bluuebunny/crossref_metadata_2025 huggingface dataset:
Preoperative Pain is the Strongest Predictor of Postoperative Pain and Diminished Quality of Life after Ventral Hernia Repair
Authors: Tsirline Victor B. , Colavita Paul D. , Belyansky Igor , Zemlyak Allay , Lincourt Amy E. , Heniford B. Todd
Published: June 2020

With evolution of hernia repair surgery, quality of life (QOL) became a major outcome measure in nearly 350,000 ventral hernia repairs (VHRs) performed annually in the United States. This study identified predictors of chronic pain after VHR. A prospective database of patient-reported QOL outcomes at a tertiary referral center was queried from 2007 to 2010; 512 patients met inclusion criteria. Factors including demographics, medical comorbidities, preoperative symptoms, and hernia characteristics were analyzed using advanced statistical modeling. Average age was 56.4 years, 57.6 per cent were males, mean body mass index was 33 kg/m2, hernia defect size was 138 cm2, and 35.5 per cent were repaired laparoscopically. Preoperatively, 69 per cent of patients had mild and 28 per cent severe pain during some activities. Pain levels were elevated in the first month postoperatively; by 6 months, patients reported significant improvement. The most significant and consistent predictor of postoperative pain was the presence of preoperative pain (odds ratio, 2.1; 95% confidence interval, 1.4 to 3.0; P = 0.0001). Older patients and men had less postoperative pain, but they also had less preoperative pain, so these factors were not independent predictors. Patients with minimal preoperative symptoms uniformly experienced resolution of pain by 6 months postoperatively. Among patients with severe preoperative pain, one-third reported long-term resolution of pain, and one-third had persistent severe pain. The former group had smaller hernias (91 vs 194 cm2, respectively, P = 0.015). Cases of new-onset, long-term pain after VHR were rare (less than 2%). Most patients’ symptoms resolve by 6 months after surgery, but those with severe preoperative pain are at risk for persistent postoperative pain.
Manifestations of Pediatric Appendicopathia Oxyurica
Authors: Jordan Mary M. , Sanders Jennifer E. , Stallworth Christina R. , Russell Scott , Titus Olivia , Hill Jeanne G. , Cina Obert A.
Published: June 2020

Enterobius vermicularis is a parasite that inhabits the human digestive tract. We present two pediatric patients with symptoms mimicking acute appendicitis who were found to have E. vermicularis infection. The first case is a 5-year-old female who presented with flank and abdominal pain associated with low-grade fever and anorexia. She had localized tenderness in the right lower quadrant and a leukocytosis with left shift. Intraoperative findings included a normal-appearing appendix, but ex vivo examination revealed Enterobius vermicularis. The second case is a 7-year-old female who presented with periumbilical abdominal pain, anorexia, and emesis. She had tenderness at McBurney's point, and ultrasound revealed a small echogenic focus within the appendix. Intraoperatively, the distal tip of the appendix appeared inflamed. Again, ex vivo examination revealed E. vermicularis. Enterobius vermicularis infection of the appendix can present with a clinical picture similar to acute appendicitis. In at-risk populations, it should be included in the differential diagnosis for children with right lower quadrant abdominal pain. Complete therapy requires treatment with mebendazole.
Delays in Treatment of Pediatric Appendicitis: A More Accurate Variable for Measuring Pediatric Healthcare Inequalities?
Authors: Ladd Mitchell R. , Pajewski Nicholas M. , Becher Robert D. , Swanson John M. , Gallaher Jared R. , Pranikoff Thomas , Neff Lucas P.
Published: June 2020

Racial and socioeconomic factors may cause barriers to healthcare access that result in delayed treatment. Because perforated appendicitis (PA) in children is thought to result from delays in treatment, it is often used as an index of barrier to access. Recent literature suggests that PA is not an inevitable consequence of delayed treatment, so it may not be the best marker for evaluating such barriers. Therefore we investigated whether racial and socioeconomic factors led directly to delays in treatment. We performed a retrospective study of 667 children undergoing appendectomy in a tertiary care center over 12.5 years. Univariate and multivariable regression analyses were used to determine if racial and socioeconomic variables were associated with increased risk of PA and increased risk of symptom duration greater than 48 hours. Hispanic children have higher rates of PA regardless of delays in treatment whereas Black children had higher PA rates likely due to delays in treatment. These differences were not from socioeconomic factors in our cohort. PA, a heterogeneous disease whose course is determined by multiple factors, is not a good metric for evaluation healthcare disparities in the pediatric population. Delays in treatment may be a more appropriate measure of healthcare inequalities in children.
Resection of a Giant Hepatic Adenoma in an Eight-year-old Girl
Authors: Morris Michael W. , Berch Barry , Westmoreland Tammy , Sawaya David E. , Blewett Christopher J.
Published: June 2020

Hepatic adenomas are benign tumors typically diagnosed in women of reproductive age, however, these tumors occur in the pediatric population although rare. We present the case of a giant hepatic adenoma in an 8-year-old female without established risk factors with progressive abdominal pain, and po intolerance, biliary obstruction, anemia, and fever. Right trisegmentectomy afforded extirpation of the 16 3 14.5 3 8.5 cm mass. The postoperative course was complicated by transient encephalopathy and a bile leak which resolved with appropriate care. The patient is well over 1 year from resection. She demonstrates age appropriate mental and physical function without disease recurrence or complication.
Effects of Race and Insurance on Outcomes of the Open Abdomen
Authors: Clark Jason M. , Cheatham Michael L. , Safcsak Karen , Alban Rodrigo F.
Published: June 2020

Recent studies have suggested improved outcomes in surgical patients with healthcare insurance, whereas several others have noted disparities in access to health care, the care provided, and the aftercare of uninsured patients. Several different strategies exist in the management and prevention of the open abdomen secondary to abdominal compartment syndrome. To date, no study has evaluated the effects of race and insurance in patients with an open abdomen (OA). A retrospective review from our OA database was queried. All patients with an OA from January 2002 to December 2010 were included for analysis. Data analyzed included patients’ demographics, race, insurance status, hospital charges, Injury Severity Scores, and outcomes. Insured patients were identified and compared with their uninsured counterparts. A total of 720 patients were treated for an OA during the study period. Of these, 273 (37.9%) died within their hospital stay. Patients who died were noted to be older and sicker with higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiologic Scores (27.6 vs 18.2, P < 0.001 and 54.6 vs 38.5, P < 0.001, respectively). Logistic regression analysis revealed that age, APACHE II, and Injury Severity Scores were independently associated with mortality. From our categorical variables, race was not associated with worse outcomes. In addition, being uninsured was significantly associated with increased mortality (odds ratio, 1.67; 95% confidence interval, 1.1 to 2.6; P = 0.05). “Self-pay” status was associated with increased mortality even after adjusting for severity of illness. Further studies incorporating baseline comorbidities need to be undertaken to further assess the reasons for these disparities.
Emergency Department Thoracotomy: Too Little, Too Much, or Too Late
Authors: Capote Allan , Michael Andrew , Almodovar Jorge , Chan Patricia , Skinner Ruby , Martin Maureen
Published: June 2020

Emergency department thoracotomy (EDT) is a dramatic lifesaving procedure demanding timely surgical intervention, technical expertise, and coordinated resuscitation efforts. Inappropriate use is costly and futile. All patients admitted to a Level II trauma center who underwent EDT from January 2003 to July 2012 were studied. The primary end point was appropriateness of EDT. Secondary end points were staff exposure, survival, and return to normal function. Eighty-seven patients including 59 patients with penetrating wounds had a mean loss of vital signs (LOV) 11.6 610.6 minutes and Injury Severity Score (ISS) of 45.8 ± 16.1, whereas 28 blunt injury patients had a mean LOVof 10.4 ± 11.5 minutes and ISS of 50.4 ± 19.4. Mortality was 81 per cent (48 of 59) in penetrating injury and 93 per cent (26 of 28) in blunt injury patients, respectively (odds ratio [OR] 2.99; P 0.21). Fifty-five EDTs were indicated with 10 survivors (18.2%) and 32 not indicated with three survivors (9.4%). Surgeons adhered to guidelines more compared with ED physicians (OR, 4.9; P = 0.03) whose patients were more likely to die (OR, 3.52; P = 0.124). Survivors (11 of 13 [84.6%]) were discharged home without significant long-term neurologic disability. EDT is lifesaving when performed for penetrating injury by experienced surgeons following established guidelines but futile in blunt injury or when performed by nonsurgeons regardless of mechanism.
Validation of Revised American Joint Committee on Cancer Staging for Gallbladder Cancer Based on a Single Institution Experience
Authors: Koh Christinay , Demirjian Aram N. , Chen Wen-Pin , Mclaren Christine E. , Imagawa David K.
Published: June 2020

Gallbladder cancer is a rare malignancy, which often goes undiagnosed until advanced stages of disease and is associated with poor prognosis. The only potentially curative treatment is surgical resection. This retrospective study aims to investigate the validity of the revised 7th edition American Joint Committee on Cancer staging criteria and determine prognostic factors. Forty-two patients with confirmed gallbladder cancer who underwent attempted curative resection from 1999 to 2012 at the University of California, Irvine Medical Center were reviewed. Survival probability was determined using the Kaplan-Meier method. Ten patients underwent laparoscopy, were deemed unresectable, and no further surgical intervention was performed. R0 surgical resection, which included radical portal lymphadenectomy, liver segment IVb/Vresection, with or without bile duct resection, was performed in the remaining 32 patients. N2 nodes were resected if positive on frozen section. Overall survival probability for Stage I to II patients was 100 per cent. Overall survival probability for Stage III patients was 80 per cent (95% confidence interval [CI], 61 to 99%) and 39.3 per cent (95% CI, 28 to 78%) for Stage IV patients. This study demonstrates that 7th edition clinical stage, T stage, and liver involvement are statistically significant predictors of prognosis. These data also demonstrate a benefit to extended resection in patients even with Stage III and IV disease.
Outcomes of Vascular Resection in Pancreaticoduodenectomy: Single-surgeon Experience
Authors: Menon Vijay G. , Puri Vichin C. , Annamalai Alagappan A. , Tuli Richard , Nissen Nicholas N.
Published: June 2020

Extension of pancreatic adenocarcinoma into adjacent vasculature often necessitates resection of the portal vein (PV) and/or superior mesenteric vein (SMV) during pancreaticoduodenectomy (PD). The vein is reconstructed primarily by end-to-end anastomosis of vein remnants or venoplasty or by use of autologous or synthetic vein grafts. The objective of this study was to review outcomes in patients undergoing PD for pancreatic adenocarcinoma, specifically comparing the short- and long-term outcomes between the patients undergoing vascular resection and those undergoing standard PD. All patients undergoing PD for pancreatic adenocarcinoma by a single surgeon between 2007 and 2012 were reviewed. Of the 61 patients identified, 18 patients underwent vascular resection of the PV (four patients), SMV (10 patients), or both (four patients). The remaining 43 patients had standard PD. Demographic, perioperative, pathological, and long-term outcomes data were collected and both vascular and standard groups were compared. Both groups had similar demographics. The vascular group had significantly longer operative times (529 vs 406 minutes; P < 0.01) with a trend to greater estimated blood loss (0.64 vs 0.53 L; P = 0.06). Pathological analysis showed no difference between the two groups with regard to lymph node status/ratio and rate of R0 resection (94 vs 91%; P = 0.57); however, the size of the tumor was significantly greater in the vascular group (4.2 vs 3 cm; P < 0.01). Short-term outcomes were similar in the vascular group and standard group, respectively, with no difference in pancreatic fistula rate (6 vs 7%; P = 1.0), transfusion rate (44 vs 35%; P = 0.57), and median length of stay (8 vs 7 days; P = 0.10), and there was no 30-day mortality in either group. Based on Kaplan-Meier methods, the median recurrence-free survival was 18 versus 23 months ( P = 0.37) in the vascular and standard groups, respectively, and the overall survival was almost identical in both groups, each with a median of 31 months ( P = 0.91). In our experience, mesenteric and PV resection during PD was performed safely and without compromise of short- or longer-term outcomes. It can be performed safely and patients have no significant difference in perioperative outcomes or overall survival.
Acute Hemodilution is Safe in Patients with Comorbid Illness Undergoing Partial Hepatectomy
Authors: Putchakayala Krishna , DiFronzo L. Andrew
Published: June 2020

Despite increased use of acute hemodilution (AH) to reduce perioperative blood transfusion in patients undergoing partial hepatectomy, there is a lack of data on safety in those with comorbid medical illness. We performed a retrospective review of 96 patients undergoing partial hepatectomy with AH and low central venous pressure (CVP) anesthesia. The cohort was compared with 63 patients undergoing partial hepatectomy using standard anesthetic management (SA) and low CVP anesthesia. All were American Society of Anesthesiologists physical status 3 or 4. 58 per cent were baseline hypertensive on medication. Hepatic resection was predominantly performed for metastatic colorectal (41%) and primary hepatic (32%) cancer. Forty per cent underwent major hepatectomy. The mean volume of blood removed for AH was 497 mL (range, 0 to 1 L). Most achieved low CVP (AH 90% vs SA 84%, P = 0.3). Blood loss was lower with AH (mean 480 mL vs 904 mL, P < 0.001). Blood transfusion rate was 74 per cent lower with AH ( P < 0.001). There was no difference in cardiac, respiratory, renal, or overall complications with AH compared with SA. Acute hemodilution is well tolerated by patients with comorbid illness undergoing partial hepatectomy, favoring ongoing use and further study.
When it is not a Spigelian Hernia: Abdominal Cutaneous Nerve Entrapment Syndrome
Authors: Towfigh Shirin , Anderson Shannon , Walker Andrea
Published: June 2020

Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be left with chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.
Proposed Classification of Pseudomyxoma Peritonei: Influence of Signet Ring Cells on Survival
Authors: Shetty Shreya , Natarajan Bala , Thomas Peter , Govindarajan Venkatesh , Sharma Poonam , Loggie Brian
Published: June 2020

The nomenclature and classification of pseudomyxoma peritonei (PMP) is confusing and controversial. Numerous classification systems have been proposed, none of which are easily reproducible or a useful guide for treatment. Patients with PMP of appendiceal origin were identified from our institution's database. Kaplan-Meier analyses were performed based on a proposed new PMP classification, a three-tiered grading system designated PMP1, PMP2, and PMP3. These results were compared with the established schemes by Ronnett and Bradley et al. There were 211 patients included in the analysis with a mean age of 51 ± 12 years at diagnosis. For PMP1, 86 patients (40.8%) included cases with abundant extracellular mucin and columnar non-stratified epithelium without dysplasia or atypia. For PMP3, 50 patients (23.7%) consisted of PMP with any percentage of signet ring cells (SRCs), For PMP2, 75 patients (35.5%) included all other patients. The mean age (± standard deviation) for PMP 1, 2, and 3 were 51 ± 12, 51 ± 12, and 51 ± 10 years, respectively ( P = 0.90). The three groups had similar sex distribution ( P = 0.24) and resection status ( P = 0.47). Kaplan-Meier analyses showed median survivals of 120, 88, and 40 months and 5-year survival rates of 85.7, 63.05, and 32.2 per cent ( P < 0.0001) for PMP 1, 2, and 3, respectively. Three distinct categories, PMP1, 2, and 3, were identified, which provide better stratification in terms of overall survival and represent differences in tumor biology that may impact treatment recommendations.
Preliminary Report of a Sutureless Onlay Technique for Incisional Hernia Repair Using Fibrin Glue Alone for Mesh Fixation
Authors: Stoikes Nathaniel , Webb David , Powell Ben , Voeller Guy
Published: June 2020

The Rives repair for ventral/incisional (V/I) hernias involves sublay mesh placement requiring retrorectus dissection and transfascial stitches. Chevrel described a repair by onlaying mesh after a unique primary fascial closure. Although Chevrel fixated mesh to the anterior fascia with sutures, he used fibrin glue for fascial closure reinforcement. We describe an onlay technique with mesh fixated to the anterior fascia solely with fibrin glue without suture fixation. From January 2010 to January 2012, 50 patients underwent a V/I hernia onlay technique with fibrin glue mesh fixation. Records were reviewed for technical details, demographics, mesh characteristics, and postoperative outcomes. Primary fascial closure with interrupted permanent suture was done with or without myofascial advancement flaps. Onlay polypropylene mesh was placed providing 8 cm of overlap. Fibrin glue was applied over the prosthesis and subcutaneous drains were placed. Mean age was 62.4 years. Mean body mass index was 30.1 kg/m2. Average mesh size was 14.5 cm 3 19.1 cm. Mean operative time was 144.4 minutes (range, 38 to 316 minutes). Mean discharge was postoperative Day 2.9 (range, 0 to 15 days). Morbidity included eight seromas, one hematoma, and three wound infections. Seventeen patients required components separation. Mean follow-up was 19.5 months with no recurrences. This is the first series describing fibrin glue alone for mesh fixation for V/I hernia repair. It allows for immediate prosthesis fixation to the anterior fascia. Early results are promising. Potential advantages include less operative time, less technical difficulty, and less long-term pain. A prospective trial is needed to evaluate this approach.
Submucosal Anoderm-Preserving Hemorrhoidectomy Revisited: A Modified Technique for the Surgical Management of Hemorrhoidal Crisis
Authors: Theodoropoulos George E. , Michalopoulos Nikolaos V. , Linardoutsos Dimitrios , Flessas Ioannis , Tsamis Dimitrios , Zografos George
Published: June 2020

Submucosal hemorrhoidectomy (Parks’ procedure) is a recognized method for treating acute hemorrhoidal crisis. Anoderm preservation has been stressed in various techniques described for elective or emergency excisional hemorrhoidal management. Mucopexy techniques have been proven useful as an adjunct to minimally resectional techniques. A modified submucosal technique with anoderm preservation and mucopexy was applied to 45 patients who presented on an emergency basis with hemorrhoidal crisis. External piles were minimally removed, the minimum possible amount of diseased mucosa was excised, a linear incision was used at the anoderm to enter the subanodermal/mucosal plane to achieve the submucosal excision, and a mucopexy was added at the approximation of the mucosal flaps. Postoperative morbidity was minimal and pain after the procedure remained at acceptable levels. This technique allows for an excision limited to the pathology with important anatomic tissue preservation. This results in conservation of the sensitive and useful anoderm, a decreased risk of stenosis, and addresses the mucosal prolapse. The level of postoperative pain with this technique is acceptable and long-term follow-up reveals a high degree of patient satisfaction.
Papillary Lesions on Core Breast Biopsy: Excisional Biopsy for All Patients?
Authors: McGhan Lee J. , Pockaj Barbara A. , Wasif Nabil , Giurescu Marina E. , McCullough Ann E. , Gray Richard J.
Published: June 2020

Excisional biopsy has been recommended for papillary lesions diagnosed on core needle biopsy (CNB) because a significant proportion of cases are upstaged to in situ/invasive cancer after surgical excision. The study goals were to identify patients at lowest risk of upstaging in whom excisional biopsy may potentially be avoided. We retrospectively evaluated 46 patients with a papillary lesion on CNB. Six patients were upstaged overall (13%), to intraductal papillary carcinoma (7%), invasive papillary carcinoma (4%), and mixed invasive ductal/lobular carcinoma (2%). The upstaging rate for patients with atypia on CNB was higher than for patients without atypia (33 vs 3%, P = 0.011). No patient younger than 65 years was upstaged to in situ or invasive carcinoma, and the mean lesion size was also higher among patients who were upstaged ( P > 0.05). Patients younger than 65 years with small papillary lesions lacking atypia on CNB may therefore represent a low-risk group that may be offered close clinical and radiologic follow-up.
One-step Laparoscopic and Endoscopic Treatment of Gallbladder and Common Bile Duct Stones: Our Experience of the Last 9 Years in a Retrospective Study
Authors: Liverani Andrea , Muroni Mirko , Santi Francesco , Neri Tiziano , Anastasio Gerardo , Moretti Marco , Favi Francesco , Solinas Luigi
Published: June 2020

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intra-operative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.
Comparison of Hand-assisted Laparoscopic and Open Radical Distal Gastrectomy for Obese Patients
Authors: Zhang Guang-Tan , Liang Dong , Zhang Xue-Dong
Published: June 2020

To evaluate the feasibility and safety of hand-assisted laparoscopic surgery for gastric cancer in obese patients, we compare the operative outcomes in obese patients who underwent hand-assisted laparoscopic distal gastrectomy (HALDG) and open distal gastrectomy (ODG). One hundred sixty-two obese patients with gastric cancer operated on in our department from January 2009 to December 2011 were divided into two groups: the open distal gastrectomy group (the ODG group) and the hand-assisted laparoscopic distal gastrectomy group (the HALDG group). Operative time, estimated blood loss, number of lymph node retrieval, wound length, times of analgesic injection, time to the first flatus, and postoperative hospital stay were compared between the two groups. Estimated blood loss, wound length, times of analgesic injection, time to the first flatus, and postoperative hospital stay were significantly less or shorter in the HALDG group than in the ODG group. There were no significant differences in tumor size, retrieved lymph nodes, American Joint Cancer Committee /Union Internationale Contre le Cancer staging, and resection margins between the two groups. Obesity should not be seen as a contraindication for HALDG. HALDG for obese patients is a safe, feasible, and oncologically sound procedure and has advantages over ODG.
Prehospital Intubation Does Not Decrease Complications in the Penetrating Trauma Patient
Authors: Taghavi Sharven , Vora Halley P. , Jayarajan Senthil N. , Gaughan John P. , Pathak Abhijit S. , Santora Thomas A. , Goldberg Amy J.
Published: June 2020

Intubation in the prehospital setting does not result in a survival benefit in penetrating trauma. However, the effect of prehospital intubation (PHI) on the development of in-hospital complications has yet to be determined. The goal of this study was to determine if PHI in patients with penetrating trauma results in reduced mortality and in-hospital complications. Patient records for all Category 1 trauma activations as a result of penetrating injury admitted to our institution from 2006 to 2010 were reviewed. There were 1615 Category 1 trauma activations with 152 (9.8%) intubated in the field. A total of 1311 survived initial resuscitative efforts to permit hospital admission with 55 (4.2%) being intubated in the field. For patients surviving to admission, pre-hospital intubation was associated with increased mortality (hazard ratio, 8.266; 95% confidence interval [CI, 4.336 to 15.758; P < 0.001). After correcting for Injury Severity Score, PHI was not protective against pulmonary complications (odds ratio [OR], 0.724; 95% CI, 0.229 to 2.289; P = 0.582), deep vein thrombosis/pulmonary embolus (OR, 0.838; 95% CI, 0.281 to 2.494; P = 0.750), sepsis (OR, 0.572; 95% CI, 0.201 to 1.633; P = 0.297), wound infections (OR, 1.739; 95% CI, 0.630 to 4.782; P = 0.286), or complications of any kind (OR, 1.020; 95% CI, 0.480 to 2.166; P = 0.959). For victims of penetrating trauma, immediate transportation by emergency medical personnel may result in improved outcomes.
Clinical Characteristics and Overall Survival in Patients with Anaplastic Pancreatic Cancer
Authors: Clark Clancy J. , Arun Janani S. , Graham Rondell P. , Zhang Lizhi , Farnell Michael , Reid-Lombardo Kaye M.
Published: June 2020

Anaplastic pancreatic cancer (APC) is a rare undifferentiated variant of pancreatic ductal adenocarcinoma with poor overall survival (OS). The aim of this study was to evaluate the clinical outcomes of APC compared with differentiated pancreatic ductal adenocarcinoma. We conducted a retrospective review of all patients treated at the Mayo Clinic with pathologically confirmed APC from 1987 to 2011. After matching with control subjects with pancreatic ductal adenocarcinoma, OS was evaluated using Kaplan-Meier estimates and log-rank test. Sixteen patients were identified with APC (56.3% male, median age 57 years). Ten patients underwent exploration of whom eight underwent pancreatectomy. Perioperative morbidity was 60 per cent with no mortality. The median OS was 12.8 months. However, patients with APC who underwent resection had longer OS compared with those who were not resected, 34.1 versus 3.3 months ( P = 0.001). After matching age, sex, tumor stage, and year of operation, the median OS was similar between patients with APC and those with ductal adenocarcinoma treated with pancreatic resection, 44.1 versus 39.9 months, ( P = 0.763). Overall survival for APC is poor; however, when resected, survival is similar to differentiated pancreatic ductal adenocarcinoma.
Who Will Benefit from Noncurative Resection in Patients with Gastric Cancer with Single Peritoneal Metastasis?
Authors: Xia Xiang , Li Chen , Yan Min , Liu Bingya , Yao Xuexin , Zhu Zhenggang
Published: June 2020

The value of noncurative resection for patients with gastric cancer with single peritoneal metastasis is still debatable. This study was undertaken to evaluate the survival benefit of resection in those patients. From 2006 to 2009, 119 patients with gastric cancer with single peritoneal metastasis were identified during surgery. Sixty-three of them had noncurative resection; the remainder had nonresection. Clinicopathological variables and survival were analyzed. Overall survival of patients in the noncurative resection group was longer than that in the nonresection group (14.869 vs 7.780 months). This survival advantage was still significantly better in the P1/P2 patients who underwent noncurative resection (mean survival time 21.164 vs 7.636 months, P = 0.001), but not in the P3 group ( P = 0.489). Multivariate analysis indicated that only noncurative resection retained a significant association with better prognosis in P1/P2 patients. The perioperative mortality rate in the resection group was not significantly higher than that of the noncurative group ( P = 0.747). Noncurative resection can prolong the survival of patients with gastric cancer with single P1/P2 peritoneal metastasis. This surgical approach should not be taken into account for those patients with P3 gastric cancer.
Isolated Caudate Lobe Resection for Huge Hepatocellular Carcinoma (10 cm or greater in diameter)
Authors: Dai Wei-Dong , Huang Jiang-Sheng , Hu Ji-Xiong
Published: June 2020

Isolated caudate lobectomy for huge hepatocellular carcinoma (HCC) (10 cm or greater in diameter) is a technically demanding surgical procedure that entails the surgeon's experience and precise anatomical knowledge of the liver. We describe our clinical experiences and evaluate the results of partial or total isolated caudate lobectomy for HCC larger than 10 cm in the caudate lobe. En bloc excisions combined with adjacent hepatic parenchyma (as part of extended hepatectomies) were excluded. Twenty-seven patients were included in the study (24 male, three3 female). Median age was 43 years (range, 18 to 81 years). All primary diagnoses were HCC. Twenty-one patients had surgical margins lesser than 1 cm. Tumor embolus within the main trunk of the portal vein was found in five patients by intraoperative ultrasound. Median operative time was 288 minutes (range, 160 to 310 minutes), and estimated intraoperative blood loss was 2260 mL (range, 200 to 7000 mL). Median blood transfusion was 1460 mL (range, 0 to 7200 mL). Postoperative morbidity rate was 44.4 per cent. There were no postoperative deaths. Overall survival rates at 1, 3, and 5 years were 80.2, 52.1, and 27.1 per cent, respectively. Nineteen patients (70.4%) had tumor recurrence as of the last follow-up. The recurrence lesion was treated in most of these patients. Isolated caudate lobectomy for huge HCC is a technically demanding but safe procedure, although the procedure is sometimes extremely difficult.
Characteristic Risk Factors in Cirrhotic Patients for Posthepatectomy Complications: Comparison with Noncirrhotic Patients
Authors: Itoh Shinji , Uchiyama Hideaki , Kawanaka Hirofumi , Higashi Takahiro , Egashira Akinori , Eguchi Daihiko , Okuyama Toshiro , Tateishi Masahiro , Korenaga Daisuke , Takenaka Kenji
Published: June 2020

There seemed to be characteristic risk factors in cirrhotic patients for posthepatectomy complications because these patients have less hepatic reserve as compared with noncirrhotic patients. The aim of the current study was to identify these characteristic risk factors in cirrhotic patients. We performed 419 primary hepatectomies for hepatocellular carcinoma. The patients were divided into the cirrhotic group (n = 198) and the noncirrhotic group (n = 221), and the risk factors for posthepatectomy complications were compared between the groups. Thirty-six cirrhotic patients (18.2%) experienced Clavien's Grade III or more complications. Tumor size, intraoperative blood loss, duration of operation, major hepatectomy (two or more segments), and necessity of blood transfusion were found to be significant risk factors in univariate analyses. Multivariate analysis revealed that major hepatectomy and intraoperative blood loss were independent risk factors for posthepatectomy complications in patients with cirrhosis. On the other hand, the duration of operation was only an independent risk factor for posthepatectomy complication in noncirrhotic patients. Cirrhotic patients should avoid a major hepatectomy and undergo a limited resection preserving as much liver tissue as possible and meticulous surgical procedures to lessen intraoperative blood loss are mandatory to prevent major posthepatectomy complications.
Prognostic Role and Significance of Paraneoplastic Syndromes in Hepatocellular Carcinoma
Authors: Qu Qiang , Wang Shaobin , Chen Shuguang , Zhou Li , Rui Jing-An
Published: June 2020

Patients with hepatocellular carcinoma (HCC) may develop paraneoplastic syndromes in the clinical course. These syndromes include hypercholesterolemia, hypoglycemia, hypercalcemia, and erythrocytosis, among others. This study was designed to assess the role of prognostic influence of paraneoplastic syndromes in patients with HCC. In a cohort of 175 patients with HCC patients, we compared the clinical features of patients with HCC with or without paraneoplastic syndromes. In addition, survival rates of patients with individual paraneoplastic syndromes and those without were also evaluated. Moreover, factors independently predicting prognosis among patients with HCC with or without paraneoplastic syndromes were analyzed. Among 175 patients with HCC, 54 patients presented paraneoplastic syndromes, and the prevalence was 30.9 per cent. There was no difference of clinical characteristics between patients with HCC with and without paraneoplastic syndromes on diagnosis. However, the patients with paraneoplastic syndromes had a significantly less survival rate comparing with those without during a 5-year follow-up. Cox regression analysis demonstrated that high Child-Pugh grade, large tumor size, portal vein tumor thrombosis, and distant metastasis were all independent unfavorable prognostic factors for survival of patients with HCC. Paraneoplastic syndromes as independent risk factors play a significant role in the progress of HCC and lead to poor prognosis in patients with HCC.
Extremity Injuries as Predictors of Emergency Care Resource Needs among Blunt Trauma Patients in Japan
Authors: Nakahara Shinji , Matsuoka Tetsuya , Ueno Masato , Mizushima Yasuaki , Ichikawa Masao , Yokota Junichiro
Published: June 2020

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.
Radiofrequency Ablation as First-line Treatment of Varicose Veins
Authors: Avery John , Kumar Keshav , Thakur Vijaya , Thakur Anjani
Published: June 2020

Endovascular radiofrequency ablation is a minimally invasive method to safely treat symptomatic refluxing varicose veins. A retrospective chart review was used to determine patient demographics, disease severity, treatment algorithm, and outcome in patients who underwent radiofrequency ablation of symptomatic refluxing veins that had failed conservative management. Statistical analysis was done using GraphPad Demo Version (San Diego, CA). Two hundred forty-one limbs in 179 patients (average age, 53 years; 73% females, 27% males) were treated. Preprocedure Clinical Etiological Anatomic and Pathologic (CEAP) scores were C2s: 236, C3s: 4, and C5s:1. Procedures were performed in the office using tumescent anesthetic; all patients could ambulate immediately after the procedure. Postprocedure total occlusion (TO) rate was seen in 93 per cent of limbs (223 limbs) at 3 months and 91 per cent of limbs (220 limbs) at 12 months posttreatment. No relationship was found between patients who did not have total occlusion and age, sex, diameter of veins, CEAP scores, preoperative reflux time, and volume of tumescent anesthetic ( P > 0.05). The VNUS procedure is an in-office, minimally invasive procedure with a low complication rate and quick recovery. Total occlusion rates are high and there is improvement in disease severity after treatment.
Niche Reconstructive Techniques for Complex Abdominal Wall Reconstruction: A Review
Authors: Sue Gloria R. , Narayan Deepak
Published: June 2020

Abdominal wall defects resulting from recurrent hernias, trauma, and radiation necrosis are difficult and challenging to repair given the high rates of recurrence and surgical morbidity. Complex abdominal wall defects often require the transposition of autologous material to bridge the fascial gap. We present a review of niche reconstructive techniques that have been used in complex abdominal wall repair. The specific techniques reviewed include use of delayed and tunneled pedicled tensor fascia lata myofascial flap, de-epithelialized flap closure, free latissimus dorsi myocutaneous flap with or without innervation, and abdominal wall transplant. These niche surgical techniques have great potential to reduce recurrence rates when used in the proper setting for complex abdominal wall reconstruction. More studies are needed to evaluate the relative use of these techniques with the more widely established surgical methods of reconstruction.
Comparison of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy with Mitomycin or Carboplatin for Diffuse Malignant Peritoneal Mesothelioma
Authors: Shetty Shreya J. , Bathla Lokesh , Govindarajan Venkatesh , Thomas Peter , Loggie Brian W.
Published: June 2020

Diffuse malignant peritoneal mesothelioma is a rare, aggressive disease. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved outcomes where systemic chemotherapy has not succeeded. In this study, we compare outcomes of patients treated with mitomycin or carboplatin as perfusate. In this retrospective study, 47 procedures (CRS + HIPEC) were conducted on 44 patients between March 2003 and August 2010 with either mitomycin or carboplatin. χ2 and Student's t test were used for comparison of clinicopathological variables and Kaplan-Meier curves and log rank test were used to compare overall survival. Median survival of the mitomycin group was 18 months with 1- and 5-year survivals of 72.3 and 27.3 per cent, respectively. Median survival of the carboplatin group was not reached and 1- and 5-year survivals were 89.7 and 62.5 per cent, respectively ( P = 0.014). Mean hospital and intensive care unit length of stay was 18.9 and 8.7 days in the mitomycin group and 12.5 and 2.3 days in the carboplatin group ( P = 0.0069). Mean number of packed red blood cell units transfused was higher in the mitomycin group compared with the carboplatin group (3.54 vs 0.83, P < 0.05). There was no postoperative mortality. HIPEC with carboplatin in diffuse malignant peritoneal mesothelioma is associated with improved overall survival and shorter hospital stay compared with HIPEC with mitomycin.
Epidemiology of 577 Pediatric Firearm Fatalities: A 2-year Review of the National Trauma Data Bank
Authors: Oyetunji Tolulope A. , Haider Adil H. , Obirieze Augustine C. , Fisher Michael , Cornwell Edward E. , Qureshi Faisal G. , Abdullah Fizan , Nwomeh Benedict C.
Published: June 2020

The purpose of this study was to delineate the epidemiology of pediatric firearm injuries, including ethno-demographic patterns with impact on years of potential life lost (YPLL). A 2-year review of the National Trauma Data Bank (2007 to 2008) was conducted. Firearm fatalities in records of patients younger than 18 years were identified. Data were analyzed by demographic and injury characteristics and YPLL was calculated by ethnicity. A total of 577 deaths were identified in the pediatric group. Blacks accounted for 49.7 per cent of the fatalities; Hispanics, 19.2 per cent; whites, 17.7 per cent, and other ethnicity, 13.4 per cent. Median Injury Severity Score was 25 with a median Glasgow Coma Scale score of 3. Traumatic brain injury was present in 84.2 per cent of the records. Assault accounted for 72.8 per cent, self-inflicted injury 12.7 per cent, and unintentional injuries were 8.2 per cent. Most firearm fatalities occurred at home (33.6%). By emergency department (ED) disposition, 29.3 per cent died in the ED, 32.9 per cent were admitted to the intensive care unit, and 30.0 per cent taken to the operating room. Blacks had a total of 17,446 YPLL, Hispanics 6,776 YPLL, and whites 6,718 YPLL. Pediatric firearm fatalities still remain an important public health concern. Inclusive gun control policies focused on primary prevention of accidental injuries may be more effective in mitigating its impact.
Benign Breast Diseases and Body Mass Index: Is There a Correlation?
Authors: O'Brien Stacey , Kowdley Gopal Chandru
Published: June 2020

Breast cancer is the leading cancer affecting women in America. Body mass index (BMI) is a known risk factor for the development of breast cancer. The relationship of BMI to benign breast disease is less clear. In addition, certain benign pathologies are associated with an increased risk of cancer. We sought to measure the incidence of benign pathologies and to correlate these findings with BMI and age. All patients undergoing breast biopsy at our center from 2000 to 2005 were identified (n = 1717). Age, BMI, family history, sex, and diagnosis were determined. Patients were grouped into BMI, age, and intervention groups. χ2 ( P < 0.05) was used to identify statistical significance. Fibrocystic disease and fibroadenoma were seen with a lower incidence for patients older than 55 years of age, whereas pathologies requiring further surgical intervention were seen in higher proportions in patients older than 55 years of age. All pathologies were noted to decrease with increasing BMI, except for fibroadenoma, which peaked in BMI group 25 to 29.9 kg/m2. The presence of benign pathologies was associated with age as expected. Interestingly, although BMI is associated with increased risk of breast cancer, increasing BMI was not associated with benign pathologies that are associated with increased risk of breast cancer. Further study of this area is warranted.
Ambroise Paré (1510 to 1590): A Surgeon Centuries Ahead of His Time
Authors: Shen James T. , Weinstein Michael , Beekley Alec , Yeo Charles , Cowan Scott
Published: June 2020

In their extensive writings, Hippocrates and Celsus counseled physicians to be knowledgeable in both the medical and surgical management of patient recovery.1 However, their words fell by the wayside because cutting of the body was forbidden by the Roman Catholic Church. Furthermore, the contemporaneous Arabic medical teachings emphasized tradition and authority over observation and personal experience. This created an ever-growing rift between the schools of surgical and pharmacologic medicine with both groups denying their involvement in the other domain. Surgeons had been plagued by postoperative complications including infection, malnutrition, and muscular wasting for centuries. Surgeons were forced to re-examine how diet and exercise affected outcomes before the advent of microbiology and advances in pharmacology. All of this changed when Ambroise Paré, a 16th century surgeon, revolutionized the medical world with his astute observations of postoperative diet and exercise.