bluuebunny/crossref_metadata_2025 huggingface dataset:
James Lawrence Cabell, One of the Most Influential of America's Early Surgeons
Authors: Dubose Joseph , Tribble Curt
Published: June 2020

Dr. James Lawrence Cabell was one of the most important, farsighted, and influential surgical educators and leaders in the United States in the 19th century. He was appointed as Chair of Surgery and Physiology at the University of Virginia by Thomas Jefferson's successor as Rector of the University, James Madison, and held that Chair for over 50 years, the longest tenure of any American medical academician. He was a founding member of the American Medical Association, the American Surgical Association, and the National Board of Health. He is best remembered as an articulate, incessant, and early proponent of public health and the delivery of quality health care in the United States. His legacy and that of his protégés has continued to influence health care in this country, especially in the realm of the prevention and treatment of infectious diseases, even into the present time.
Can Routine Trauma Bay Chest X-ray be Bypassed with an Extended Focused Assessment with Sonography for Trauma Examination?
Authors: Soult Michael C. , Weireter Leonard J. , Britt Rebecca C. , Collins Jay N. , Novosel Timothy J. , Reed Scott F. , Britt L. D.
Published: June 2020

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.
Preservation of Beta Cell Function after Pancreatic Islet Autotransplantation: University of Chicago Experience
Authors: Savari Omid , Golab Karolina , Wang Ling-Jia , Schenck Lindsay , Grose Randall , Tibudan Martin , Ramachandran Sabarinathan , Chon W. James , Posner Mitchell C. , Millis J. Michael , Matthews Jeffrey B. , Gelrud Andres , Witkowski Piotr
Published: June 2020

The aim of the study was to assess the rate of insulin independence in patients after total pancreatectomy (TP) and islet autotransplantation in our center. TP followed by islet auto-transplantation was performed in 10 patients. Severe unrelenting pain associated with chronic pancreatitis was the major indication for surgery. Islets were isolated using the modified Ricordi method and infused through the portal vein. Exogenous insulin therapy was implemented for at least two months posttransplant to support islet engraftment and was subsequently weaned off, if possible. Median follow-up was 26 months (range, 2 to 60 months). Median islet yield was 158,860 islet equivalents (IEQ) (range, 40,203 to 330,472 IEQ) with an average islet yield of 2,478 IEQ/g (range, 685 to 6,002 IEQ/g) of processed pancreas. One patient developed transient partial portal vein thrombosis, which resolved without sequela. Five (50%) patients are currently off insulin with excellent glucose control and HbA1c below 6. Patients who achieved and maintained insulin independence were transplanted with significantly more islets (median, 202,291 IEQ; range, 145,000 to 330,474 IEQ) than patients who required insulin support (64,348 IEQ; range, 40,203 to 260,476 IEQ; P < 0.05). Patient body mass index and time of chronic pancreatitis prior transplant procedure did not correlate with the outcome. The remaining five patients, who require insulin support, had present C-peptide in blood and experience good glucose control without incidence of severe hypoglycemic episodes. Islet autotransplantation efficiently preserved beta cell function in selected patients with chronic pancreatitis and the outcome correlated with transplanted islet mass.
The Impact of Surgical Diversion Before Neoadjuvant Therapy for Rectal Cancer
Authors: Anderson Brandon J. , Hill Elizabeth G. , Sweeney Robert E. , Wahlquist Amy E. , Marshall David T. , O'Carroll Kevin F. Staveley , Cole David J. , Camp Ernest Ramsay
Published: June 2020

Up-front fecal diversion can palliate emergent symptoms related to locally advanced rectal cancer (LARC) allowing patients to receive neoadjuvant chemoradiation therapy (nCRT). We analyzed outcomes of pretreatment-diverted LARC patients relative to nondiverted patients to define the impact of this management strategy. We retrospectively collected data on 103 LARC patients treated with nCRTand surgery. Medical records were reviewed for patient characteristics, staging, treatment plan, and outcomes. Thirteen LARC patients underwent pretreatment diversion for urgent symptoms and 90 LARC patients proceeded directly to nCRT. In all, 50 per cent of diverted patients presented with T4 tumor compared with 14 per cent in the nondiverted patients ( P = 0.003). Diverted patients experienced a delay in time-to-treatment initiation of 12 days, although this difference was not statistically significant. Similar rates of chemoradiation and surgical toxicities were observed. Even though diverted patients demonstrated less pathologic response to nCRT compared with nondiverted patients ( P = 0.04), there was no significant difference in overall survival. In conclusion, our study demonstrates the effectiveness of up-front fecal diversion at managing emergent obstructive symptoms related to advanced rectal cancer without additional complications, allowing patients to proceed with nCRT followed by radical surgery.
Machine Perfusion: Not Just for Marginal Kidney Donors
Authors: Cannon Robert M. , Brock Guy N. , Garrison R. Neal , Marvin Michael R. , Franklin Glen A. , Davis Eric G.
Published: June 2020

Interest in machine perfusion (MP) for donated kidneys has markedly increased in the past decade as a means to improve graft function, although the donor populations in which it should be applied have not yet been resolved. All adults undergoing de-novo isolated kidney transplantation from standard-criteria donors in the UNOS database 2005 to 2011 were reviewed with the primary endpoint of delayed graft function (DGF), defined as dialysis within seven days of transplantation, in those who received kidneys that underwent MP versus cold storage (CS) alone. Three methods were used to control for differences between groups. Multivariable logistic regression was performed, adjusting for donor and recipient characteristics significantly associated with DGF. Rates were also compared in a cohort of propensity-matched MP vs CS recipients. Finally, a paired-kidney study was performed, where one kidney underwent MP and the contralateral underwent CS. There were 36,323 patients, with unadjusted DGF rates of 18.6 per cent (n = 1830/9882) and 22.4 per cent (n = 5931/26,441; P < 0.001) in the MP vs CS groups, respectively. After multivariable analysis, the odds ratio for DGF in the MP group was 0.59 ( P < 0.001) versus CS. In the propensity-matched cohort, there were 8929 patients each in the MP and CS groups. DGF occurred in 16.8 per cent of the MP group vs 25.3 per cent with CS ( P < 0.001, OR 0.59). In the paired-kidney study, rates of DGF were 16.7 per cent vs 24.3 per cent ( P < 0.001) in the 1665 recipients each in the MP versus CS groups (OR 0.6). In conclusion, machine perfusion is beneficial in reducing DGF even when standard donors are utilized, and thus should not be limited to marginal kidneys.
Operative Failure Rate and Documentation of Family History in Young Patients Undergoing Focused Parathyroidectomy for Primary Hyperparathyroidism
Authors: Stephen Elsa T. , Quillo Amy R. , Lewis Kelsey E. , Harden Farrah L. , Bumpous Jeffrey M. , Flynn Michael B. , Callender Glenda G.
Published: June 2020

Primary hyperparathyroidism in multiple endocrine neoplasia type I usually affects all parathyroid glands, making focused parathyroidectomy (FP) inappropriate. The risk of previously undiagnosed multiple endocrine neoplasia type I in a younger patient with primary hyperparathyroidism is higher than in an older patient. We hypothesized that FP may lead to a higher failure rate in younger versus older patients. A retrospective review was performed of a single-institution database of patients who underwent parathyroidectomy for primary hyperparathyroidism. Routine statistical analysis was performed, including Fisher's exact test. A total of 635 patients were included. Operative failure occurred in 7/55 (13%) younger patients and 21/580 (4%) older patients ( P = 0.007). In conclusion, operative failure occurred in a statistically significantly higher percentage of younger versus older patients undergoing FP. This is partly explained by undiagnosed multiple endocrine neoplasia syndrome type I in the younger patient group. Endocrine surgeons must make every effort to preoperatively identify multiple endocrine neoplasia syndrome type I in the younger patient population.
The Rationality of Resectional Surgery and Palliative Interventions in the Management of Patients with Gallbladder Cancer
Authors: Ercan Metin , Bostanci Erdal B. , Cakir Tebessum , Karaman Kerem , Ozer Ilter , Ulas Murat , Dalgic Tahsin , Ozogul Yusuf , Aksoy Erol , Akoglu Musa
Published: June 2020

The aim of the present study was to evaluate in a retrospective manner, the survival period and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions. Between 2003 and 2012, 67 patients diagnosed with gallbladder carcinoma were retrospectively analyzed. Patient demographics, the survival period, and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions were retrospectively analyzed. Sixty-seven patients were diagnosed with gallbladder carcinoma. Thirty-eight patients (56.7%) were female and 29 patients (43.3%) were male. The median survival period was significantly longer in stage II and III diseases than in stage IV disease ( P < 0.001). The R0, R1, and R2 resection rates in patients who underwent surgery with curative intent were 67.7, 19.4, and 12.9 per cent, respectively. The R0 resection rate according to the tumor stages was 100 per cent for stage I, 87.5 per cent for stage II, 66.7 per cent for stage III, and 42.8 per cent for stage IV disease. The median follow-up period was six months (eight days to 36 months). During this follow-up period, 53 patients (79.1%) died. In conclusion, R0 resection rate decreases when tumor stage increases. The highest survival rates after R0 resection are achieved in patients with stage I, II, and III diseases. Radical surgery has no benefit over palliative surgery for stage IV disease in terms of survival.
Adhesive Small Bowel Obstruction: Early Operative versus Observational Management
Authors: Bauer Joel , Keeley Brieze , Krieger Beth , Deliz Juan , Wallace Kojo , Kruse Danielle , Dallas Kai , Bornstein Joseph , Chessin David , Gorfine Stephen
Published: June 2020

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with non-operative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.
The Aging of America: A Comprehensive Look at over 25,000 Geriatric Trauma Admissions to United States Hospitals
Authors: Maxwell Cathy A. , Miller Richard S. , Dietrich Mary S. , Mion Lorraine C. , Minnick Ann
Published: June 2020

A 2001 study on geriatric trauma by trauma center (TC) status was based on 1989 Medicare data. The purpose of this study was to compare 1989 findings with a 2009 sample, and to examine patient characteristics and outcomes by TC status. From 2009 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) data, we examined a geographically representative sample ( n = 25,512) of injured older adults (>/= age 65) admitted to 127 TCs and non-TCs in 24 states. Data analysis included descriptive statistics for eight patient characteristics and four outcome variables (mortality, discharge disposition, length of stay, and total charges). χ2 tests were conducted to examine differences between 1989 and 2009 for age groups, gender, and mortality. Higher percentages of patients were in older age groups in 2009, however mortality declined overall (4.8% vs 3.4%, P < .001). Consistent incremental patterns of differences were observed among TC levels for all patient characteristics and outcomes. Level I TCs admitted highest percentages of: lower age groups, males, nonwhite race, motor-vehicle related trauma, and intracranial injuries. Non-TCs admitted highest percentages of oldest age groups, comorbidities, falls, femur neck fractures, and patients requiring OR procedures. Although Level I TCs had higher lengths of stay and total charges, a higher percentage of patients were discharged home. Despite a growing number of patients in older age groups, inpatient mortality declined over two decades. Level I TCs are managing patients at highest risk for decompensation and mortality; a significant percentage of patients are going to non-TCs.
Reoperative Heller Myotomy: More Pain, Less Gain
Authors: Wood Thomas W. , Ross Sharona B. , Ryan Carrie E. , Bowman Ty A. , Jacobi Benjamin L. , Konstantinidis Michael G. , Rosemurgy Alexander S.
Published: June 2020

Heller myotomy provides durable and effective treatment of achalasia. Due to recurrence or persistence of symptoms, a small subset of patients seeks reoperation. This study was undertaken to determine if reoperative Heller myotomy provides salutary amelioration of symptoms. 609 patients undergoing laparoscopic Heller myotomy between 1992 to 2013 were prospectively followed; 38 underwent reoperative myotomy. Patients graded their symptom frequency and severity before and after myotomy on a Likert scale. Median data are reported. Patients undergoing reoperative myotomy, when compared to those undergoing their first myotomy, experienced a higher conversion rate to an “open” myotomy (8% vs 1%, P < 0.05) and a longer length of stay (3 vs 1 day, P < 0.05). Reoperative myotomy led to improvement in symptoms, but the magnitude of improvement in symptoms (e.g., dysphagia, choking, and coughing) was less than for patients undergoing their first myotomy (all P < 0.05). Patients undergoing reoperative Heller myotomy were less likely to report symptoms occurring once per month or less (83% vs 56%, P < 0.01). Patients undergoing reoperative myotomy note improvement in symptoms, although to a lesser extent than patients undergoing their first myotomy. Patients undergoing reoperative Heller myotomy can expect to experience less improvement of symptoms, denoting the importance of the first myotomy.
Electromagnetic Navigational Bronchoscopy: A Safe and Effective Method for Fiducial Marker Placement in Lung Cancer Patients
Authors: Bolton William D. , Richey John , Ben-Or Sharon , Hale Allyson L. , Ewing Joseph A. , Stephenson James E.
Published: June 2020

The emergence of Electromagnetic Navigational Bronchoscopy (ENB) as a diagnostic tool for small peripheral lung nodules has introduced a new method for delivery of fiducial markers. This technique has not been well studied in the literature. The purpose of our study was to evaluate the safety and effectiveness of ENB when used in fiducial marker placement. We reviewed all patients undergoing ENB fiducial placement between June 2010 and February 2014 (n = 64). These 64 patients had 68 lung lesions, in which we placed a total of 190 markers. Primary end points were marker retention and postoperative complications. The retention rate for the study was 82 per cent (n = 156). Upper lobe lesions had a 78 per cent retention rate and the middle/lower lobe lesions had an 89 per cent retention rate; the difference was not significant ( P = 0.126). Complications included hospital admissions, respiratory failure, and pneumothorax. The difference in complication rates between upper and middle/lower lobe markers was not significant. We found ENB to be a safe method for the placement of fiducial markers. We also found that placement of an average of three markers/lesion led to an adequate retention rate to allow for successful treatment of lung cancer in nonsurgical patients using lung-sparing stereotactic radiation.
Coagulation Profile Changes Due to Thromboprophylaxis and Platelets in Trauma Patients at High-Risk for Venous Thromboembolism
Authors: Allen Casey J. , Murray Clark R. , Meizoso Jonathan P. , Ray Juliet J. , Teisch Laura F. , Ruiz Xiomara D. , Hanna Mena M. , Guarch Gerardo A. , Manning Ronald J. , Livingstone Alan S. , Ginzburg Enrique , Schulman Carl I. , Namias Nicholas , Proctor Kenneth G.
Published: June 2020

We hypothesize there are coagulation profile changes associated both with initiation of thromboporphylaxis (TPX) and with change in platelet levels in trauma patients at high-risk for venous thromboembolism (VTE). A total of 1203 trauma intensive care unit patients were screened with a VTE risk assessment profile. In all, 302 high-risk patients (risk assessment profile score ≥ 10) were consented for weekly thromboelastography. TPX was initiated between initial and follow-up thromboelastography. Seventy-four patients were analyzed. Upon admission, 87 per cent were hypercoagulable, and 81 per cent remained hypercoagulable by Day 7 ( P = 0.504). TPX was initiated 3.4 ± 1.4 days after admission; 68 per cent received unfractionated heparin and 32 per cent received low-molecular-weight heparin. The VTE rate was 18 per cent, length of stay 38 (25–37) days, and mortality of 17.6 per cent. In all, 76 per cent had a rapid clotting time at admission versus 39 per cent at Day 7 ( P < 0.001); correcting from 7.75 (6.45–8.90) minutes to 10.45 (7.90–15.25) minutes ( P < 0.001). At admission, 41 per cent had an elevated maximum clot formation (MCF) and 85 per cent had at Day 7 ( P < 0.001); increasing from 61(55–65) mm to 75(69–80) mm ( P < 0.001). Platelets positively correlated with MCF at admission (r = 0.308, R2 = 0.095, P = 0.008) and at Day 7 (r = 0.516, R2 = 0.266, P < 0.001). Change in platelet levels correlated with change in MCF (r = 0.332, R2 = 0.110, P = 0.005). In conclusion, hypercoagulability persists despite the use of TPX. Although clotting time normalizes, MCF increases in correlation with platelet levels. As platelet function is a dominant contributor to sustained trauma-evoked hypercoagulability, antiplatelet therapy may be indicated in the management of severely injured trauma patients.
HIDA Scan with Ejection Fraction is over Utilized in the Management of Biliary Dyskinesia
Authors: Eckenrode Amanda H. , Ewing Joseph A. , Kotrady Jennifer , Hale Allyson L. , Smith Dane E.
Published: June 2020

Patients with upper abdominal pain, nausea, and vomiting are often evaluated with ultrasound to diagnose symptomatic cholelithiasis or cholecystitis. With a normal ultrasound, a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. The purpose of this study was to evaluate whether the HIDA scan with EF was appropriately utilized in considering cholecystectomy. Over 18 months, we performed 1533 HIDA scans with EF. After exclusion, 1501 were analyzable, 438 of whom underwent laparoscopic cholecystectomy. Patients were divided into two groups: those with typical and atypical symptoms of biliary colic. Our primary endpoint was symptom resolution of those who underwent laparoscopic cholecystectomy. Symptom resolution was assessed by chart review of postop visits or readmissions. In patients with typical symptoms, resolution occurred in 66 per cent of patients with positive HIDA and 77 per cent with negative HIDA ( P = 0.292). In patients with atypical symptoms, resolution occurred in 64 per cent of patients with positive HIDA and 43 per cent with negative HIDA ( P = 0.013). A HIDA scan with EF was not useful in patients with typical symptoms of biliary colic and negative ultrasounds, and should not be used to make a decision for cholecystectomy. However, this test can be helpful in patients with atypical symptoms, as it does predict symptom improvement in this group.
Synergistic Effect of Combined Hollow Viscus Injuries on Intra-Abdominal Abscess Formation
Authors: Paulus Elena M. , Croce Martin A. , Shahan Charles P. , Zarzaur Ben L. , Sharpe John P. , Dileepan Amirtha , Boyd Brandon S. , Fabian Timothy C.
Published: June 2020

The strong association between penetrating colon injuries and intra-abdominal abscess (IAA) formation is well established and attributed to high colon bacterial counts. Since trauma patients are rarely fasting at injury, stomach and small bowel colony counts are also elevated. We hypothesized that there is a synergistic effect of increased IAA formation with concomitant stomach and/or colon injuries when compared to small bowel injuries alone. Consecutive patients at a level one trauma center with penetrating small bowel (SB), stomach (S), and/or colon (C) injuries from 1996 to 2012 were reviewed. Logistic regression determined associations with IAA, adjusting for age, gender, Injury Severity Score (ISS), admission Glasgow Coma Score, transfusions, and concurrent pancreas or liver injury. A total of 1518 patients (91% male, ISS = 15.9 ± 8.4) were identified: 496 (33%) SB, 231 (15%) S, 288 (19%) C, 40 (3%) S + SB, 69 (5%) S + C, 338 (22%) C + SB, and 56 (4%) S + C + SB. 148 (10%) patients developed IAA: 4 per cent SB, 9 per cent S, 10 per cent C, 5 per cent S + SB, 22 per cent S + C, 13 per cent C + SB, and 25 per cent S + C + SB. Multiple logistic regression demonstrated that ISS, 24 hour blood transfusions, and concomitant pancreatic or liver injuries were associated with IAA. Compared with reference SB, S or S + SB injuries were no more likely to develop IAA. However, S + C, SB + C, and S + C + SB injuries were significantly more likely to have IAA. In conclusion, combined stomach + colon, small bowel + colon, and stomach, colon, + small bowel injuries have a synergistic effect leading to increased IAA formation after penetrating injuries. Heightened clinical suspicion for IAA formation is necessary in these combined hollow viscus injury patients.
Incisional Hernia Classification Predicts Wound Complications Two Years after Repair
Authors: Baucom Rebeccah B. , Ousley Jenny M. , Oyefule Omobolanle O. , Stewart Melissa K. , Holzman Michael D. , Sharp Kenneth W. , Poulose Benjamin K.
Published: June 2020

Classification of ventral hernias (VHs) into categories that impact surgical outcome is not well defined. The European Hernia Society (EHS) classification divides ventral incisional hernias by midline or lateral location. This study aimed to determine whether EHS classification is associated with wound complications after VH repair, indicated by surgical site occurrences (SSOs). A retrospective cohort study of patients who underwent VH repair at a tertiary referral center between July 1, 2005 and May 30, 2012, was performed. EHS classification, comorbidities, and operative details were determined. Primary outcome was SSO within two years, defined as an infection, wound dehiscence, seroma, or enterocutaneous fistula. There were 538 patients included, and 51.5 per cent were female, with a mean age of 54.2 ± 12.4 years and a mean body mass index of 32.4 ± 8.6 kg/m2. Most patients had midline hernias (87.0%, n = 468). There were 47 patients (8.7%) who had a lateral hernia, and 23 patients (4.3%) whose repair included both midline and lateral components. Overall rate of SSO was 39 per cent (n = 211) within two years. The rate of SSO by VH location was: 39 per cent (n = 183) for midline, 23 per cent (n = 11) for lateral, and 74 per cent (n = 17) for VHs with midline and lateral components ( P = <0.001). Patients whose midline hernia spanned more than one EHS category also had a higher rate of SSOs ( P = 0.001). VHs are often described by transverse dimension alone, but a more descriptive classification system offers a richness that correlates with outcomes.
Outcomes of Laparoscopic versus Open Fascial Component Separation for Complex Ventral Hernia Repair
Authors: Ng Nathaniel , Wampler Mallory , Palladino Humberto , Agullo Francisco , Davis Brian R.
Published: June 2020

Ventral hernia recurrence rates have improved with advancements in technique. Open and laparoscopic fascial component separation techniques improve recurrence rates by allowing a tension free closure. This study examines laparoscopic component separation (LCS) and open component separation (OCS) techniques in the repair of complex ventral hernias and compares factors affecting patient outcomes. A retrospective chart review of patients who underwent ventral hernia repair with LCS and OCS was conducted between 2009 and 2013. Patient characteristics and outcomes were documented. Hernia recurrence was determined using physical exam and computed tomography if physical exam was equivocal. Univariate and multivariate analyses were performed. Ten patients underwent LCS and 38 underwent OCS. The rate of wound infection in the LCS group was 20 per cent versus 50 per cent in the OCS group. The overall rate of recurrence after LCS was 20 per cent, and 26 per cent in the OCS group. For body mass index > 30, the recurrence rate was 20 per cent in the LCS group and 29 per cent ( P = 0.5) in the open group. The use of LCS demonstrates a trend in the reduction of hernia recurrence and wound infection overall and in patients with body mass index > 30 compared with OCS.
The Relationship of Endoscopic Proficiency to Educational Expense for Virtual Reality Simulator Training Amongst Surgical Trainees
Authors: Raque Jessica , Goble Adam , Jones Veronica M. , Waldman Lindsey E. , Sutton Erica
Published: June 2020

With the introduction of Fundamentals of Endoscopic Surgery™, training methods in flexible endoscopy are being augmented with simulation-based curricula. The investment for virtual reality simulators warrants further research into its training advantage. Trainees were randomized into bedside or simulator training groups (BED vs SIM). SIM participated in a proficiency-based virtual reality curriculum. Trainees’ endoscopic skills were rated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) in the patient care setting. The number of cases to reach 90 per cent of the maximum GAGES score and calculated costs of training were compared. Nineteen residents participated in the study. There was no difference in the average number of cases required to achieve 90 per cent of the maximum GAGES score for esophagogastroduodenoscopy, 13 (SIM) versus11 (BED) ( P = 0.63), or colonoscopy 21 (SIM) versus 4 (BED) ( P = 0.34). The average per case cost of training for esophagogastroduodenoscopy was $35.98 (SIM) versus $39.71 (BED) ( P = 0.50), not including the depreciation costs associated with the simulator ($715.00 per resident over six years). Use of a simulator appeared to increase the cost of training without accelerating the learning curve or decreasing faculty time spent in instruction. The importance of simulation in endoscopy training will be predicated on more cost-effective simulators.
Safety of Outpatient Chest Tube Management of Air Leaks after Pulmonary Resection
Authors: Royer Anna M. , Smith Jeremy S. , Miller Ashley , Spiva Marlana , Holcombe Jenny M. , Headrick James R.
Published: June 2020

Prolonged air leaks are the most common postoperative complication following pulmonary resection, leading to increased hospital length of stay (LOS) and cost. This study assesses the safety of discharging patients home with a chest tube (CT) after pulmonary resection. A retrospective review was performed of a single surgeon's experience with pulmonary resections from January 2010 to January 2015. All patients discharged home with a CT were included. Discharge criteria included a persistent air leak controlled by water seal, resolution of medical conditions requiring hospitalization, and pain managed by oral analgesics. Patient demographics, type of resection, LOS, and 30-day morbidity and mortality data were analyzed. Comparisons were made with the Society of Thoracic Surgery database January 2011 to December 2013. Four hundred ninety-six patients underwent pulmonary resection. Sixty-five patients (13%) were discharged home postoperatively with a CT. Fifty-eight patients underwent a lobectomy, two patients a bilobectomy, and five patients had a wedge excision. Two patients were readmitted: One with a lower extremity deep venous thrombosis and the other with a nonlife threatening pulmonary embolus. Four patients developed superficial CT site infections that resolved after oral antibiotics. Patients discharged home with a CT following lobectomy had a shorter mean LOS compared to lobectomy patients (3.65 vs 6.2 days). Mean time to CT removal after discharge was 4.7 days (range 1–22 days) potentially saving 305 inpatient hospital days. Select patients can be discharged home with a CT with reduced postoperative LOS and without increase in major morbidity or mortality.
Present Status of Autonomy in Surgical Residency—a Program Director's Perspective
Authors: Patel Mitesh , Bhullar Jasneet S. , Subhas Gokulakkrishna , Mittal Vijay
Published: June 2020

As surgery residents graduate and begin their careers as junior attending surgeons, the question of whether a surgeon can complete a case alone still lingers. Allowing autonomy during residency answers this question. The purpose of this study was to gather input from general surgery residency program directors on how they achieve autonomy for residents in their programs. An online survey of 18 questions was sent to all general surgery residency program directors in the United States between April and June of 2013 via e-mail. Questions were asked regarding classification of autonomy, percentage of case completed by the resident independently, and in what area a resident worked with minimal supervision. Of the 202 delivered, 85 program directors were responded (42%). Seventy-eight per cent of programs classified a resident as surgeon junior whether the resident completed more than 50 per cent of the case. Most classified autonomy as either the resident completing >75 per cent of a case (41%) or completing the critical steps of a surgery (41%). Eighty-eight per cent stated that chief residents completed the majority of cases under supervision, whereas only 12 per cent stated the chief had autonomy in the operating room and also acted as teaching assistant. While, 60 per cent stated their chief residents did not work in any area of the hospital independently. Despite differences in how autonomy is defined among programs, most program directors feel that their chief residents do not achieve complete autonomy. Programs should allow their residents to work in a progressive responsibility as they progress into their fourth and fifth years of residency to achieve autonomy.
A Single Institutions First 100 Patients Undergoing Laparoscopic Anti-Reflux Fundoplications: Where are They 20 Years Later?
Authors: Sadowitz Benjamin D. , Luberice Kenneth , Bowman Ty A. , Viso Alexandra M. , Ayala Daniel E. , Ross Sharona B. , Rosemurgy Alexander S.
Published: June 2020

Although anti-reflux surgery has been used liberally over the past decades for the treatment of gastroesophageal reflux disease (GERD), few studies report follow-up after 10 years. This study was undertaken to report follow-up on 100 consecutive GERD patients up to 22 years after utilizing a laparoscopic fundoplication. Hundred consecutive patients undergoing laparoscopic fundoplication for GERD were prospectively followed beginning in 1992. The frequency and severity of symptoms before and after laparoscopic fundoplication were scored on a Likert scale (1 = never/none to 10 = always/very bothersome). Median data are reported. Of the 100 patients who underwent laparoscopic fundoplication for their GERD, nine were reoperations. Twenty-six patients are deceased on average 11 years after their fundoplications. Seventy-four patients are alive, with 27 patients, actively followed for 19 years after their fundoplications. At most recent follow-up, patients experienced long-term amelioration of symptom frequency and severity after fundoplication (e.g., heartburn frequency = 8–2, severity = 8–1; P < 0.01 for each). Eighty-four per cent of patients rated their symptom frequency as less than once per month. Eighty-eight per cent of patients were satisfied with their postoperative results, and 95 per cent of patients confirmed they would have the operation again knowing what they know now. Long-term follow-up documents high patient satisfaction and durable symptomatic relief up to two decades after laparoscopic fundoplication for GERD. Patients should seek this operation not only for symptomatic relief, but to mitigate the deleterious effects of long-term acid exposure and anti-acid therapy.
Emergency General Surgery: Defining Burden of Disease in the State of Maryland
Authors: Bruns Brandon R. , Tesoriero Ronald , Narayan Mayur , Klyushnenkova Elena N. , Chen Herbert , Scalea Thomas M. , Diaz Jose J.
Published: June 2020

Acute care surgery services continue expanding to provide emergency general surgery (EGS) care. The aim of this study is to define the characteristics of the EGS population in Maryland. Retrospective review of the Health Services Cost Review Commission database from 2009 to 2013 was performed. American Association for the Surgery of Trauma-defined EGS ICD-9 codes were used to define the EGS population. Data collected included patient demographics, admission origin [emergency department (ED) versus non-ED], length of stay (LOS), mortality, and disposition. There were 3,157,646 encounters. In all, 817,942 (26%) were EGS encounters, with 76 per cent admitted via an ED. The median age of ED patients that died was 74 years versus 61 years for those that lived ( P < 0.001). Twenty one per cent of ED admitted patients had a LOS > 7 days. Of 78,065 non-ED admitted patients, the median age of those that died was 68 years versus 59 years for those that lived ( P < 0.001). Twenty eight per cent of non-ED admits had LOS > 7 days. In both ED and non-ED patients, there was a bimodal distribution of death, with most patients dying at LOS ≤ 2 or LOS > 7 days. In this study, EGS diagnoses are present in 26 per cent of inpatient encounters in Maryland. The EGS population is elderly with prolonged LOS and a bimodal distribution of death.
Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses
Authors: Farach Sandra M. , Danielson Paul D. , Chandler Nicole M.
Published: June 2020

The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.
Comparison between Ultrasound and Pathologic Status of Axillary Lymph Nodes in Clinically Node-negative Breast Cancer Patients
Authors: Bailey Amanda , Layne Ginger , Shahan Cimmie , Zhang Jianjun , Wen Siji , Radis Sarah , Richmond Bryan , Partin Jessica , Hazard Hannah
Published: June 2020

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in clinically node-negative breast cancer patients. Ultrasound (US) has shown promise when used to assess axillary lymph nodes preoperatively, thus aiding surgical decision making. We examined the correlation between preoperative US and SLNB results to further clarify the role of US in clinicopathologic staging of breast cancer when the axilla is clinically negative on physical examination. Our institutional cancer registry was used to identify clinically node-negative patients diagnosed with breast cancer from January 1, 2009 to December 31, 2012. Variables including age, body mass index, date of surgery, date of diagnosis, US results, US-directed biopsy results, SLNB results, and final pathology were recorded. Incomplete charts were excluded. In all, 249 patients were included. Sensitivity/specificity of US in the clinically negative axilla were 7.4 per cent and 91.8 per cent, respectively. The false-positive rate was 80 per cent, whereas the negative predictive value was 78 per cent. The effect of time from diagnosis/US to SLNB, interpreting radiologist, year in which US was performed, and body mass index were not statistically significant. US in the clinically node-negative patient, although useful when it leads to a positive needle biopsy result, is unlikely to replace SLNB owing to its low sensitivity and a high false-positive rate. Further prospective study into the role of US in the evaluation of the clinically negative axilla is warranted.
Assessing Incidence and Risk Factors of Cervical Spine Injury in Blunt Trauma Patients Using the National Trauma Data Bank
Authors: Young Andrew J. , Wolfe Luke , Tinkoff Glenn , Duane Therese M.
Published: June 2020

Despite the potentially devastating impact of missed cervical spine injuries (CI), there continues to be a large disparity in how institutions attempt to make the diagnosis. To better streamline the approach among institutions, understanding incidence and risk factors across the country is paramount. We evaluated the incidence and risk factors of CI using the National Trauma Databank for 2008 and 2009. We performed a retrospective review of the National Trauma Databank for 2008 and 2009 comparing patients with and without CI. We then performed subset analysis separating injury by patients with and without fracture and ligamentous injury. There were a total of 591,138 patients included with a 6.2 per cent incidence of CI. Regression found that age, Injury Severity Score, alcohol intoxication, and specific mechanisms of motor vehicle crash (MVC), motorcycle crash (MCC), fall, pedestrian stuck, and bicycle were independent risk factors for overall injury ( P < 0.0001). Patients with CI had longer intensive care unit (8.5 12.5 vs 5.1 7.7) and hospital lengths of stay (days) (9.6 14.2 vs 5.3 8.1) and higher mortality (1.2 per cent vs 0.3%), compared with those without injury ( P < 0.0001). There were 33,276 patient with only fractures for an incidence of 5.6 per cent and 1875 patients with ligamentous injury. Just over 6 per cent of patients suffer some form of CI after blunt trauma with the majority being fractures. Higher Injury Severity Score and MVC were consistent risk factors in both groups. This information will assist in devising an algorithm for clearance that can be used nationally allowing for more consistency among trauma providers.
Incidence of Venous Thromboembolic Events in Mandated Risk Assessment versus Optional DVT Prophylaxis Era at a Large Tertiary Cancer Center
Authors: Kukar Moshim , Asaro Joseph , Aquino Anthony , Groman Adrienne , Skitzki Joseph , Kane John M.
Published: June 2020

Cancer patients are thought to be at high risk for venous thromboembolic events (DVT/PE). Beginning in October 2007, our tertiary cancer center instituted “mandated risk assessment” computerized DVT prophylaxis order entry, for all hospital admissions with an option for active opt out by the physician with a stated reason. Retrospective review of all DVT/PE events within 30 days of a hospital admission [any inpatient admission (IA) and outpatient surgery (OPS)] in comparable “optional (O)” (January 2005—September 2007) vs “mandated risk assessment (M)” (October 2007–May 2010) DVT prophylaxis order eras. Patient demographics, admission details, type of prophylaxis, treatment, and outcome were also analyzed. There were 16,363 for the O (11,944 IA/4,419 OPS) and 17,757 for the M (12,957 IA/4,800 OPS) DVT prophylaxis order eras. The number of DVT/PE events in the O era was 67 (prevalence 0.41%) versus 102 for the M era (prevalence 0.57%), P = 0.037. In the DVT/PE patients, DVT prophylaxis had been ordered during the index admission in 66 per cent for O versus 83 per cent for M ( P = 0.008). Low-molecular-weight heparin was increasingly used in M era (33% vs 16%, P = 0.009). There was also no difference between O vs M era for status at DVT/PE diagnosis (outpatient 36% vs 24%) or associated symptoms. There were no deaths attributable to DVT/PE in the O era versus 3 deaths in the M era. Although DVT prophylaxis use improved with “mandated risk assessment” ordering, the DVT/PE incidence did not decrease. It may be difficult to overcome the surprisingly low baseline prevalence and multiple risk factors in this population.
Identification and Referral of Patients at Risk for Post-traumatic Stress Disorder: A Literature Review and Retrospective Analysis
Authors: Bolduc Aaron , Hwang Brice , Hogan Christopher , Bhalla Varun K. , Nesmith Elizabeth , Medeiros Regina , Alexander Cassie , Holsten Steven B.
Published: June 2020

Post-traumatic stress disorder (PTSD) is a well-established psychological disorder after severe traumatic injury but remains poorly recognized. Recent changes in the “Resources for Optimal Care of the Injured Trauma Patient 2014” stress the need for comprehensive screening and referral for PTSD and depression after injury. Our purpose was to review the current PTSD literature and perform a retrospective chart review to evaluate screening at our institution. We hypothesized a lack of documentation and thus referral of these patients to mental health professionals. We performed a literature review of 43 publications of risk factors for PTSD in the civilian adult population followed by a retrospective review. Records were analyzed for basic demographics, risk factors found in the literature, and referrals to mental health providers. Risk factors included amputation, dissociative symptoms, female gender, history of mental health disorder, and peri-traumatic emotionality. Traumatic amputation status and gender were recorded in all patients. History of mental health disorder was present in 11.5 per cent patients, absent in 80.75 per cent, and not recorded in 7.75 per cent with an overall documentation of 91.75 per cent. Dissociative symptoms and peri-traumatic emotionality were recorded in 0.5 per cent and 1.0 per cent of patients, respectively. Only 13 patients of 400 (3.25%) were referred to mental health professionals. Despite extensive evidence and literature supporting risk factors for the development of PTSD, identification and treatment at our level 1 trauma center is lacking. There is a need for consistent screening among trauma centers to identify PTSD risk factors and protocols for risk reduction and referrals for patients at risk.
Long-term Outcomes Favor Duodenum-preserving Pancreatic Head Resection over Pylorus-preserving Pancreaticoduodenectomy for Chronic Pancreatitis: A Meta-analysis and Systematic Review
Authors: Sukharamwala Prashant B. , Patel Krishen D. , Teta Anthony F. , Parikh Shailraj , Ross Sharona B. , Ryan Carrie E. , Rosemurgy Alexander S.
Published: June 2020

Pylorus-preserving pancreaticoduodenectomy (PPPD) and duodenum-preserving pancreatic head resection (DPPHR) are important treatment options for patients with chronic pancreatitis. This meta-analysis was undertaken to compare the long-term outcomes of DPPHR versus PPPD in patients with chronic pancreatitis. A systematic literature search was conducted using Embase, MEDLINE, Cochrane, and PubMed databases on all studies published between January 1991 and January 2013 reporting intermediate and long-term outcomes after DPPHR and PPPD for chronic pancreatitis. Long-term outcomes of interest were complete pain relief, quality of life, professional rehabilitation, exocrine insufficiency, and endocrine insufficiency. Other outcomes of interest included perioperative morbidity and length of stay (LOS). Ten studies were included comprising of 569 patients. There was no significant difference in complete pain relief ( P = 0.24), endocrine insufficiency ( P = 0.15), and perioperative morbidity ( P = 0.13) between DPPHR and PPPD. However, quality of life ( P < 0.00001), professional rehabilitation ( P = 0.004), exocrine insufficiency ( P = 0.005), and LOS ( P = 0.00001) were significantly better for patients undergoing DPPHR compared with PPPD. In conclusion, there is no significant difference in endocrine insufficiency, postoperative pain relief, and perioperative morbidity for patients undergoing DPPHR versus PPPD. Improved intermediate and long-term outcomes including LOS, quality of life, professional rehabilitation, and preservation of exocrine function make DPPHR a more favorable approach than PPPD for patients with chronic pancreatitis.