two experienced cerebrovascular events. Five patients had transthoracic echocardiography and six had aortography; none of these identified the source of embolization. All were diagnosed by TEE. Mobile aortic thrombus was the primary source in three patients, paradoxical embolization occurred in two, and two others had a combination of findings. Two patients received operative management with one mortality, and five received nonoperative management. The source of arterial emboli remains obscure in some patients. TEE can be valuable in identifying sources or mechanisms of embolization when angiography and conventional echocardiography are negative.
Six-Year Experience with Management of Subclavian Artery Injuries
Authors: Vikram Kalakuntla , Patel Vijaykumar , Tagoe Albert , Weaver William
Published: November 2022

Penetrating injuries of the subclavian artery are rare; however, the associated morbidity and mortality may be high. Retrospective data on 25 patients who sustained penetrating subclavian artery injuries are reported. Diagnosis of subclavian artery injuries was made clinically and was followed by expedient surgical exploration in 65.4 per cent of patients. Patients who were hemo-dynamically unstable at presentation (26.9%) underwent immediate operation. The remaining hemodynamically stable group of patients with hard signs indicative of vascular injury were also expediently taken to the operating room after initial evaluation and resuscitation. Angiographic evaluation was performed in 34.6 per cent of patients who were stable hemodynamically. Preoperative angiography localized the injury and helped in planning the optimal incision and approach to obtain vascular control. Vascular flow was reestablished in all patients operated except for three who underwent ligation of subclavian artery. Limb salvage rate was 100 per cent, and operative mortality was less than 5 per cent. Morbidity was related to hemodynamic stability at presentation and associated injuries. A low morbidity and mortality rate was achieved by aggressive initial resuscitation and early surgical intervention coupled with selective use of preoperative angiography in hemodynamically stable patients.
Sentinel Lymph Node Mapping for Carcinoma of the Colon: A Pilot Study
Authors: Gregory S. Waters , Kim R. Geisinger , Garske Diane D. , Brian W. Loggie , Edward A. Levine
Published: November 2022

Sentinel lymph node (SLN) mapping has evolved into the standard of care for melanoma and may replace routine node dissection in the treatment of breast cancer. There are few data evaluating sentinel node mapping in patients with cancer of the colon. This trial represents our initial experience with SLN mapping for carcinoma of the colon. SLN mapping was performed in 22 patients most of whom had biopsy-proven adenocarcinoma of the colon. One milliliter of isosulfan blue was injected with a 25-gauge needle into the subserosa at four sites around the edge of the palpable tumor. The SLN was identified visually and excised. A standard lymphadenectomy was then performed. The SLN was analyzed with standard hematoxylin and eosin evaluation. Immunohistochemical techniques for carcinoembryonic antigen and cytokeratin (Imm) were performed if the H&E was negative. The mapping added approximately 5 minutes to the total operative time and no adverse reactions to the dye occurred. A SLN was identified in 20 of 22 cases. In cases with negative lymph nodes the SLN was predictive of all the regional nodes by both H&E and Imm (14 of 14). In patients with positive lymph nodes the SLN was predictive in all cases (six of six). In one case the only node with disease was the SLN, and in this case the diease was identified by only Imm; thus this patient was upstaged. SLN mapping is feasible and safe and can readily be performed in patients with colonic cancer. In conjunction with SLN mapping, Imm techniques may upstage a subset of patients likely to be at increased risk for metastatic disease. Consequently SLN mapping of colon cancer should be evaluated in large prospective trials.
Isoproterenol Inhibits Bacterial Lipopolysaccharide-Stimulated Release of Tumor Necrosis Factor-α from Human Heart Tissue
Authors: Smart Kenneth R. , Warejcka Debra J. , Castresana Manuel R. , Dalton Martin L. , Webb Jerry G. , Newman Walter H.
Published: November 2022

Recent evidence suggests that inflammatory cytokines, particularly tumor necrosis factor a (TNF-α), may play a role in heart disease. Elevated plasma levels of the cytokine have been reported in congestive heart failure and severe angina and after myocardial infarction. The exact role of TNF-α in heart disease and how production is stimulated and regulated in the heart are current areas of investigation. Regarding regulation of production, isoproterenol elevates cyclic AMP and inhibits TNF-α release in macrophages. Therefore we hypothesized that stimulation of β-adrenergic receptors of the sympathetic nervous system would inhibit release of the cytokine from heart tissue. With Institutional Review Board approval and patient consent atrial tissue was obtained during preparation for cardiac bypass. The tissue was divided into segments, placed in culture medium, and incubated for various times in the presence or absence of lipopolysaccharide (LPS) (20 μg/mL) and/or isoproterenol (1 μM). The medium was removed and analyzed for biologically active TNF-α by the L929 cell cytotoxicity assay. Tissue samples were weighed and TNF-α release was expressed as pg TNF-α/mg tissue. Initially, to determine the time course of release, measurements were made at 2, 5, 10, 15, 30, 60, 120, 180, and 360 minutes after the addition of LPS. Elevated TNF-α levels in the culture medium were reliably detected at 360 minutes after exposure to LPS. In atrial tissue obtained from seven patients TNF-α released into the culture medium at 360 minutes was 6 ± 3 pg/mg tissue. In the presence of LPS, levels of the cytokine in the culture medium increased to 604 ± 233 pg/mg tissue ( P < 0.05 vs LPS alone). When isoproterenol and LPS were simultaneously added to the culture medium release of TNF-α was reduced by 87 per cent to 82 ± 40 pg/mg tissue ( P < 0.05 vs LPS alone). Our results show that activation of the β-adrenergic receptor inhibits myocardial production of TNF-α. This finding suggests that the sympathetic nervous system inhibits production of the cytokine and that impaired sympathetic function in heart failure may play a role in the elevated levels of TNF-α.
Self-Expanding Esophageal Metallic Stents in the Treatment of Esophageal Obstruction
Authors: Cordero Juan A. , Moores Darroch W.O.
Published: November 2022

Esophageal obstruction from any cause is debilitating. In patients with malignant obstruction palliation to relieve pain and dysphagia is the primary goal. Conventional endoluminal prostheses allow variable palliation. Covered expandable metallic stents with an 18-mm lumen allow improved deglutition. From December 1994 through December 1998, 59 patients underwent placement of self-expanding silicone-covered esophageal stents for esophageal obstruction. There were 36 men and 23 women ranging in age from 41 to 94. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation placement of the stent was performed under fluoroscopic control. Follow-up was complete in all patients. Technical success was achieved in all patients. There was one postoperative death (bronchopulmonary fistula), one migration of the stent requiring removal, and one recurrent obstruction. The remaining stents were well tolerated even in the cervical region (four patients). All patients returned to a diet of solid foods. We conclude that covered self-expanding esophageal metallic stents are technically simple and safe to insert and appear to provide durable excellent palliation of esophageal obstruction due to either benign or malignant conditions.
Inflammatory Pseudotumor Presenting as a Cystic Tumor of the Pancreas
Authors: Liu Terrence H. , Consorti Eileen T.
Published: November 2022

Inflammatory pseudotumor (IPT) of the pancreas occurs rarely. Eighteen cases have been described in the English literature. In all previous patients IPT of the pancreas presented as solid pancreatic mass. We are reporting a case of IPT presenting as a cystic mass of the pancreas, which has not been described previously. A review of IPT of the pancreas and a discussion regarding the management of pancreatic cystic neoplasm is provided.
Effect of the Antiadhesive Treatments, Carboxymethylcellulose Combined with Recombinant Tissue Plasminogen Activator and Seprafilm™, on Bowel Anastomosis in the Rat
Authors: Buckenmaier Chester C. , Summers Mark A. , Hetz Stephen P.
Published: November 2022

Abdominal adhesions are a significant cause of increased morbidity, mortality, and cost in patients undergoing abdominal surgery. Carboxymethylcellulose combined with recombinant tissue plasminogen activator (CMC + rtPA) and Seprafilm™ (sodium hyaluronate/carboxymethylcellulose bioresorbable membrane) have been shown to reduce adhesion formation in animal models. The effect these treatments may have on a healing bowel anastomosis is unknown. Forty-eight rats underwent a laparotomy and the distal colonic segment was transected and an anastomosis of the transected ends performed. Before abdominal closure one of three treatments—CMC + rtPA, Seprafilm™, and saline (control)—was placed in the rat abdomen around the anastomosis. A necropsy was performed 75 to 96 hours later and bowel anastomosis adhesions were scored using an adhesion scale. The anastomosis strength was then evaluated using a saline infusion bursting pressure model. No difference was observed in the extent of adhesion formation involving the bowel anastomosis among all groups. No statistically significant difference was found among the groups in the bursting strength of the colonic anastomosis. We conclude that CMC + rtPA and Seprafilm™ do not significantly reduce colonic bowel anastomosis bursting strength in the rat model.
Carotid Endarterectomy for Severe Asymptomatic Carotid Stenosis: A Perioperative Experience at a Community Hospital
Authors: Johna Samir , Gaw Felix , Berten Ralph , Miro Javier
Published: November 2022

The purpose of this study was to evaluate the safety and feasibility of carotid endarterectomy (CEA) for severe asymptomatic carotid stenosis in a community setting with direct surgical resident participation. The medical records of all patients who had undergone CEA for severe asymptomatic carotid stenosis between 1989 and 1997 were retrospectively reviewed to ascertain perioperative morbidity and mortality. One hundred forty-seven CEAs were performed on 131 patients over the 8-year interval. Perioperative stroke and death rate was 0 per cent. However, one patient had a postoperative transient ischemic attack, and one patient had vocal cord dysfunction due to vagus nerve injury (1.3%). Three other patients had perioperative complications not directly related to CEA (2.1%). Therefore the total perioperative complication rate of (3.4%) compares favorably with results reported by several large tertiary referral centers. CEA for severe asymptomatic carotid stenosis can be safely performed in a community hospital setting with direct surgical resident participation.
Utilization of FAST (Focused Assessment with Sonography for Trauma) in 1999: Results of a Survey of North American Trauma Centers
Authors: Boulanger Bernard R. , Kearney Paul A. , Brenneman Frederick D. , Tsuei B. , Ochoa Juan
Published: November 2022

Although much has been written about FAST (Focused Assessment with Sonography for Trauma) in the last decade little is known about its present clinical utilization. The purpose of this study was to evaluate and characterize the contemporary utilization of FAST at trauma centers in the United States and Canada. In 1999 trauma directors or their delegates at Level I regional trauma centers in the United States and Canada were surveyed either by fax or phone regarding the present utilization and the future of FAST at their center. The overall survey response rate was 91 per cent with 96 of 105 centers completing the survey. Of the 96 centers surveyed 78 were in the United States and 18 were in Canada. Of the 78 U.S. centers surveyed 62 (79%) routinely use FAST, and it is done by surgeons in 39 per cent, surgeons and emergency departments in 21 per cent, emergency departments in 5 per cent, and radiologists in 35 per cent. Most centers (79%) thought that it sped up their workups, and 89 per cent said it was an advance in patient care. FAST is used in penetrating injury at 58 per cent of centers, and some centers use FAST to assess organ injury. The utilization of diagnostic peritoneal lavage and CT has markedly decreased at many centers. Almost all respondents thought that FAST should be a component of surgery resident training. The utilization of FAST is significantly less in Canada than in the United States ( P < 0.05). Our conclusions are the following. FAST has become routinely used at the majority of the U.S. centers surveyed. FAST is performed by clinicians at 65 per cent of the trauma centers surveyed. The utilization of CT and diagnostic peritoneal lavage has changed. Many centers have broadened the scope of FAST to include the assessment of organ, pediatric, and penetrating injury.
Spontaneous Hepatic Hemorrhage Secondary to Retained Intraperitoneal Gallstones
Authors: Jost Corey J. , Smith John L. , Smith R. Stephen
Published: November 2022

We describe the first reported case of spontaneous hepatic hemorrhage as a result of retained gallstones in the region of Morison's pouch eroding into the liver parenchyma. The patient presented with acute right upper quadrant abdominal pain 7 months after laparoscopic cholecystectomy. She sustained an episode of limited spontaneous hepatic hemorrhage as noted by abdominal sonography, computerized tomography, and a 4-g/dL hemoglobin drop. Laparoscopic exploration revealed the source of hemorrhage to be an inflammatory source created by retained intraperitoneal gallstones.
Trauma in Cirrhotics: Survival and Hospital Sequelae in Patients Requiring Abdominal Exploration
Authors: Wahlstrom Kyle , Ney Arthur L. , Jacobson Steve , Odland Mark D. , Van Camp Joan M. , Rodriguez Jorge L. , West Michael A.
Published: November 2022

Hepatic cirrhosis significantly increases the mortality and morbidity of elective surgery; therefore we hypothesized that cirrhosis would adversely impact outcome after abdominal trauma. We used the trauma registry to identify 17 patients with cirrhosis who sustained trauma injuries requiring emergent exploratory laparotomy. Patients were characterized with respect to age, sex, hospital days, intensive care unit days, and trauma scores. A control group (n = 73) was constructed from the registry by matching age, sex, Injury Severity Score (ISS) and Abbreviated Injury score. Mortality rates were compared by Fisher's exact test and age, ISS, Revised Trauma Score 2, and hospital and intensive care unit days were compared by Student's t test. Despite similar ISS between cirrhotic patients and controls, patients with cirrhosis had a fourfold increase in mortality (mortality odds ratio = 7.2; 95% confidence interval = 2.2–24.0). Cirrhotic trauma patients had a complication rate of 71 per cent and a mortality of 44 per cent. We conclude that cirrhosis is a major independent risk factor for mortality in trauma patients with injuries that require emergent abdominal surgery.
Mallory-Weiss Syndrome: Possible Link to Water Immersion and Subsequent Air Flight
Authors: Pikarsky Alon J. , Zamir Gideon , Belzberg Howard , Crookes Peter , Rivkind Avraham I.
Published: November 2022

Mallory-Weiss Syndrome (MWS) lesions account for up to 15 per cent of upper gastrointestinal bleeding episodes. Typically these lesions present as a consequence of vomiting that is often associated with alcoholism. Recently other conditions such as pregnancy, migraine, hiatal hernia, gastric ulcer, biliary disease, and various medications have been associated with MWS. We report on a 32-year-old male who developed a MSW lesion after a prolonged period of swimming followed by an extended commercial airplane flight. The hemodynamic changes associated with swimming (increased central distribution of blood volume) and the pressure changes in commercial aircraft (a reduction of 0.3 atmospheres of pressure) are discussed. We conclude that the combination of these factors contributed to the development of a MWS lesion and gastrointestinal bleeding in this patient. We recommend that both air travel and athletic activities be considered as possible contributing factors in the evaluation of the cause of new-onset gastrointestinal bleeding.
Long-Term Outcomes of Stereotactic Breast Biopsies
Authors: Makoske Theodore , Preletz Rudolph , Riley Lee , Fogarty Kevin , Swank Mark , Cochrane Peter , Blisard Deanna
Published: November 2022

Stereotactic core needle biopsies (SCNBs) are accurate and relatively convenient for the patient; however, the long-term follow-up of benign results has not been reported. All patients between 1993 and 1998 undergoing SCNB at a community-based hospital were entered into a registry. Follow-up was obtained by a retrospective analysis of the charts. Biopsies were performed on 865 lesions. One hundred thirty-one (15%) were malignant, 42 (5%) were suspicious for malignancy, 687 (79%) were benign, and five (1%) were lobular carcinoma in situ. Of the 42 patients with suspicious findings 38 underwent biopsy. Ten were malignant and 28 benign. Of the 687 patients with benign pathology, 377 had follow-up available with a mean length of 1.7 years. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SCNB for benign lesions in our study are all 100 per cent. Eight lesions were worrisome and await final analysis. Of 687 patients with benign lesions 310 were lost to follow-up. This study suggests that patients with a benign diagnosis should be returned to routine mammography. These data also extend the reported follow-up to 1.7 years and establish an acceptable level of accuracy for SCNB. The lost patients remind us that follow-up is essential despite a benign diagnosis.
Effects of Empiric Antibiotic Administration for Suspected Pneumonia on Subsequent Opportunistic Pulmonary Infections
Authors: Koontz Curt S. , Chang Michael C. , Meredith J. Wayne
Published: November 2022

Optimal guidelines for empiric antibiotic (EAB) therapy in cases of suspected post-traumatic ventilator-associated pneumonia (VAP) are not well defined. EAB administration is thought to increase the incidence of opportunistic organisms; however, culture-directed (as opposed to empiric) treatment may delay antibiotic administration with possible adverse consequences. Our goal was to examine the impact of EAB administration on the incidence of subsequent VAP and opportunistic organisms in a series of critically injured patients with sepsis syndrome. This is a retrospective review of all patients admitted to a Level I trauma center who underwent multiple fiberoptic bronchoscopies (FOBs) for diagnosis of suspected VAP as the cause of postinjury sepsis syndrome. The relationships between EAB administration, positive cultures (>105 colony-forming units) at repeat FOB, and prevalence of opportunistic organisms (methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Stenotrophomonas species, Acinetobacter species, and/or yeast) were evaluated. Over a 13-month period ending on January 1, 1999, 36 intubated trauma patients underwent more than one FOB during their intensive care unit stay. Twenty-nine patients received EAB immediately after the initial FOB. There was no difference in the rate of EAB administration in patients who developed subsequent VAP after initial FOB (19 of 24,79%) versus those who did not develop VAP (10 of 12, 83%; P = 0.65). There were 30 VAPs diagnosed in 58 subsequent FOBs ( i.e., after the initial FOB) of which 23 were due to an opportunistic organism compared with two VAPs due to an opportunistic organism diagnosed at initial FOB ( P < 0.001). Twenty-one of the 23 opportunistic VAPs at subsequent FOBs had received EAB before the first FOB compared with four of seven nonopportunistic organisms ( P = 0.06). Administration of EAB does not impact the incidence of subsequent VAP. However, EAB may be related to the development of subsequent opportunistic pulmonary infections.
Surgical Experience with Nonfunctioning Neuroendocrine Tumors of the Pancreas
Authors: Matthews Brent D. , Heniford B. Todd , Reardon Patrick R. , Brunicardi F. Charles , Greene Fredrick L.
Published: November 2022

Nonfunctioning neuroendocrine tumors of the pancreas are rare slow-growing tumors with a more indolent natural history compared with pancreatic adenocarcinoma. This retrospective report reviews the surgical experience with nonfunctioning neuroendocrine tumors in an academic referral center. Statistical analysis was performed using Student's t test and Kaplan-Meier method compared with log-rank tests. Thirty-eight patients (24 males and 14 females) underwent surgery for a neuroendocrine tumor of the pancreas from 1984 through 1999. Twenty-eight patients with a mean age of 59.9 years had nonfunctioning islet cell tumors and 10 patients with a mean age of 59.1 years had functioning islet cell tumors (four gastrinomas, three glucagonomas, two insulinomas, and one vipoma). The nonfunctioning islet cell tumors were located in the head, neck, or uncinate process in 14 patients (50%), the body in seven (25%), and the tail in seven (25%). Operative procedures for the nonfunctioning islet cell tumors included nine pancreaticoduodenectomies, 12 distal pancreatectomies, three palliative bypasses, and four exploratory laparotomies without a resection or bypass. Mean survival for the four patients explored and not resected or bypassed was 7 months. Median survival for node-negative patients was 124 months, for node-positive patients 75 months, and for patients with metastasis to the liver 9 months. Estimated 2-year actuarial survival for the node-negative patients was 77.8 per cent, for node-positive patients 71.4 per cent, and for patients with metastasis to the liver 36.4 per cent. Six patients (60%) with node-negative disease, three (43%) with node-positive disease, and one (9%) with metastasis to the liver are alive at a mean follow-up of 41.8 months (range 1–167). Significant differences in median survival and 2-year survival were demonstrated between the node-positive/node-negative patients and those with metastasis to the liver ( P = 0.003). Patients with localized nonmetastatic disease should be considered for pancreatic resection as estimated median survival is 75 months or greater. Hepatic metastasis is a major predictor of survival.
Unusually Aggressive Rectal Carcinoid Metastasizing to Larynx, Pancreas, Adrenal Glands, and Brain
Authors: Danikas Dimitrios , Theodorou Spero J. , Matthews William E. , Rienzo Albert A.
Published: November 2022

Rectal carcinoids are slow-growing tumors. They metastasize when their size is more than 2 cm. Common sites of metastasis are the liver, lungs, and bones. Metastases to thyroid, pancreas, kidneys, adrenal glands, pituitary glands, posterior fossa, and spleen are very rare. We present the case of a 79-year-old white man with dysphagia and left vocal cord paralysis from a rapidly growing mass in his neck. Needle biopsy suggested thyroid anaplastic carcinoma, and the patient underwent total laryngectomy, total thyroidectomy, and left radical neck dissection. Pathology showed undifferentiated carcinoid of the larynx. Biopsy of a rectal mass suggested poorly differentiated carcinoma. Postoperatively the patient developed cardiac arrhythmias and died after 5 weeks. Autopsy showed a 5-cm carcinoid of the rectum with extensive vascular invasion extending into the perirectal fat. There was metastatic disease to both lungs, liver, pancreas, both adrenal glands, peritoneum, subcutaneous tissues of thorax and abdomen, ribs, vertebrae, skull, and the leptomeninges of the cerebrum. Rectal carcinoids may present a variable histologic picture. Poorly differentiated tumors can present with widespread metastases and have poor prognosis. Extensive surgery may not improve the survival of patients with this pattern of unusually aggressive carcinoid.
Effect of a Composite Membrane of Chitosan and Poloxamer Gel on Postoperative Adhesive Interactions
Authors: Vlahos Angie , Yu Pingyang , Lucas Charles E. , Ledgerwood Anna M.
Published: November 2022

Excessive postoperative adhesion formation is a major result of surgery. The adhesion reduction effects of a chitosan membrane and poloxamer gel barrier were measured in a rat peritoneal model. Forty-four male Sprague-Dawley rats were divided into four groups (control, poloxamer, chitosan, and poloxamer+chitosan sandwich). Two cm2 of cecal serosa and the adjacent abdominal wall were abraded. The denuded cecum was covered with either a chitosan membrane, a poloxamer gel, chitosan in a sandwich configuration with poloxamer on both sides, or neither (control group) and apposed to the abdominal wall. Fourteen days after surgery adhesions were graded using a whole-number scoring system of zero to five. Adhesion strength was determined using a whole-number system of one to four. Adhesion area was measured on a continuous scale of adhesion severity. Adhesion grades were highest in the control group (5.00 ± 0.00) and were significantly ( P < 0.05) lower in the poloxamer group (3.50 ± 1.35), the chitosan group (1.64 ± 1.63), and the poloxamer+chitosan group (1.18 ± 1.25). The two chitosan-containing groups also had significantly ( P < 0.05) reduced adhesion grades in comparison with the poloxamer group. Adhesion area in both chitosan-containing groups was reduced in comparison with control and adhesion strength was reduced significantly ( P < 0.05) in all groups compared with control. The poloxamer+chitosan group had significantly ( P < 0.05) reduced adhesion strength versus poloxamer only. There was a significant ( P < 0.05) linear correlation ( r = 0.931, P < 0.001) between adhesion grade and adhesion strength. We conclude that chitosan and the combination of poloxamer+chitosan were shown to effectively reduce adhesion area, grade, and strength.
Evolving Techniques in the Treatment of Carotid Artery Kinking: The Use of Resected Redundant Arterial Segment
Authors: Gugulakis A.G. , Matsagas M.I. , Vasdekis S.N. , Giannakakis S.G. , Lazaris A.M. , Sechas M.N.
Published: November 2022

Internal carotid artery kinking is frequently accompanied by atheromatous disease at the carotid bifurcation, and in this case both lesions may be treated simultaneously. Various surgical techniques have been used to correct carotid kinking but no particular one has been widely established. We conducted a retrospective review of 18 patients operated upon for internal carotid kinking during the last 5 years, which represents 4.1 per cent of the total carotid procedures performed during the same period. In 13 of the 18 patients carotid endarterectomy was performed before the repair of the kink. In four patients resection of the kinked segment with end-to-end anastomosis was performed combined with longitudinal arteriotomy at the carotid bifurcation. Two patients developed restenosis at the site of anastomosis requiring reoperation with patch angioplasty. Three patients were treated with eversion endarterectomy and end-to-side anastomosis, whereas in six patients we performed resection of the redundant internal carotid artery combined with longitudinal arteriotomy at the bifurcation. The posterior wall was reconstructed with interrupted sutures and the procedure was completed with patch angioplasty of the anterior wall. In four of these cases we used the autogenous resected arterial segment as patch material. None of these patients developed restenosis or symptoms in a follow-up period of 3 to 32 months. In cases in which significant carotid artery stenosis and internal carotid kinking coexist resection of the involved segment with end-to-end anastomosis of the posterior wall and patch angioplasty using the resected autogenous arterial segment constitute a convenient and satisfactory method of reconstruction.
Splenic Abscess: Report of Six Cases and Review of the Literature
Authors: Green Bryan T.
Published: November 2022

Splenic abscesses are rare but appear to be increasing in frequency. Recent advances in radiologic techniques have affected the diagnosis and management. The purpose of this study was to evaluate these effects. The medical records of one institution were retrospectively reviewed and six cases of splenic abscesses seen between 1989 and 1999 were identified. All patients had predisposing conditions with metastatic hematogenous infection in three and one each with trauma, immunodeficiency, and a contiguous site of infection. Fever was present in all patients with chills and vomiting in five and three patients, respectively. Left upper quadrant tenderness appeared in four patients and leukocytosis was found in every patient except one with the acquired immunodeficiency syndrome. Chest roentgenograms were abnormal in five patients with a left pleural effusion most common. Ultrasound revealed the defect in both patients it was utilized in and computed tomography was diagnostic in all cases. The causative organisms were anaerobes in two cases and Candida albicans, Streptococcus viridans, Escherichia coli, and Citro-bacter freundii each present in one case. Radiology guided percutaneous drainage was attempted in four patients but was only successful in one. Splenectomy with antibiotics was curative in the remainder with a 100 per cent survival. These data suggest that percutaneous drainage may be appropriate for certain patients initially, but the high failure rate demonstrates that splenectomy remains the standard treatment.
The Potential Value of Intraoperative Imprint Cytology of Axillary Sentinel Lymph Nodes in Breast Cancer Patients
Authors: Cserni Gábor
Published: November 2022

Axillary sentinel nodes predict the node status and may allow dissection of the axilla on a selective basis. Seventy-two sentinel nodes from 60 patients identified with Patent blue and/or the high radioactivity due to the uptake of 99m-Tc-labeled colloidal albumin were bisected for hematoxylin and eosin-stained touch preparations. The sentinel nodes were submitted in toto for permanent step sections and immunostained for cytokeratins. The imprints had a sensitivity of 83 per cent, a negative predictive value of 86 per cent, and a false negative rate of 17 per cent when the cut surface histology was considered. These corresponding values were 59, 68, and 41 per cent on a patient basis when the whole sentinel node histology was considered as many micrometastases did not appear in the cut surface sampled by the imprints. Although up to two-fifths of patients with tumor cells in the sentinel lymph nodes may be undetected by the method imprint cytology is valuable in the intraoperative assessment of sentinel nodes. This series suggests that 78 per cent of the patients can be adequately selected for a one-step axillary operation on the basis of intraoperative imprints. Results may be improved if the surface sampled is appropriately large and well selected.
Metastatic Soft Tissue Squamous Cell Carcinoma
Authors: Kim Christina J. , Day Scott , Yeh Karen A.
Published: November 2022

Metastatic squamous cell carcinoma of the soft tissue is extremely rare. We report two patients with soft tissue metastasis from squamous cell carcinoma of the cervix in one and scalp in another. Case 1: A 63-year-old black woman with a history of cervical cancer presented with a painful mass over the right scapula. An incisional biopsy revealed squamous cell carcinoma. She underwent radiation treatment followed by wide local excision with en bloc resection and a myocutaneous flap closure. Case 2: A 46-year-old white man with a history of squamous cell carcinoma of the scalp and two kidney transplantations requiring long-term immunosuppression presented with a 2-month history of a left proximal arm mass. Magnetic resonance imaging revealed that the mass was within the triceps muscle and fixed to the humerus. Biopsy revealed squamous cell carcinoma. He underwent a shoulder disarticulation for tumor invasion into the adjacent humerus and neurovascular bundles. The patients remain disease-free at 12 and 8 months, respectively. To our knowledge there are no reports of soft tissue squamous cell carcinoma metastatic from the cervix and only rare cases from the lung, head, and neck. The optimal mode of treatment and prognosis is undefined in these patients because of its rare incidence. Surgery and radiation with curative intent were used.
Vagus Nerve Stimulation in Pediatric Patients with Intractable Epilepsy: Case Series and Operative Technique
Authors: Farooqui Shuaib , Boswell William , Hemphill J. Michael , Pearlman Eric
Published: November 2022

Patients with epilepsy refractory to medical therapy or who experience intolerable side effects from the medication may benefit from placement and activation of a vagus nerve stimulator (VNS) (Cyberonics, Houston, TX). We present our experience with the VNS implanted by a pediatric surgeon and its activation managed by a pediatric neurologist. Six patients (one male and five females) with average age 11 years, 10 months (range 7 years, 4 months to 18 years, 1 month) received VNS implants at a community-based teaching hospital. One patient developed a self-inflicted wound complication secondary to persistent trauma at the implant site that led to removal of the implant. Before VNS implantation the frequency of seizures among the remaining five patients averaged 73 per patient per month (range 20–165). Length of follow-up averaged 6.5 months (range 1.5–11 months). At most recent follow-up seizure frequency averaged 14 per month (range 1–42); this represents an average reduction of 78 per cent (range 30–99%). We conclude that a pediatric surgeon with pediatric neurologic support can safely and effectively perform the VNS implantation at a hospital equipped to administer anesthesia to pediatric patients.
Nonoperative Management of Blunt Splenic and Hepatic Trauma in the Pediatric Population: Significant Differences between Adult and Pediatric Surgeons?
Authors: Jacobs Ira A. , Kelly Kathleen , Valenziano Carl , Pawar Joanne , Jones Carol
Published: November 2022

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.
The Effects of Triiodothyronine Augmentation on Antithrombin III Levels in Sepsis
Authors: Chapital Alyssa D. , Hendrick Steven R. , Lloyd Larry , Pieper David
Published: November 2022

Sepsis and multisystem organ failure are often associated with disseminated intravascular coagulation and consumption of coagulation inhibitors such as antithrombin III (ATIII). The “sick euthyroid syndrome” is also seen in association with significant illnesses and consists of decreased levels of circulating triiodothyronine (T3). We evaluated whether T3 supplementation would affect ATIII levels in septic rats. Thirty Sprague-Dawley rats were divided into three groups: sham laparotomy (S) plus saline, cecal ligation and puncture (CLP) plus saline, and CLP plus T3 (3 ng/hour) via an osmotic minipump. Twenty-four hours after laparotomy blood was drawn, and T3 and ATIII levels were then compared with baseline values. T3 supplementation partially negated the sepsis-induced decrease in circulating T3 levels. The levels are expressed as percentage change from the levels before surgery (S, -12.9 ± 3.1; CLP, -60.0 ± 5.3; CLP + T3, -34.9 ± 4.3; mean ± standard error; P < 0.05). T3 supplementation also statistically changed the percentage difference in ATIII levels toward the control (S, 9.6 ± 2.8; CLP, - 37.9 ± 5.4; CLP + T3, -16.0 ± 4.5; mean ± standard error; P < 0.01). T3 supplementation reduced the sepsis-induced decrease in ATIII levels. Whether this was accomplished by decreased consumption or increased production of ATIII via the direct anabolic effect of T3 on acute-phase protein synthesis in the liver is unknown and warrants further investigation.
Risk of Parathyromatosis after Fine-Needle Aspiration
Authors: Kendrick Michael L. , Charboneau J. William , Curlee Kathleen J. , Van Heerden Jon A. , Farley David R.
Published: November 2022

Reoperative surgery for hyperparathyroidism (HPT) is fraught with hazard. When preoperative imaging studies are inconclusive or patient comorbidities are extensive fine needle-aspiration (FNA) is helpful to confirm the presence of suspected parathyroid tissue in the neck. Some surgeons refrain from using FNA because of the concern of tissue implantation (parathyromatosis). A retrospective review (1984–1996) of all patients diagnosed with HPT undergoing FNA of suspected parathyroid tissue was performed to document whether a correlation exists between FNA of suspected parathyroid tissue and subsequent development of parathyromatosis. Parathyromatosis was considered to have occurred when proven by histology or suspected on the basis of clinical studies. Of 81 patients with HPT undergoing ultrasound-guided FNA to assess abnormalities in the neck 41 patients with confirmed parathyroid tissue were identified. The indications for FNA in these 41 patients were: prior failed cervical exploration (n = 33), prior neck surgery and/or radiation (n = 2), inconclusive noninvasive imaging studies (n = 15), and severe comorbidities (n = 8). Mean follow-up was 5.8 years. No case of FNA-induced parathyromatosis was identified. FNA is useful to confirm the presence of parathyroid tissue in very select patients with hyperparathyroidism. FNA often eliminates the need for other imaging studies, may prevent a needless or likely fruitless re-exploration, and does not cause parathyromatosis.
Treatment of Severe Acute Respiratory Distress Syndrome: A Final Report on a Phase I Study
Authors: Hardaway Robert M. , Harke Henning , Tyroch Alan H. , Williams Charles H. , Vazquez Yvonne , Krause Gary F.
Published: November 2022

Adult respiratory distress syndrome (ARDS) has a high mortality. Its only effective treatment is respiratory therapy. If this fails mortality is probably 100 per cent. No other treatment for ARDS has proved effective including “magic bullets.” Twenty patients suffering from ARDS secondary to trauma and/or sepsis failed to respond to treatment with mechanical ventilation and positive end-expiratory pressure. On the assumption that disseminated intravascular coagulation initiates ARDS by occluding the pulmonary microcirculation with microclots, the patients were treated with plasminogen activators. The patients responded with significant improvement in partial pressure of oxygen in arterial blood. No bleeding occurred and clotting parameters remained normal. We conclude that ARDS can be safely treated with plasminogen activator.
Jejunoileal Causes of Overt Gastrointestinal Bleeding: Diagnosis, Management, and Outcome
Authors: Schwesinger Wayne H. , Sirinek Kenneth R. , Gaskill Harold V. , Velez Jose P. , Corea Juan J. , Strodel William E.
Published: November 2022

Major bleeding from the small intestine is uncommon and difficult to localize. We examined its etiologies and assessed available diagnostic and therapeutic approaches. The records of all adults undergoing operation for small intestinal hemorrhage over a 10-year period (1/89–12/98) were reviewed. There were eight men and four women with a mean age of 54 years. Six patients presented with arteriovenous malformations. Preoperative diagnosis was by endoscopy (three of six), scintigraphy (two of two), and/or angiography (two of six). Intraoperative panendoscopy was used for localization in 5 cases. Three other patients had tumors (leiomyoma, leiomyosarcoma, and adenocarcinoma) by CT scan (two) and/or scintigraphy (two). All were resected but one patient died of recurrence. Two patients underwent resection of a Meckel's diverticulum, one after angiographic diagnosis. Another patient with Crohn's disease had a positive angiogram and colonoscopy before resection. There were no operative deaths but major morbidity occurred in five patients (42%) and hospitalization averaged 17 days. We conclude that jejunoileal lesions are a rare cause of intestinal bleeding but can be associated with substantial morbidity. Arteriovenous malformations and tumors remain the most common causes. An accurate diagnosis and definitive management depend on selective preoperative imaging and judicious operative exploration.
Closure of the Abdominal Midline Fascia: Meta-Analysis Delineates the Optimal Technique
Authors: Rucinski James , Margolis Mark , Panagopoulos Georgia , Wise Leslie
Published: November 2022

The current surgical literature has not clearly demonstrated an optimal technique for abdominal closure. Prospective randomized studies published between 1980 and 1998 were analyzed and the relevant data derived from those studies were pooled for statistical evaluation. The outcome variables of dehiscence, infection, hernia formation, suture sinus formation, and pain were studied and the probability of their occurrence in association with different techniques was calculated. In relation to the outcome features of dehiscence and infection no statistically significant difference was seen when absorbable suture material was compared with nonabsorbable material. In regard to the probability of hernia formation no statistically significant difference was seen when monofilament absorbable material was compared with nonabsorbable material. There was, however, a higher incidence of hernia formation when braided absorbable suture material was used. In addition there was a higher incidence of incision pain and suture sinus formation when nonabsorbable suture material was used. Absorbable monofilament suture material is superior to both absorbable braided and nonabsorbable suture for abdominal fascial closure. A continuous mass (all-layer) closure with absorbable monofilament suture material is the optimal technique for fascial closure after laparotomy.