bluuebunny/crossref_metadata_2025 huggingface dataset:
Differences in Morbidity and Mortality with Percutaneous versus Open Surgical Drainage of Postoperative Intra-abdominal Infections: A Review of 686 Cases
Authors: Politano Amani D. , Hranjec Tjasa , Rosenberger Laura H. , Sawyer Robert G. , Leon Carlos A. Tache
Published: June 2020

Intra-abdominal infections following surgical procedures result from organ-space surgical site infections, visceral perforations, or anastomotic leaks. We hypothesized that open surgical drainage is associated with increased patient morbidity and mortality compared with percutaneous drainage. A single-institution, prospectively collected database over a 13-year period revealed 2776 intra-abdominal infections, 686 of which required an intervention after the index operation. Percutaneous procedures (simple aspiration or catheter placement) were compared with all other open procedures by univariate and multivariate analyses. Analysis revealed 327 infections in 240 patients undergoing open surgical drainage and 359 infections in 260 patients receiving percutaneous drainage. Those undergoing open drainage had significantly higher Acute Physiology Score (APS) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and were more likely to be immunosuppressed, require intensive care unit treatment, and have longer hospital stays. Mortality was higher in the open group: 14.6 versus 4.2 per cent ( P = 0.0001). Variables independently associated with death by multivariate analysis were APACHE II, dialysis, intensive care unit (ICU) care, age, immunosuppression, and drainage method. Open intervention for postsurgical intra-abdominal infections is associated with increased mortality compared with percutaneous drainage even after controlling for severity of illness by multivariate analysis. Although some patients are not candidates for percutaneous drainage, it should be considered the preferential treatment in eligible patients.
The Impact of Lymphovascular Invasion on Lymph Node Status in Patients with Breast Cancer
Authors: Cornwell Laura B. , Mcmasters Kelly M. , Chagpar Anees B.
Published: June 2020

Lymphovascular invasion (LVI) is not uniformly found or reported in breast cancer tumor reports. We sought to determine the impact of the finding of LVI on various parameters of lymph node status in patients with breast cancer. A chart review was performed of 400 node-positive patients from a cohort of patients in a prospective multicenter national sentinel node registry. The finding of LVI was then correlated to number of positive sentinel nodes, the number of positive non-sentinel nodes, the lymph node ratio, and the size of the largest metastatic deposit. Of the 400 patients, data regarding LVI were missing in 98 (24.5%) cases. Although all of these patients were node-positive, LVI was noted to be present in 155 patients (38.8%) and absent in 147 (36.8%). LVI was found to correlate with more positive sentinel nodes (mean, 1.72 vs 1.35; P < 0.001), more positive nonsentinel nodes (mean, 2.16 vs 0.54; P < 0.001), and a higher lymph node ratio (0.29 vs 0.16; P < 0.001). LVI also correlated with size of largest metastatic deposit ( P = 0.002). Although LVI is known to be associated with lymph node status, it is not frequently noted on pathology reports. Given its prognostic value, LVI should be carefully evaluated and reported.
Minimally Invasive Training During Surgical Residency
Authors: Subhas Gokulakkrishna , Mittal Vijay K.
Published: June 2020

The field of postgraduate minimally invasive surgery training has undergone substantial growth and change. A survey was sent to all program directors in surgery. Minimally invasive training patterns, facilities, their views, and performance of residents were examined. Ninety-five directors (38%) responded to the questionnaire. Of these, 51 per cent (n = 48) had a program size of three to four residents and 33 per cent (n = 31) had a program size of five to six residents. In 3 per cent of programs (n = 3), residents could not achieve the minimum Accreditation Council for Graduate Medical Education required numbers for advanced laparoscopic cases. Only 47 per cent of programs (n = 45) had dedicated rotations in minimally invasive surgery, ranging from 2 to 11 months. Up to 10 per cent (n = 9) of program directors felt that the current training in minimally invasive surgery was insufficient. Fifty-five per cent (n = 52) felt that laparoscopic adhesiolysis was an advanced laparoscopic procedure, and 33 per cent (n = 31) felt that there should be a separate minimum requirement for each of the commonly performed basic and advanced laparoscopic cases by Accreditation Council for Graduate Medical Education. Fifty-six per cent (n = 53) of programs were performing robotic surgery. Minimally invasive surgery training for surgical residents needs to increase opportunities so that they are able to perform laparoscopic procedures with confidence. There should be specific number requirements in each category of individual basic and advanced laparoscopic procedures.
Lysostaphin-Coated Mesh Prevents Staphylococcal Infection and Significantly Improves Survival in a Contaminated Surgical Field
Authors: Belyansky Igor , Tsirline Victor B. , Montero Paul N. , Satishkumar Rohan , Martin Terry R. , Lincourt Amy E. , Shipp John I. , Vertegel Alexey , Heniford B. Todd
Published: June 2020

Mesh and wound infections during hernia repair are predominantly caused by Staphylococcus aureus. Human acellular dermis (HAD) is known to lose its integrity in the face of large bacterial loads. The goal of this study was to determine if lysostaphin (LS), a naturally occurring anti-Staphylococcal protein, can protect HAD mesh from S. aureus infection. HAD samples, 3 cm X 3 cm, were implanted in the onlay fashion on the anterior abdominal wall of rats (n = 75). Subjects were grouped based on presence of antimicrobial bound to HAD (none or LS) and presence of S. aureus inoculum (sterile, 106, 108 CFU). At 60 days, meshes were explanted, and bacterial growth, histology, and mesh tensile strength were examined. None of the controls receiving bacterial inoculation without LS survived to 60 days. All LS-HAD sterile and LS-106 animals survived to explantation. The LS-HAD 108 group had a mortality rate of 50 per cent. All surviving LS-treated animals (n = 25) had negative wound and mesh cultures. Blinded gross and histologic evaluation and measured tensile strengths between all LS groups were comparable. Animals implanted with LS-HAD had a dramatically improved rate of survival. All animals surviving to 60 days had completely cleared S. aureus from their wounds with maintenance of mesh integrity and tensile strength. These findings strongly suggest the clinical use of LS-treated mesh in contaminated fields may translate into a more durable hernia repair.
Computerized Tomography Utilization in Children with Appendicitis—Differences in Referring and Children's Hospitals
Authors: Neff Lucas P. , Ladd Mitchell R. , Becher Robert D. , Jordanhazy Ryan A. , Gallaher Jared R. , Pranikoff Thomas
Published: June 2020

Increasingly, physicians rely on computerized tomography (CT) to aid in the workup of acute appendicitis (AA) in children despite the potential negative effects of CT-associated radiation exposure. Few studies have investigated the context or location in which the decision to perform CT for AA is made. We sought to determine where the decision to use CT was made during the initial workup of pediatric patients who later underwent an appendectomy. We reviewed the medical record of all patients at a children's hospital (CH) receiving appendectomy over 10.5 years. We abstracted clinical variables using an established clinical AA scoring system, demographics and outcome variables. Patients who underwent CT were compared with those who did not. Additionally, we identified the location where the CT was performed. Our children's hospital was compared with referring hospitals (RHs) with regard to utilization of CT imaging. Five hundred and forty-six patients underwent appendectomy for AA at CH. Of these, 50 per cent underwent CT. Patients who initially presented at the RHs underwent CT at a significantly higher rate than those first presenting to CH ( P < 0.0001). Moreover, we found that unlike at the RHs, patients with a higher AA score underwent CT at CH less often ( P < 0.0002). RHs used CT more often than CH to diagnose AA in our cohort. CH avoided CT for patients with higher Alvarado scores. Further research is needed to elucidate factors that lead healthcare providers to use CT for children with suspected AA to eliminate unnecessary CT-associated radiation exposure.
Denver Peritoneovenous Shunts for the Management of Malignant Ascites: A Review of the Literature in the Post LeVeen Era
Authors: White Michael A. , Agle Steven C. , Padia Reema K. , Zervos Emmanuel E.
Published: June 2020

Most case series describing peritoneovenous (PV) shunts for malignant ascites include both LeVeen and Denver shunts. Conclusions based on these studies are no longer clinically relevant since the LeVeen shunt has been discontinued. The purpose of this study was to identify outcomes specific to Denver shunts to establish expected results in the modern era. Case series describing PV shunts for malignant ascites between 1980 and 2008 were identified through a keyword PUBMED search. Whenever possible, results attributable to Denver shunts were abstracted and analyzed. Nineteen series describing 341 patients undergoing 353 Denver PV shunts for malignant ascites were identified. The primary indications for PV shunts were unspecified or cancers of unknown origin (40%), ovarian cancer (16%), and pancreatic cancer (8%). Primary patency averaged 87 ± 57 days. Seventy-four per cent of patients died with functioning shunts. Complications occurred in 38% of patients including occlusion (24%) and disseminated intravascular coagulation (9%). Average survival of all patients was 3.0 ± 1.7 months and shunts provided effective palliation in 75.3%. One and a half per cent of 133 patients who had autopsies were reported to have hematologic dissemination. These results are not statistically different than overall results reported for both shunts combined or LeVeen shunts alone. Studies that report combined outcomes with Denver and LeVeen shunts for malignant ascites are neither negatively, nor positively influenced by one specific shunt. Expectations following PV shunting for malignant ascites do not have to be revised because LeVeen shunts are no longer available.
Differential Trends in Racial Preferences for Cosmetic Surgery Procedures
Authors: Prendergast Tahira I. , Ong'Uti Sharon K. , Ortega Gezzer , Khoury Amal L. , Onwuka Ekene , Bolorunduro Oluwaseyi B. , Cornwell Edward E. , Paul Henry
Published: June 2020

There appears to be an increasing acceptance of cosmetic surgery procedures among minority populations in America. Our objective was to determine trends in elective cosmetic procedure utilization as they apply to racial/ethnic differences. A retrospective analysis was performed using the Nationwide Inpatient Sample. Adult patients undergoing elective cosmetic procedures defined by the appropriate International Classification of Disease 9 Clinical Modification procedure codes were included. Demographic characteristics and hospital course particulars were evaluated. There were 71,775 patients meeting the inclusion criteria. Median age was 48 years. The majority were female (90%), and white (65%). The median household income for the patient's zip code was most commonly in the highest economic quartile (4th quartile, 40%). The most common cosmetic procedure was liposuction (67%). The overall mean percentage change in the frequency of these procedures showed a 1.8 per cent decline among white patients, whereas Black, Hispanic, Asian, and Native American patients had an increase of 7.5 per cent, 4.7 per cent, 14.5 per cent, and 105.5 per cent, respectively. We conclude that there is an identified increasing trend in the proportion of racial/ethnic minorities represented among the recipients of cosmetic surgery procedures.
Mortality by Decade in Trauma Patients with Glasgow Coma Scale 3
Authors: Ley Eric J. , Clond Morgan A. , Hussain Omar N. , Srour Marissa , Mirocha James , Bukur Marko , Margulies Dan R. , Salim Ali
Published: June 2020

The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.
Transoral Incisionless Fundoplication: Initial Experience in Patients Referred to an Integrated Academic Institution
Authors: Nguyen Allan , Vo Thomas , Nguyen Xuan-Mai T. , Smith Brian R. , Reavis Kevin M.
Published: June 2020

Transoral incisionless fundoplication is a new treatment for patients with gastroesophageal reflux disease. We present our initial experience with 10 patients undergoing this procedure with varying past surgical histories. All procedures were performed under general nasotracheal anesthesia. RAND-36 and Visual Analog Scale symptom scores were collected at pre and postoperative appointments for a mean of 9.2 months. The mean procedure time was 68 minutes. There were no intraoperative or postoperative complications. Patients with prior pancreaticoduodenectomy had observed reduced working space due to prior distal gastrectomy and required additional insufflation due to no pyloric resistance to insufflation of the small bowel. The patient with prior fundoplication required additional time and force for fastener penetration of the resultant scar from the partially disrupted fundoplication. All patients were discharged within 23 hours of the procedure. Throughout the follow-up period, patients reported gradual changes in medication requirements and symptom scores. There were no late complications. Transoral incisionless fundoplication is technically safe in well-selected patients including those with prior esophageal and gastric surgery.
Factors Predictive of Venous Thromboembolism in Bariatric Surgery
Authors: Masoomi Hossein , Buchberg Brian , Reavis Kevin M. , Mills Steven D. , Stamos Michael , Nguyen Ninh T.
Published: June 2020

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.
Outreach in Surgery at the Undergraduate Level: An Opportunity to Improve Surgical Interest among Women?
Authors: Ourian Ariel J. , Nasseri Yosef , Kohanzadeh Som , Margulies Daniel R. , Gewertz Bruce L. , Chen Steve C. , Towfigh Shirin
Published: June 2020

Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course (“Surgery 99”) offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.
Popliteal Artery Injuries in an Urban Trauma Center with a Rural Catchment Area: Do Delays in Definitive Treatment Affect Amputation?
Authors: Simmons Jon D. , Gunter Joseph W. , Schmieg Robert E. , Manley Justin D. , Rushton Fred W. , Porter John M. , Mitchell Marc E.
Published: June 2020

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 ( P < 0.01), and length of stay, 43 versus 15 days ( P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent ( P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.
Pharmacomechanical Thrombolysis for Phlegmasia Cerulea Dolens
Authors: Erdoes Luke S. , Ezell Jessica B. , Myers Stuart I. , Hogan Michael B. , Lesar Christopher J. , Sprouse L. Richard
Published: June 2020

Phlegmasia cerulea dolens (PCD) is limb-threatening. Traditional treatments are very morbid. We examine the efficacy of percutaneous treatment of PCD. Between May 2005 and September 2008, we treated 21 limbs in 20 patients with lower extremity PCD who were candidates for thrombolysis. Diagnosis was by clinical examination and duplex ultrasound. Catheter access to the deep venous system was obtained through a popliteal vein. Therapy used pulse spray thrombolysis with tissue plasminogen activator (tPA). Infusion catheters and adjunctive percutaneous techniques were used as indicated. Postoperatively, patients were treated with systemic anticoagulation, compression hose, and interval follow-up. Limbs were graded according to the CEAP classification. Twenty patients (13 male) were treated with a mean age of 55.8 years. Nine patients had hypercoagulable states, four May Thurner syndrome, three a history of cancer, one postcolon resection, one acute myocardial infarction, and one postfemoral vein puncture. All patients had resolution of PCD without the need for open surgery. The initial tPA dose was 19.5 mg with pulse spray thrombolysis. Infusion catheters were required in 18 patients and used for 16.1 hours (range, 8 to 36 hours) until complete thrombolysis. Venous angioplasty was necessary in 14 patients with nine of these requiring venous stents. One patient required above-knee amputation despite successful treatment of her PCD. Mean follow-up was 10.7 months (range, 1 to 39 months). All patients demonstrated no or minimal residual thrombus and intact valvular function and a mean clinical CEAP score of 2.4. Percutaneous treatment of PCD produced excellent results with minimal morbidity.
The Reversal of a Protective Stoma Is Feasible Before the Complete Healing of a Colorectal Anastomotic Leak
Authors: Palmisano Silvia , Piccinni Giuseppe , Casagranda Biagio , Balani Alessandro , De Manzini Nicolo
Published: June 2020

A proximal diverting stoma is recommended in “high-risk” conditions after total mesorectal excision. The aim of the study is to assess whether, after checking the anastomosis by using a water-soluble contrast enema (WCE), the closure of the ileostomy is feasible and safe, even in the presence of a persistent radiological leak. From 2003 to 2010, 210 colorectal anastomoses were performed. Ileostomy was carried out in “high-risk” anastomosis. A radiological control was performed 2 weeks later. If a leakage was present, conservative therapy controlled by serial WCEs was prescribed. Ileostomy closure was performed in the absence of leakage or with persistent leakage without clinical signs of pelvic infections. Seventy patients (33.3%) had a protective ileostomy. Fifty-eight of these (82.9%) had an uneventful course, whereas 12 (17.1%) had clinical leakage. All 70 patients were submitted to WCE after 2 weeks. Nine of 58 patients (15.5%) and eight of 12 patients with clinical anastomotic leakage showed a leakage at radiology. All these patients were scheduled another WCE 2 months later. It showed that the anastomosis had been healed in seven patients, whereas the 10 patients with leaks remained with ostomy until the third enema 1 month later. For all these patients, closure of the ileostomy was planned despite persistent radiological and subclinical leakage. A radiological study using WCE before closure of the stoma is essential and stoma closure, in the presence of a persistent leakage, is possible in selected patients.
Cervical Neck Dissection Without Drains in Well-Differentiated Thyroid Carcinoma
Authors: Abboud Bassam , Sleilaty Ghassan , Tannoury Jenny , Daher Ronald , Abadjian Gerard , Ghorra Claude
Published: June 2020

This study aims to review the safety of thyroidectomy combined with cervical neck dissection without drainage in well-differentiated thyroid carcinoma (WDTC). The medical records of consecutive patients who underwent thyroidectomy without drainage for WDTC were retrospectively reviewed. Group 1 included 123 patients who underwent thyroidectomy with central neck dissection and Group 2 included 46 patients who underwent thyroidectomy with central and lateral neck dissection. One hundred twenty-seven patients underwent thyroidectomy without neck dissection and were included in Group 3. Overall, 16 patients (5%) developed postoperative hematoma and/or seroma, seven patients (6%) in the Group 1, three patients (7%) in the Group 2, and six patients (5%) in Group 3. All patients had minor bleeding or seroma not requiring surgical intervention. Overall, 68 patients (23%) had transient postoperative hypocalcaemia, and four patients(l%) had permanent hypoparathyroidism. Seventeen patients (6%) had transient postoperative hoarseness and three had permanent vocal cord paralysis (0.6%). The postoperative stay for all groups was 1 day in 91 per cent of the cases. Patients from Groups 1 and 2 had no increased perioperative local complications or length of stay as compared with Group 3. Cervical neck dissection and thyroidectomy without drains is safe and effective in the treatment of WDTC.
Comparison of Staple-Line Leakage and Hemorrhage in Patients Undergoing Laparoscopic Sleeve Gastrectomy with or Without Seamguard
Authors: Simon Todd E. , Scott Joshua A. , Brockmeyer Joel R. , Rice Robert C. , Frizzi James D. , Husain Farah A. , Choi Yong U.
Published: June 2020

Laparoscopic sleeve gastrectomy (LSG) has been recognized as a primary procedure for the surgical management of morbid obesity. Staple-line leaks and hemorrhage are two associated complications. Staple-line buttressing materials have been suggested to decrease these complications. When used during LSG, few published papers exist that compare the incidence of leak or hemorrhage to that of nonreinforced staple-lines. The purpose of this study was to compare the incidence of leak and hemorrhage in patients who did and did not receive reinforcement with Seamguard (W.L. Gore & Associates, Flagstaff, AZ). This is a retrospective analysis of patients undergoing LSG. All patients met National Institutes of Health criteria and each had an extensive preoperative evaluation. Data was collected from inpatient and outpatient medical records. Fifty-nine patients received reinforcement and 80 patients did not. There was no significant difference in mean body mass index, age, or gender make-up between the two groups. The overall incidence of leak was 3.60 per cent. The incidence was 3.39 per cent in patients who received reinforcement and 3.75 per cent in those who did not. This was not statistically significant. There was no incidence of staple-line hemorrhage in either group. There is no conclusive evidence that Seamguard reduces staple-line leakage or hemorrhage. Studies involving a larger number of patients are necessary before recommending staple-line reinforcement.
Local and National Trends in General Surgery Residents’ Operative Experience: Do Work Hour Limitations Negatively Affect Case Volume in Small Community-Based Programs?
Authors: Markelov Alexey , Sakharpe Aniket , Kohli Harjeet , Livert David
Published: June 2020

The goals of this study were to analyze the impact of work hour restrictions on the operative case volume at a small community-based general surgery residency training program and compare changes with the national level. Annual national resident case log data from Accreditation Council for Graduate Medical Education (ACGME) website and case logs of graduating Easton Hospital residents (years 2002-2009) were used for analysis. Weighted average change in total number of cases in our institution was —1.20 ( P = 0.52) vs 1.78 ( P = 0.07) for the national program average with statistically significant difference on comparison ( P = 0.027). We also found significant difference in case volume changes at the national level compared with our institution for the following ACGME defined subcategories: alimentary tract [8.19 ( P < 0.01) vs -1.08 ( P = 0.54)], abdomen [8.48 ( P < 0.01) vs -6.29 ( P < 0.01)], breast [1.91 ( P = 0.89) vs -3.6 ( P = 0.02)], and vascular [4.03 ( P = 0.02) vs -3.98 ( P = 0.01)]. Comparing the national trend to the community hospital we see that there is total increase in cases at the national level whereas there is a decrease in case volume at the community hospital. These trends can also be followed in ACGME defined subcategories which form the major case load for a general surgical training such as alimentary tract, abdominal, breast, and vascular procedures. We hypothesize that work hour restrictions have been favorable for the larger programs, as these programs were able to better integrate the night float system, restructure their call schedule, and implement institutional modifications which are too resource demanding for smaller training programs.
Management and Outcomes of Traumatic Colon Injury in Civilian and Military Patients
Authors: Sambasivan Chitra N. , Underwood Samantha J. , Kuehn Reed B. , Cho S. D. , Kiraly Laszlo N. , Hamilton Gregory J. , Flaherty Stephen F. , Dorlac Warren C. , Schreiber Martin A.
Published: June 2020

Divergent injury patterns may indicate the need for differing strategies in combat and civilian trauma patients. This study aims to compare outcomes of colon injury management in these two populations. Parallel retrospective reviews were conducted comparing warfighters (n = 59) injured downrange and subsequently transferred to the United States with civilians (n = 30) treated at a United States Level I trauma center. Patient characteristics, mechanisms of injury, treatment course, and complications were compared. The civilian (CP) and military (MP) populations did not differ in Injury Severity Score (MP 20 vs CP 26; P = 0.41). The MP experienced primarily blast injuries (51%) as opposed to blunt trauma (70%; P < 0.01) in the CP. The site of colon injury did not differ between groups ( P = 0.15). Initial management was via primary repair (53%) and resection and anastomosis (27%) in the CP versus colostomy creation (47%) and stapled ends (32%) in the MP ( P < 0.001). Ultimately, the CP and MP experienced equivalent continuity rates (90%). Overall complications (MP 68% vs CP 53%; P = 0.18) and mortality (MP 3% vs CP 3%; P = 0.99) did not differ between the two groups. The CP and MP experience different mechanisms and initial management of colon injury. Ultimately, continuity is restored in the majority of both populations.
Outcomes and Long Term Follow-up after Emergent Cricothyroidotomy: Is Routine Conversion to Tracheostomy Necessary?
Authors: Graham David B. , Eastman Alexander L. , Aldy Kim N. , Carroll Elizabeth A. , Minei Joseph P. , Brakenridge Scott C. , Phelan Herb A.
Published: June 2020

The purpose of this study is to identify factors associated with survival after cricothyroidotomy (CRIC), and to ascertain long-term outcomes in patients simply decannulated after CRIC versus those revised to tracheostomy. All CRICs between October 1, 1995 and June 20, 2010 were reviewed. Patients were contacted by phone, visited at their last known address, or queried in the Center for Disease Control's National Death Index. DECAN were those CRICs decannulated without revision. TRACH were those revised to a tracheostomy at any point. Ninety-five CRIC patients were identified. In 94 per cent of survivors of initial admission, a Glasgow Coma Score (GCS) of 15 was noted at disposition. Cardiopulmonary resuscitation before or during CRIC performance was strongly associated with all-cause death during index admission, and increasing head Abbreviated Injury Score was associated with lower odds of a neurologically intact survival. Of survivors, 82 per cent of DECAN and 57 per cent of TRACH patients were followed-up with at medians of 48 (interquartile range 19-57) and 53 (20-119) months, respectively. DECAN occurred at a median of 4 days (2-7) whereas TRACH revision occurred at a median of 2 days (1-7). Endoscopy was performed on 36 per cent of DECAN patients and 22 per cent of TRACH patients. Two DECAN patients with acute subglottic edema/stenosis decannulated successfully on days 9 and 15 postinjury and had no problems at 54 and 91 months postinjury. At follow-up, no patient in either group had suffered a clinically evident airway complication. The need for cardiopulmonary resuscitation before or during CRIC portends poorly for neurologically intact survival. Simple decannulation is appropriate for CRIC patients when their need for airway protection has resolved.
Platelet Function after Cessation of Chronic Clopidogrel Therapy
Authors: Perakis Peter G. , Yunus Tahir , Long Graham , Cheema Zulfiqar F. , Hammond Robert , Shanley Charles J.
Published: June 2020

Surgeons increasingly encounter patients on clopidogrel therapy who are preparing to undergo surgery. The goal of this study was to examine the change in platelet function after the common clinical scenario of discontinuing chronic clopidogrel therapy in those patients preparing to undergo an elective surgery, and the time course of platelet function recovery after clopidogrel discontinuation. Patients on clopidogrel therapy scheduled for an elective surgical procedure had their platelet function tested using a Verify Now P2Y12 device (Accumetrics, San Diego, CA). Platelet inhibition was evaluated at baseline before clopidogrel discontinuation, and subsequently studied every other day in the week before their scheduled procedure. Mean platelet inhibition was 32.1 per cent on Day 0 (before clopidogrel discontinuation), decreasing to 3.7 per cent on Day 4. Platelet inhibition decreased significantly after discontinuation of clopidogrel in a time-dependent manner ( P = 0.011), although a considerable interindividual variability of P2Y12 reaction units values was observed over the study period. Patients on concomitant proton pump inhibitors and clopidogrel demonstrated a decreased effect of clopidogrel. In conclusion, individual platelet function monitoring may assist the surgeon in perioperative decision-making in patients receiving clopidogrel therapy preparing to undergo elective surgery.
Quality of Life after Laparoscopic Cholecystectomy for Biliary Dyskinesia in the Pediatric Population: A Pilot Study
Authors: Maxwell Damian , Thompson Stephanie , Richmond Bryan , McCagg Jillian , Ubert Adam
Published: June 2020

This pilot study examined symptom relief and quality of life in pediatric patients who received laparoscopic cholecystectomy surgery at our institution for biliary dyskinesia. We used two validated questionnaires: the Child Health Questionnaire (CHQ-PF28), to assess general well-being, and the Gastrointestinal Quality of Life Index (GIQLI), to measure gastrointestinal-related health. After Institutional Review Board approval, all patients under the age of 18 years who underwent laparoscopic cholecystectomy for biliary dyskinesia between November 2006 and May 2010 received mailed questionnaires. Preoperative and postoperative data were retrospectively collected from respondents and included age, race, symptoms, gallbladder ejection fraction values, pathologic findings, and clinical course. Of 89 patients meeting inclusion criteria, 21 responded. Mean age at surgery was 13.08 years (range, 8 to 17 years). The most common preoperative symptoms consisted of nausea (100%), postprandial pain (90.5%), right upper quadrant pain (81.0%), and vomiting (66.7%). Mean long-term follow-up interval was 18.9 months (range, 7 to 40 months; SD 10.37). Patients with long-term symptom relief reported significantly higher GIQLI scores than those with enduring symptoms. Examination of the results from the CHQ-PF28 revealed significantly lower scores than a general U.S. pediatric sample in both the Physical and Psychosocial Summary Measures ( P < 0.05). Children experiencing long-term symptom cessation after laparoscopic cholecystectomy reported higher quality of life than those who had incomplete or only short-term relief. However, regardless of the degree of symptom relief, the degree of quality of life experienced by our study sample of patients with biliary dyskinesia is lower than that of a comparable U.S. pediatric sample.
Case-Controlled Comparison of Video-Assisted and Conventional Minimally Invasive Parathyroidectomy
Authors: Melck Adrienne L. , Armstrong Michael J. , Yip Linwah , Carty Sally E.
Published: June 2020

Video-assisted parathyroidectomy (VAP) is a new approach to parathyroid exploration for primary hyperparathyroidism (PH). We examined the VAP learning curve and hypothesized that compared with conventional minimally invasive parathyroidectomy (MIS), VAP has similar complication rates and the added benefit of a shorter hospital length of stay. Using a case-control study design, patients with PH with single-focus imaging results undergoing VAP or MIS were compared during a 5-year VAP implementation period. VAP was possible in 18 per cent of patients undergoing initial parathyroid exploration. In comparing 125 VAP cases with 95 MIS control subjects, patients undergoing MIS had higher mean preoperative levels of calcium ( P = 0.007) and parathyroid hormone ( P = 0.008), greater mean adenoma weight ( P < 0.001), and increased long-term mortality (4% MIS vs 0% VAP, P = 0.03). Mean operative time, in-house analgesia use, and operative complications did not differ. The rate of conversion from VAP to MIS was 14 per cent. Patients undergoing VAP were less likely to require an overnight hospital stay ( P = 0.01). VAP is a safe surgical option for selected patients with PH, offering improved cosmesis with operative times comparable to conventional MIS. VAP can be done with a low conversion rate even during implementation and allows the added benefit of shorter hospital stay.
Organ Donation and Hispanic American High School Students: Attitudes, Beliefs, Perceptions, and Intent to Donate
Authors: Berry Cherisse , Salim Ali , Ley Eric J. , Schulman Danielle , Anderson Jacqui , Navarro Sonia , Zheng Ling , Chan Linda S.
Published: June 2020

The growing need for transplantable organs continues to outpace supply. This discrepancy is most pronounced in minority populations. Hispanic Americans, however, are significantly less likely to donate their organs for reasons that remain poorly understood. We sought to identify factors that influence Hispanic American high school students’ intent to donate organs. A prospective observational study was conducted in five Los Angeles high schools within four separate zip codes known for a high percentage of Hispanic Americans. High school students, ages 15 to 20 years, were surveyed to assess demographic factors, cultural factors, awareness and knowledge, perception, and belief regarding organ donation and the intent to donate. A total of 5444 surveys were collected over a 4-month period. After logistic regression analysis, independent risk factors for predicting the intent to donate were: family support, 11th and 12th grade high school students, being female, religion, and the belief that Hispanics are more likely to need an organ transplant. This study represents the largest study to date examining factors associated with the intent to donate in Hispanic American high school students. To address the organ shortage crisis in Hispanic Americans, these risk factors should be considered using specific, effective educational programs.
Diagnostic Accuracy of Intra-abdominal Fluid Collection Characterization in the Era of Multidetector Computed Tomography
Authors: Allen Brian C. , Barnhart Huiman , Bashir Mustafa , Nieman Christopher , Breault Steven , Jaffe Tracy A.
Published: June 2020

The purpose of this study was to test the hypothesis that with improved technology, the presence of abscess in a postoperative fluid collection may be prospectively made. This is an Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective review of computed tomography (CT)-guided intra-abdominal fluid collection drainages. The diagnostic CT scans of 95 consecutive patients performed on 16- and 64-multidetector CT (MDCT) were reviewed by four readers with varying abdominal imaging expertise. Readers were asked to determine fluid content, to document whether infection was present, and to rate reader confidence for infection. A fifth radiologist reviewed the collections for imaging characteristics. The gold standard for presence of infection was microbiological Gram stain and culture. The logistic regression model showed that both fluid collections containing gas or high attenuation fluid (average CT density 20 or greater Hounsfield units) are significant predictors of infection ( P = 0.001). The average sensitivity over the four readers for determining presence of infection was 83.4 per cent and specificity was 39.3 per cent. Even in the era of MDCT, the ability to predict whether or not a fluid collection is infected or not, based on imaging findings alone, is limited. Presence of gas is a strong indicator of infection, but no imaging finding is characteristic of a sterile fluid collection.
Obesity Does Not Impact Outcomes for Appendicitis
Authors: DeUgarte Daniel A. , Stark Rebecca , Kaji Amy H. , Yaghoubian Arezou , Tolan Amy , Lee Steven L.
Published: June 2020

Obesity has long been considered a risk factor for surgery. The purpose of this study was to evaluate the impact of obesity on outcomes after appendectomy. A retrospective study was performed using discharge abstract data obtained from patients with documented body mass index (BMI) undergoing appendectomy for appendicitis (n = 2919). Complications and length of stay for different BMI categories were compared. Obese patients (BMI > 30 kg/m2) had similar rates of perforation (20%) and were as likely to undergo a laparoscopic approach (85%) as nonobese patients. On multivariable and univariate analysis, no significant differences were observed when comparing obese and nonobese patients for the outcomes of length of stay, infectious complications, and need for readmission. On multivariate analysis, laparoscopy predicted lower complication rates and decreased length of stay. In this study, obesity did not significantly impact rates of perforation, operative approach, length of stay, infectious complications, or readmission.
Surgeon's Requirement for Obesity Reduction: Its Influence on Weight Loss
Authors: Goldberg Ross F. , Parker Michael , Stauffer John A. , Moti Salman , Sylvia Jacob , Ames Gretchen E. , Asbun Horacio J. , Lynch Scott A. , Smith C. Daniel , Bowers Steven P.
Published: June 2020

The objective of this study was to examine whether preoperative recommendation for specific reductions in body mass index (BMI) influenced weight loss in obese surgical patients. We retrospectively reviewed the electronic medical records of 48 patients who enrolled between January 2007 to June 2010 in an 800-calorie per day liquid meal replacement (LMR) weight loss program. Of these, 9 patients (surgical group) enrolled as a result of general surgeon-directed weight loss to enable nonbariatric surgery and 39 enrolled seeking weight loss (medical group). Patients enrolled in the LMR program before bariatric surgery were excluded from analysis. All patients were seen in the setting of a comprehensive weight loss program supervised by a medical bariatrician and followed for a period of 4 months. There were no significant differences in mean initial BMI between surgical and medical patients (41.7 ± 4.55 and 41.6 ± 8.54 kg/m2, respectively) or participation time in the weight loss program (120 days vs 133 days). Of the nine surgical patients, only five (56%) reached their weight goal and underwent the planned surgical procedure. Weight loss was significantly less in the surgical compared with medical patients (BMI reduction 4.03 ± 3.99 vs 7.75 ± 4.90 kg/m2, respectively; P < 0.05). Weight loss was significantly lower in patients directed to undergo BMI reduction to enable a general surgical procedure. Future studies are needed to assess factors influencing weight loss (metabolism, exercise capacity, motivation) in patients requiring weight loss to enable a surgical procedure.
Management of Traumatic Vascular Injuries to the Neck: A 7-Year Experience at a Level I Trauma Center
Authors: Simmons Jon D. , Ahmed Naveed , Donnellan Kimberly A. , Schmieg Robert E. , Porter John M. , Mitchell Marc E.
Published: June 2020

Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.
Doppler-Guided Hemorrhoidal Artery Ligation: Experience with 2 Years Follow-up
Authors: Yilmaz İbrahim , Sücüllü İlker , Özgür Karakaş Dursun , Özdemİr Yavuz , Yücel Ergün , Akin Mehmet Levhi
Published: June 2020

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal disease, consisting of the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis. The aim of the study was to assess the efficacy and safety of DGHAL, define its indications, and identify its possible advantages and limitations for the treatment of second- and third-degree hemorrhoids. The procedure was performed using a specially designed proctoscope. The Doppler probe was used to locate all the terminal branches of hemorrhoidal arteries, which were then sutured. Patients were followed up for 2 years. From November 2006 to May 2009, 50 patients (29 female, mean age 38.2 years) underwent this procedure. The procedure was performed under local anesthesia. An average of five ligatures was placed. Average length of hospital stay was 2 hours and return to work was 2.5 days. The mean postoperative pain score was 1.72. There were no intra- or immediate postoperative major complications. In 44 patients (88%), surgery resolved the symptoms completely in a 2-year follow-up period. DGHAL is a safe and effective procedure. DGHAL can be the choice for second- and third-degree hemorrhoids with minimal postoperative pain and quick recovery.