bluuebunny/crossref_metadata_2025 huggingface dataset:
Location, not Staging, of Cholangiocarcinoma Determines the Role for Adjuvant Chemoradiation Therapy
Authors: Serafini Francesco M. , Sachs Donald , Bloomston Mark , Carey Larry C. , Karl Richard C. , Murr Michael M. , Rosemurgy Alexander S.
Published: November 2022

The role of adjuvant chemoradiation therapy (CT/XRT) in the treatment of cholangiocarcinoma is controversial. We undertook this study to determine whether CT/XRT is appropriate after resection of cholangiocarcinomas. One hundred ninety-two patients with cholangiocarcinomas were treated from 1988 to 1999. After resection, patients were assigned a stage (TNM) and were stratified by location of the tumor as intrahepatic, perihilar, and distal tumors. Data are presented as mean ± standard deviation. Of 192 patients 92 (48%) underwent resections of cholangiocarcinomas. Thirty-four patients had liver resections, 25 had bile duct resections, and 33 underwent pancreaticoduodenectomies. Thirty-four patients had adjuvant CT/XRT, three had adjuvant chemotherapy, four had neoadjuvant CT/XRT, and 50 had no radiation or chemotherapy. Mean survival of resected patients with adjuvant CT/XRT was 42 ± 37.0 months and without CT/XRT it was 29 ± 24.5 months ( P = 0.07). Mean survival of patients with distal tumors receiving or not receiving CT/XRT was 41 ± 21.8 versus 25 ± 20.1 months, respectively, ( P = 0.04). Adjuvant chemoradiation improves survival after resection for cholangiocarcinoma ( P = 0.07) particularly in patients undergoing resection for distal tumors ( P = 0.04). Benefits of adjuvant CT/XRT are apparent when stratified by location of cholangiocarcinomas rather than staging.
Laparoscopic Splenectomy in Patients with Normal-Sized Spleens versus Splenomegaly: Does Size Matter?
Authors: Heniford B. Todd , Park Adrian , Walsh R. Matthew , Kercher Kent W. , Matthews Brent D. , Frenette Gary , Sing Ronald F.
Published: November 2022

Laparoscopic resection has become the standard means for removal of normal-sized spleens in many medical centers. The application of minimally invasive techniques in the setting of splenomegaly is less well defined and was previously considered a contraindication to the laparoscopic approach. The purpose of this prospective study of consecutive patients was to compare the outcomes of patients undergoing laparoscopic splenectomy for normal-sized spleens (150 g or less) versus those with clear evidence of splenomegaly (500 g or greater). One hundred forty-two patients met the inclusion criteria. The most common diagnosis in the normal-sized spleen group was idiopathic thrombocytopenia purpura (67 of 82, 82%). Malignant hematologic diseases (lymphoma and leukemia) were the most common diagnoses in the splenomegaly group (35 of 60, 58%). Mean operative times (127 vs 172 minutes) and estimated blood loss (123 vs 173 cm3) were lower for those patients with normal-sized spleens ( P < 0.05). There were no statistical differences in conversion rates, lengths of stay, or complications between the two groups. We conclude that laparoscopic splenectomy is safe and effective in the setting of splenomegaly despite modest but statistically longer operative times and increased operative blood loss when compared with laparoscopic splenectomy for normal-sized spleens.
Mesenteric Ischemia: An Unusual Presentation of Traumatic Intrahepatic Arterioportal Fistula
Authors: English William P. , Johnson Mathew B. , Borman Karen R. , Turner William W.
Published: November 2022

Traumatic hepatic arterioportal fistulae (APF) are described infrequently as sequelae of hepatic trauma. These anomalies are usually associated with blunt hepatic trauma or iatrogenic injury. The majority of APF present within weeks to months of injury with gastrointestinal hemorrhage, hemobilia, abdominal pain, and diarrhea. When presenting remotely APFs are associated with portal hypertension, heart failure, gastrointestinal hemorrhage, ascites, and splenomegaly. We report an unusual case of mesenteric ischemia due to an APF that resulted from a penetrating liver injury 20 years before presentation. Successful treatment of the APF was achieved by intravascular catheter occlusion resulting in resolution of symptoms.
A Continuum between Scapulothoracic Dissociation and Traumatic Forequarter Amputation: A Review of the Literature
Authors: Estrada Lance S. , Alonso Jorge , Rue Loring W.
Published: November 2022

Both traumatic forequarter amputation and scapulothoracic dissociation are rare and life-threatening injuries. We present the case of a 31-year old woman who was ejected from a car after a motor vehicle accident and sustained an apparent partial forequarter amputation. Upon examination her injury was found to share many characteristics with a scapulothoracic dissociation injury. With both injuries mortality is high and prompt diagnosis and treatment imperative. By viewing scapulothoracic dissociation and forequarter amputation as a continuum faster recognition and appropriate treatment may be implemented for these devastating injuries.
Leiomyosarcoma of the Gallbladder: A Case Report
Authors: Danikas Dimitrios , Theodorou Spiro J.V. , Singh Robert , Camal Debra E.
Published: November 2022

Primary sarcoma of the gallbladder is a rare disease. The tumor occurs more frequently in women. Usually gallstones are present. Symptoms resemble those of cholelithiasis or cholecystitis. The diagnosis is rarely made preoperatively. The patient was a 51-year-old woman with a 2-month history of right upper quadrant pain, nausea, vomiting, and a 10-pound weight loss. Ultrasound showed cholelithiasis and cholecystitis. Laparoscopic cholecystectomy was converted to open as a result of dense tissue in the middle to distal gallbladder. Exploration by a right subcostal incision revealed multiple implants on the surface of the liver and the peritoneum of the upper abdomen. The wall of the gallbladder was very thick and inflamed. Cholecystectomy with liver biopsy was performed. Pathology revealed poorly differentiated epithelioid leiomyosarcoma of the gallbladder with extension to the liver. The disease followed a very aggressive course and the patient died 3 weeks after the procedure. Recommended treatment is extensive surgical resection that can be followed by radiotherapy or chemotherapy. The tumor follows a very aggressive course, which often lasts a few weeks. Prognosis is poor with rare reported 5-year survivals.
Follicular Neoplasms of the Thyroid: Predictors of Malignancy?
Authors: Zdon Michael J. , Fredland Allan J. , Zaret Phillip H.
Published: November 2022

Follicular neoplasms of the thyroid present a therapeutic challenge. Initial limited thyroidectomy may result in some patients requiring completion thyroidectomy for malignancy. In the current study we examined age, gender, race, time from nodule discovery to operation in months, history of radiation exposure, tumor size (cm), and cell type in patients with follicular neoplasms identified at the time of thyroidectomy in two socioeconomically diverse settings from 1993 through 2000 to identify possible factors associated with a greater chance of malignancy. Of 36 follicular lesions identified in 35 patients seven (19%) were malignant on permanent section. Hurthle cell histology was present in six of 36 lesions. Mean age of patients with benign lesions was 47 ± 13 versus 50 ± 15 in malignant cases ( P > 0.05). Benign lesions measured 2.6 ± 1.2 cm versus 3.1 ± 1.7 cm in malignant ( P > 0.05). Other factors found not to be significant included gender and time nodule was present (12.8 ± 19 months benign vs 11.8 ± 20 months malignant) ( P > 0.05). Hurthle cell histology was associated with a 50 per cent malignancy rate (three of six) versus 13 per cent (four of 30) with non-Hurthle cell histology ( P < 0.05). Two patients with exposure to radiation fallout had malignancies in lesions of one and 2 cm ( P < 0.05). Patients from a socioeconomically disadvantaged setting had a malignancy rate of 50 per cent (six of 12) compared with a malignancy rate of 3 per cent (one of 24) from a socioeconomically affluent population ( P < 0.05). In conclusion Hurthle cell histology and exposure to radiation fallout were associated with significantly higher rates of malignancy in follicular neoplasms and should be taken into account when deciding on the initial extent of thyroidectomy. The difference in malignancy rates observed between socioeconomic settings while significant requires further investigation.
Extra-Abdominal Pneumodissection after Laparoscopic Antireflux Surgery
Authors: Harris James A. , Gallo Captain Dominic R. , Brummett Darin M. , Mullins Major Daniel J. , Figueroa-Ortiz Ramon E.
Published: November 2022

The presence of pneumoperitoneum during laparoscopic antireflux surgery can lead to the dissection of carbon dioxide into the mediastinum, retroperitoneum, subcutaneous tissues, and neck (pneumodissection). The purpose of this study is to describe the incidence, extent, duration and pathways of pneumodissection during laparoscopic antireflux surgery. Twenty patients who underwent laparoscopic antireflux surgery from August 1998 through May 1999 were studied. Physical examination and chest radiographs were performed in the recovery room and each day postoperatively. Noncontrast computerized tomography (CT) of the neck, chest, and upper abdomen was also performed on postoperative day one. Subcutaneous emphysema and radiologic evidence of pneumodissection occurred commonly and typically resolved within 4 days postoperatively. The incidence of pneumomediastinum (85%) seen on CT scan was similar to that of pneumodissection into the neck (80%). The most common pathway of dissection of gas was through the anterior mediastinum and into the neck through the carotid space. Other findings on CT scan revealed pneumoperitoneum in 70 per cent, pneumoretroperitoneum in 10 per cent, and pneumothorax in 0 per cent. The dissection of gas into the mediastinum, neck, and subcutaneous tissues is very common after laparoscopic antireflux surgery. Subcutaneous emphysema on physical examination and radiographic pneumodissection typically resolves within 3 to 4 days. After this time one should consider the presence of any substantial amount of gas as a potential complication related to the procedure.
Bovine Pericardial Patch Angioplasty in Carotid Endarterectomy
Authors: Grimsley Brad R. , Wells Joe K. , Pearl Gregory J. , Garrett Wilson V. , Shutze William P. , Talkington C. Mack , Gable Dennis R. , Smith Bertram L. , Thompson Jesse E.
Published: November 2022

Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the incidence of both early and late complications. Controversy continues, however, over the ideal patch material. Bovine pericardium (Vascu-Guard Biovascular Inc., Saint Paul, MN) offers an attractive alternative to other patch materials because of its handling and suturing characteristics that are similar to that of autogenous material. This study examines the perioperative and midterm results of bovine pericardial patch angioplasty during CEA. We studied 112 patients who underwent 129 CEAs with bovine pericardial patch angioplasty during an 18-month period. Data were collected regarding demographics, operative indications, perioperative complications, and the occurrence of late adverse outcomes based primarily on follow-up arterial duplex studies. Among this group there were 63 male (56%) and 49 female (44%) patients whose mean age was 71.8 ± 9.1 years. In these patients there was the typical distribution of atherosclerotic risk factors. Seventy-four patients (66%) had symptomatic disease preoperatively and the remaining 38 patients (34%) were asymptomatic. Temporary cranial nerve palsy occurred in three patients (2%). There were no perioperative strokes, acute occlusions, bleeding episodes requiring reoperation, or deaths. The patients were followed up to 54 months postoperatively with a mean follow-up time of 41.7 ± 4.4 months. During this period two patients (2%) developed three significant restenoses (70–99%). All required reoperation. There were no asymptomatic occlusions, infections, aneurysms, or rupture. These data demonstrate that bovine pericardial patch angioplasty during CEA is associated with a low incidence of both perioperative and midterm adverse outcomes.
Use of the Prolene Hernia Sstem for Inguinal Hernia Repair: Retrospective, Comparative Time Analsis versus Other Inguinal Hernia Repair Sstems
Authors: Murph John W.
Published: November 2022

No data are available for the duration of surger for the various procedures currentl used in hernia repair. This retrospective stud was undertaken to determine the time required for the surgical repair of unilateral primar inguinal hernias using currentl available procedures and to show specificall that the duration of surger using the PROLENE™ Hernia Sstem (PHS) was equal to or less than the duration of surger using a plug-and-patch device. Data were collected from 1032 sequential hernia procedures performed b 16 surgeons at a communit hospital between 1997 and 1999. To gain more accurate information to compare the PHS and plug-and-patch procedures data from four surgeons who had performed at least five of each procedure were used as the primar analsis database. The two most frequentl used devices were the PHS (35.9%) and plug and patch (41.0%). The average times of surger for these procedures were not significantl different (25.4 vs 27.2 minutes, respectivel; P = 0.236). A significant variabilit was observed between surgeons in the duration of surger and there was evidence for an inverse relationship between the duration of surger and the number of procedures a surgeon had performed. Both procedures take approximatel the same time to perform.
“General Surgical Pearls” for the Anterior Exposure of Vertebral Fractures
Authors: Barone Gary W. , Pait Thomas G. , Eidt John F. , Howington John A.
Published: November 2022

Recently interest has been increasing in the anterior surgical approach for spinal cord decompression and bony stabilization of vertebral compression fractures. Our neurosurgical spine service routinely consults us to provide anterior operative exposure and wound closure for all levels of the thoracic and lumbar vertebral spine. Averaging about 30 exposures per year we have developed an excellent operative experience with these vertebral exposures. With no complete general surgery reference on anterior vertebral identified this summary of our “general surgical pearls” that we have learned and/or have developed should significantly aid other general and trauma surgeons who may be asked by their neurosurgical and/or orthopedic surgical colleagues for assistance with these operations.
Chest Wall Metastasis from Recurrent Meningioma
Authors: Williamson Barry E. , Stanton Constance A. , Levine Edward A.
Published: November 2022

Meningiomas are generally considered benign lesions. A minority, however, are capable of metastasis. The ones most likely to do so are commonly recurrent or frankly malignant in nature. The optimal management of such metastases is unclear. This is the first reported case of meningioma presenting as an isolated metastasis to the chest wall. This case involves a 64-year-old woman without significant medical or family history who underwent resection of a meningioma of the right cerebral hemisphere. She was treated 10 years later for recurrence by stereotactic radiosurgery. Three years after that, the patient's family noticed a mass on the left chest wall. A CT scan revealed destruction of the ninth rib laterally and subpleural extension. The patient subsequently underwent resection of full-thickness chest wall for a presumed soft-tissue sarcoma. Further pathologic evaluation including electron microscopy and immunohistochemistry revealed metastatic meningioma. The patient received adjuvant radiation to the chest wall and is currently free of disease at the chest wall one year after surgery. This case illustrates the difficulty in establishing an accurate diagnosis of metastatic meningioma. Consequently in selected patients with a history of the disease the diagnosis of metastatic meningioma must at least be considered. Resection of an isolated metastasis in this setting appears warranted.
Preoperative Radiographic Staging for Ureteral Injuries is Not Warranted in Patients Undergoing Celiotomy for Trauma
Authors: Digiacomo J. Christopher , Frankel Heidi , Rotondo Michael F. , Schwab C. William , Shaftan Gerald W.
Published: November 2022

Preoperative radiographic staging of the urinary tract has been shown to be inaccurate with regard to the ureter. The purpose of this study was to assess the need for radiographic staging of the injured patient for the diagnosis of ureteral injury before operative exploration. We conducted a retrospective review of all patients who sustained injury of the ureter as the result of external trauma over an 8 ½-year period at an urban and suburban Level I trauma center. All patients were injured through penetrating mechanisms and underwent laparotomy. Only three patients had preoperative radiographic staging of the urinary tract. No ureteral injuries were missed. We conclude that surgical exploration of the ureter is sufficiently accurate to obviate the need for preoperative radiographic staging of the ureters in patients who have sustained penetrating injury and warrant laparotomy.
Octylcyanoacrylate Tissue Adhesive as an Alternative to Mechanical Fixation of Expanded Polytetrafluoroethylene Prosthesis
Authors: Birch Daniel W. , Park Adrian
Published: November 2022

In minimally invasive incisional hernia repair positioning and fixation of the expanded polytetrafluoroethylene (ePTFE) mesh prosthesis on the deep surface of the abdominal wall may be facilitated using tissue adhesives. Octylcyanoacrylate (OCTYL), a new adhesive, forms a strong flexible bond with antimicrobial properties. In a rabbit model for incisional hernia we investigated characteristics of the bond created by OCTYL between ePTFE and abdominal wall musculature. We studied initial bond strength and the postoperative host response to the adhesive over a 6-week period. We compared sutured, stapled, and glued mesh prostheses and examined the tissue-prosthesis interface. The ePTFE mesh was fixed successfully to the abdominal wall with OCTYL and remained tightly attached at 6 weeks. Prostheses fixed with OCTYL and spiral tacks induced few intra-abdominal adhesions compared with sutured mesh. All prostheses were completely reperitonealized at 2 weeks. The force required to displace mesh fixed with sutures and staples was greater than mesh fixed with OCTYL. Analysis of the ePTFE/tissue interface by light and scanning electron microscopy showed host cellular migration into the interstices of the mesh with fixation by tacks and suture, whereas an inflammatory infiltrate was seen on the muscular surface with OCTYL fixation of the mesh.
Endometriosis in Abdominal Scars: A Report of Three Cases Diagnosed by Fine-Needle Aspiration Biopsy
Authors: Simsir Aylin , Thorner Kim , Waisman Jerry , Cangiarella Joan
Published: November 2022

Endometrioma in an operative scar is rare. The majority of patients have no prior history of endometriosis, and symptoms may mimic postoperative hernias. Fine-needle aspiration biopsy (FNAB) can be a valuable diagnostic aid in the evaluation of these subcutaneous abdominal masses. We present the cytologic findings in three cases of abdominal wall endometriomas diagnosed by FNAB. The patients ranged from 31 to 51 years of age. None had a history of endometriosis, but all had prior abdominal operations (two abdominal hysterectomies for fibroids and one cesarean section). They presented 6 months to 7 years later with painful subcutaneous abdominal nodules in their scars ranging from 2 to 6 cm. FNAB was performed by a cytopathologist. The smears were cellular and comprised two distinct cell populations. An epithelial component consisted of flat sheets of polygonal cells with round to oval nuclei and scant cytoplasm. The second component consisted of clusters of fusiform stromal cells. Numerous hemosiderin-laden macrophages were noted in the background. Cytokeratin highlighted the epithelial clusters, and vimentin stained the stromal cells. Electron microscopy showed two epithelial cell types: one with cilia and abundant rough endoplasmic reticulum and the other with numerous microvilli and scattered mitochondria indicative of endometrial differentiation. FNAB provided a rapid and accurate preoperative diagnosis in each case.
A Loop-Forming Duplicate Recurrent Laryngeal Nerve: Report of a Case and Clinical Relevance in Thyroid Surgery
Authors: Sato Tomoyuki , Ogura Shigeto , Okazaki Mutsumi , Kanazawa Kyotaro , Nagai Hideo
Published: November 2022

This is a report of a unilateral loop-forming duplicate recurrent laryngeal nerve and its clinical relevance. A 72-year-old woman with a giant goiter underwent a total thyroidectomy. At operation we identified two recurrent laryngeal nerves on the right side and one on the left side. The nerve on the right was smaller and displaced laterally by the. goiter, whereas the other was adjacent to the trachea and behind the goiter, and it was accidentally divided. Both nerves were united before innervating the larynx. The divided nerve was microsurgically reanastomosed but a postoperative assessment revealed hoarseness. This case report of an anomalous loop-forming duplicate recurrent laryngeal nerve indicates that it may not be sufficient to identify a single recurrent laryngeal nerve on one side during thyroid surgery especially when the observed recurrent nerve is relatively smaller than usual.
Desmoplastic Melanoma
Authors: Payne Wyatt G. , Kearney Robert , Wells Karen , Blue Martin , Walusimbi Mbaga , Mosiello Gerald , Cruse C.W. , Reintgen Douglas
Published: November 2022

Desmoplastic melanoma is an uncommonly encountered variant of malignant melanoma. Three histological subtypes exist: desmoplastic, neurotropic, and neural transforming. Desmoplastic melanoma commonly presents in conjunction with existing melanocytic lesions or as an amelanotic firm nodule. Local recurrences are common. Thirty patients over a 6-year period were treated at our institution for desmoplastic melanoma. All lesions were treated with local excision. Local recurrence occurred in seven patients (23%) and was treated by aggressive re-excision in each instance. Clinical regional metastasis (lymph nodal basins) were detected in two patients (6%). Distant metastasis (lung) developed in two patients (6%). Twenty-three patients (76%) were found to have desmoplastic subtype, whereas five (17%) had neurotropic subtype. Six patients (20%) had associated pigmented melanotic lesions. Average length of follow-up has been 18 months. Overall survival is 96 per cent. Presentations and histologic diagnosis can sometimes be difficult and misleading. Treatment is aggressive local excision with follow-up necessary to detect resectable recurrent lesions.
Minimally Invasive Parathyroidectomy without Intraoperative Localization
Authors: Sprouse L. Richard , Roe S. Michael , Kaufman Henry J. , Williams Nancy
Published: November 2022

Minimally invasive parathyroidectomy (MIP) is gaining popularity as an alternative to traditional bilateral exploration for patients with primary hyperparathyroidism. The success of MIP relies on the ability of preoperative and intraoperative localization studies to guide a directed exploration for resection of a diseased gland. We hypothesize that excellent results can be achieved with MIP when only technetium-99m sestamibi (MIBI) is used for localization. We conducted a prospective analysis of all patients presenting with a biochemical diagnosis of primary hyperparathyroidism between January 1997 and November 2000. Patients meeting inclusion criteria were given a choice of MIP and directed exploration versus traditional bilateral exploration. Fifty patients chose MIP. Three patients who chose MIP had a negative MIBI, which left 47 patients in the primary study group. The MIBI correctly identified a parathyroid adenoma in 42 patients (89.3%). In two other patients MIBI was inaccurate; however, directed exploration was successfully converted to a bilateral exploration. Overall 44 of 47 (93.6%) patients in the study group were rendered normocalcemic after the initial operation. Three patients experienced persistent hypercalcemia and subsequently underwent successful bilateral exploration. Including those patients choosing a bilateral exploration, a total of 59 positive MIBI scans were evaluated. There were 54 true positives (positive predictive value 91.5%), and if all patients had chosen a MIP 94.9 per cent would have been successfully treated at the initial operation. Mean operative time for MIP was 54.6 minutes, and in 32 patients (68.1%) MIP was performed with local anesthesia and sedation. Twenty-six patients (55.3%) were discharged the same day of the procedure. There were no significant complications in any group analyzed. We conclude that MIP can be successfully performed on the basis of a positive MIBI scan. The present study highlighting many of the advantages of MIP questions the necessity of additional adjuncts such as intraoperative parathyroid hormone measurement and γ-probe localization.
Radical Resection Improves Survival for Patients with pT2 Gallbladder Carcinoma
Authors: Wise Paul E. , Shi Yun-Ying , Washington M. Kay , Chapman William C. , Wright J. Kelly , Sharp Kenneth W. , Pinson C. Wright
Published: November 2022

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T2 gallbladder carcinoma (pT2 GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT2 GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT2 disease after cholecystectomy. The patients had an average age of 64 ± 13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT2 GBCa after radical resection was significantly greater than with cholecystectomy alone ( P < 0.05). The difference in length of survival between the two groups was also significant ( P < 0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT2 GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT2 GBCa.
Anal Carcinoma or “Just Hemorrhoids”?
Authors: Winburn Ginger B.
Published: November 2022

Cancers of the anal margin and anal canal are extremely rare and often misdiagnosed. Only one to two per cent of large bowel cancers arise in this area. Current management of these cancers includes surgery, combined chemoradiation, or both. From January 1985 through July 2000, 50 patients were diagnosed with anal cancer at two institutions. This retrospective review includes all available cases of anal cancer including all histologies. Patient charts were analyzed for diagnosis, staging, treatment, survival, and recurrence rate. The patients ranged in age from 27 to 92 years (median age 51 years; mean age 52.8 years); there were 22 men and 28 women. The pathologic diagnosis included 44 (88%) with squamous cell carcinoma, three (6%) with melanoma, two (4%) with adenocarcinoma, and one (2%) with Paget's disease. At presentation nine (18%) were classified as stage 0, five (10%) stage I, 21 (42%) stage II, eight (16%) stage III, and seven (14%) stage IV. Mean follow-up data were available on 100 per cent of the patients. Chemoradiotherapy was the primary treatment modality in 25 patients (50%). Ten patients (20%) underwent abdominoperineal resection (APR) in the study. Three patients (6%) received an APR as primary treatment, three (6%) in combination with chemoradiation, and four (8%) for salvage therapy. Fourteen patients (28%) underwent wide local excision (WLE) as the primary treatment. Two patients (4%) underwent WLE plus chemoradiation therapy. One patient (2%) underwent WLE and chemotherapy. There were 18 deaths (36%) in this series. Thirteen patients (26%) died of anal cancer; the average time to death from diagnosis was 13.2 months. Three of these deaths were in patients with melanoma who presented with stage IV disease. Thirty-two patients (64%) are alive, and 30 (60%) of these patients are free of disease (mean time since diagnosis 32.5 months, range 2–151 months). Six patients (12%) had recurrence after treatment (mean time to recurrence 12.6 months; range 3–26 months). Anal cancers continue to present at an advanced stage, with a high mortality rate. Anal melanoma in particular is an aggressive and highly fatal cancer. APR remains the recommended salvage therapy for advanced anal carcinomas that fail primary treatment. In our series only one of four patients has had a disease-free survival of 4 months. Early recognition and detection of primary and recurrent disease is necessary for improved outcome.
Transcutaneous Oxygen Measurements Predict a Beneficial Response to Hyperbaric Oxygen Therapy in Patients with Nonhealing Wounds and Critical Limb Ischemia
Authors: Grolman Rodney E. , Wilkerson Donald K. , Taylor Jan , Allinson Peter , Zatina Michael A.
Published: November 2022

Hyperbaric oxygen (HBO) therapy may be a useful adjunct in the treatment of patients with wounds associated with critical limb ischemia. These patients either cannot undergo a successful bypass or may not heal after vascular reconstruction alone. Identification of patients likely to benefit from HBO is essential before treatment, as this therapy is time-consuming, costly, and not without risk. Transcutaneous oxygen measurements (TCOM) can be used to evaluate the degree of hypoxia in ischemic tissue. In this study we evaluated whether TCOM could be used to identify those patients who would or would not benefit from HBO therapy. Our hypothesis is that a difference in transcutaneous oxygen tension readings measured near the ischemic lesion with the patient breathing room air and while breathing 100 per cent oxygen at ambient pressure may be predictive of wound healing with adjunctive hyperbaric oxygen therapy. Thirty-six patients with critical limb ischemia and nonhealing ulcers were referred for HBO therapy. They were deemed either nonreconstructible from a vascular surgical viewpoint, had failed prior revascularization attempts, or could not achieve complete wound healing even after a successful revascularization. Pretreatment assessment included a room air and post-100 per cent-O2 challenge TCOM reading obtained in the vicinity of the open wound. Hyperbaric oxygen treatments at 2.0 to 2.5 atm were then administered until healing occurred or failure was confirmed. All patients undergoing HBO had a baseline TCOM of <40 torr. Twenty-seven patients had an increase in TCOM of >10 torr with oxygen inhalation at initial evaluation. Of these patients, 19 (70%) healed their wounds with HBO therapy. Conversely the increase in TCOM was <10 torr in nine patients, and only one of these patients (11%) ultimately healed ( P < 0.01). Patients with nonhealing ischemic extremity wounds may heal with adjunctive HBO therapy. We can predictably identify patients who are likely to benefit from this modality using TCOM at the time of initial evaluation. An increase of tissue O2 tension of ≥10 torr when breathing pure O2 suggests that the patient may benefit from HBO therapy. Those patients with an increase of <10 torr are unlikely to receive benefit from this treatment modality.
Group A Streptococcus (GAS) Soft-tissue Infections: A Lethal Organism on the Rise
Authors: Bochicchio Grant V. , Joshi Mrinal , Joshi Manjari , Henry Sharon , Scalea Thomas
Published: November 2022

Several reports over the past decade have suggested that there has been an increase in the number of invasive streptococcal infections with young children and the elderly being at the highest risk. We evaluated the incidence of group A Streptococcus (GAS) and compared it with historic data collected at our institution. Prospective data were collected on patients diagnosed with GAS (with and without shock) admitted to a tertiary-care center from July 1995 to July 2000. Each patient was followed by an infectious disease specialist throughout the hospital stay. Definitions of streptococcal toxic shock syndrome (STSS) developed by the Centers for Disease Control and Prevention were used. Thirty-eight patients (mean age of 39 ± 12) presenting with GAS soft-tissue infections were admitted to our institution over a 5-year period (7.6 patients per year). Fourteen (37%) were diagnosed with STSS. This represents a greater than fourfold increase in the average number of cases per year of patients diagnosed with GAS and a nearly 4.5 times greater increase in the annual number of patients diagnosed with STSS. The overall mortality of patients diagnosed with GAS was 13 per cent, which increased to 36 per cent in patients diagnosed with STSS. We conclude that there has been a significant increase in the incidence of GAS soft-tissue infections over the past 5 years at our institution. This may represent a new virulent strain, as the majority of these infections did not occur in typical high-risk patients at the extremes of their lives. Further epidemiologic population-based studies are needed to further delineate the severe nature of this problem.
When a Hernia is Not a Hernia: The Evaluation of Inguinal Hernias in the Cirrhotic Patient
Authors: Horn Thomas W. , Harris James A. , Martindale Robert , Gadacz Thomas
Published: November 2022

Herniorrhapy in patients with advanced portal hypertension and ascites should be approached with caution, and treated conservatively whenever possible. Cirrhosis increases the risk of significant perioperative complications such as infection, recurrence, and ascites leak. This paper reports two patients operated on for suspected inguinal hernias. The first patient was referred for elective repair of a presumed inguinal hernia before liver transplantation. The second patient presented with a history of an incarcerated inguinal hernia that was previously reduced in the emergency center. After examination by residents and senior faculty the patients were scheduled for elective herniorrhaphy. Intraoperatively no inguinal hernia could be identified in either patient. However, massively dilated veins (1.5–2.0 cm in diameter) were noted entering with the spermatic cord at the internal inguinal ring. In both cases the veins were clamped, transected, and suture ligated at the internal ring. Given the unusual presentation of these dilated veins in both patients we advocate the use of preoperative Doppler ultrasound in patients with cirrhosis and suspected inguinal hernias.
Traumatic Head Injury in the Anticoagulated Elderly Patient: A Lethal Combination
Authors: Karni Amir , Holtzman Robert , Bass Thomas , Zorman Greg , Carter Lee , Rodriguez Luis , Bennett-Shipman Vicki J. , Lottenberg Lawrence
Published: November 2022

Warfarin is the most common oral anticoagulant used for chronic anticoagulation therapy. Even without any antecedent trauma overanticoagulation can result in intracranial hemorrhage. The triad of anticoagulation with warfarin, age greater than 65 years, and traumatic head injury frequently produces a lethal brain hemorrhage. A retrospective review of more than 2000 patients admitted to the Trauma Service between September 1998 and May 2000 produced 278 patients with head injury and CT-documented intracranial hemorrhage. Of these patients 21 were admitted with an elevated prothrombin time (FT) due to anticoagulation with warfarin. Eighteen patients (86%) were above the age of 70. The most common indications for anticoagulation were atrial fibrillation (71%), deep venous thrombosis (19%), aortic valve replacement (9%), and ischemic cerebral infarcts (9%). Fourteen injuries were the result of a fall, one resulted from a gunshot wound, and one resulted from an assault. The remaining five patients were excluded as their history, workup, and evaluation by neurosurgery suggested a spontaneous bleed leading to fall rather than a fall causing a traumatic bleed. The average Glasgow Coma Score on admission was 11. The average PT and International Normalized Ratio (INR) on admission were 19.2 and 2.99 respectively. Eight of the 16 patients analyzed died. The risk of intracranial hemorrhage with relatively minor head injury is increased dramatically in the anticoagulated patient. A mortality rate of 50 per cent far exceeds the mortality rate in patients with similar head injuries who are not anticoagulated. In addition the risk/benefit equation of anticoagulation for the elderly is more complex and differs from that for younger patients. Perhaps more frequent and judicious monitoring of prothrombin time levels with lower therapeutic ranges (INR 1.5–2) is necessary.
Does Alcohol Intoxication Alter the Assessment and Outcome of “Observation-Status” Trauma Patients?
Authors: Mccadams Joseph S. , Daley Brian J. , Enderson Blaine L.
Published: November 2022

We assessed the effect of blood alcohol concentration (BAC) on the evaluation, outcome, and hospital charges of our observation-status trauma patient population. We conducted a retrospective study over 18 months; any patient initially admitted with <24-hour observation status, Glasgow Coma Score of 15, and negative drug screen was eligible. Patients were divided on the basis of BAC (BAC+ = >80 mg/dL; BAC- = <80 mg/dL). Two hundred twenty-six patients were observed during the study (2765 admissions). For the 66 BAC+ patients (range 90–392 mg/dL) there was a strong male predominance. There was no difference in diagnostic evaluation schema, delayed diagnosis, complications, cost, or conversions to full admission between the groups. We conclude that evaluation, outcome, and charges of observation trauma patients are the same regardless of BAC. Intoxication did not mask injury; therefore BAC+ patients do not require observation on the sole basis of intoxication if their evaluation is otherwise negative.
Tensile Strength of Wound Closure with Cyanoacrylate Glue
Authors: Shapiro Cpt Andrew J. , Dinsmore Maj Robert C. , North Ltc James H.
Published: November 2022

2-Octyl cyanoacrylate tissue adhesive is increasingly being used for closure of traumatic lacerations. Data regarding the strength of incisions closed with 2-octyl cyanoacrylate are limited. We compared the strength of disruption of closure with glue with that of more conventional methods of wound closure. Segments of fresh porcine skin measuring 3.5 x 10 cm were approximated by one of four methods: 1) 2-octyl cyanoacrylate glue, 2) surgical staples, 3) 0.5 inch Steri-Strips, and 4) interrupted 4–0 poliglecaprone 25 sutures in a subcuticular fashion. Fifteen specimens were used to test each type of closure. The strength of closure was tested on an Instron 4502 tensionometer. The peak force required for disruption of the closure was recorded and the strength of the closure was compared. Staples provided the strongest closure. Skin glue proved superior to Steri-Strips but inferior to stapled closure. The difference between skin glue and suture closure was not statistically significant ( P = 0.12). Patterns of failure differed between the groups. Skin glue failed because of disruption of the skin-glue interface. 2-Octyl cyanoacrylate glue provides a wound closure that is similar to closure with an interrupted subcuticular absorbable suture. This study validates the clinical use of skin glue for closure of surgical incisions. The technique should be used with caution in areas of the body that are subject to tension.
Intravenous Interleukin-6 Levels Predict Need for Laparotomy in Patients with Bowel Obstruction
Authors: Firoozmand Eiman , Fairman Nathan , Sklar Jeff , Waxman Kenneth
Published: November 2022

Interleukin-6 (IL-6) has been identified as a marker of ischemia. However, its association with bowel obstruction has not been studied. Fifty-seven patients diagnosed with bowel obstruction were evaluated in a prospective blinded study and managed either medically (n = 29) or surgically (n = 28) per decision of attending surgeon. Serum IL-6 levels were obtained at the time of diagnosis and serially during hospitalization. Mean IL-6 levels at the time of diagnosis were significantly higher in patients who required operation compared with medically treated patients (63.9 vs 19.6 pg/mL respectively; P = 0.027). Levels returned to those seen in medically treated patients 3 days after operation. There was no difference in temperature, white blood cell count, or lactic acid levels. Five patients required resection for ischemic bowel. Patients with ischemic bowel had significantly higher initial mean IL-6 (146.6 vs 45.9 pg/mL; P = 0.034) and lactic acid (23.6 vs 11.8 mg/dL; P = 0.035) at time of diagnosis compared with surgically treated patients without bowel ischemia. No difference in white blood cell count was seen. IL-6 was a sensitive predictor of patients with bowel obstruction requiring operation and for presence of ischemic bowel. IL-6 screening may allow for earlier and more selective operation potentially decreasing morbidity and mortality.
The Topography of Colorectal Cancer Varies by Race/Ethnicity and Affects the Utility of Flexible Sigmoidoscopy
Authors: Theuer Charles P. , Taylor Thomas H. , Brewster Wendy R. , Campbell Brian S. , Becerra Juan C. , Anton-Culver Hoda
Published: November 2022

Colorectal cancer screening beginning at age 50 is recommended for all Americans considered at “average” risk for the development of colorectal cancer either with flexible sigmoidoscopy and fecal occult blood testing (FOBT) or with colonoscopy. Patients who elect flexible sigmoidoscopy and FOBT undergo full colonoscopy only if left-sided neoplasia is detected or if the FOBT is positive. Unfortunately in blacks and whites most right-sided colorectal lesions are unaccompanied by left-sided sentinel lesions, which leads some to prefer colonoscopic screening in these patients. The topography of colorectal cancer in Asians and Latinos is unavailable. We used 1988–1995 California Cancer Registry data to determine the topography of 105,906 consecutive colorectal cancers among Asian, black, Latino, and white patients. We found that the proportion of colorectal cancer distal to the splenic flexure and therefore detectable by flexible sigmoidoscopy varied by ethnicity: Asian (71%) > Latino (63%) > white (57%) > black (55%); P < 0.001. These differences were significant after adjusting for age and sex. The risk of distal disease relative to whites was 1.61 in Asians, 1.15 in Latinos, and 0.82 in blacks ( P < 0.001). Flexible sigmoidoscopy detects a higher proportion of colorectal cancers in Asians and Latinos than in whites or blacks. Further study is needed to assess whether the topography of benign colorectal neoplasia parallels that of malignant disease. Colorectal screening recommendations may need to incorporate racial and ethnic differences in colorectal neoplasia topography.
Timing, Safety, and Efficacy of Thoracoscopic Evacuation of Undrained Post-Traumatic Hemothorax
Authors: Vassiliu Pantelis , Velmahos George C. , Toutouzas Konstantinos G.
Published: November 2022

Residual post-traumatic hemothorax (RPTH) occurs in 3 to 8 per cent of patients with tube thoracostomy and may cause serious infectious complications. Surgical evacuation is recommended, and thoracoscopic evacuation (THEVA) tends to replace open thoracotomy for this purpose. The objective of this study is to evaluate the optimal timing, safety, and efficacy of THEVA. Over 5 years patients with tube thoracostomy for trauma who had unresolved opacities on plain chest radiograph were evaluated by CT. If the residual fluid volume was estimated to be more than 500 mL3 on CT the patients were offered THEVA. Unstable patients were excluded. A score ranging from one (easy) to three (difficult) was used to grade the difficulty of the operation according to the attending surgeon's perception. Of 1728 chest trauma patients 143 (8%) were evaluated by CT for persistent opacity on plain film, 31 (1.8%) were found to have RPTH, and 24 (1.4%) were eventually taken for THEVA at 3.5 ± 2 days after admission. Low oxygen saturation (less than 94%) was found in 58 per cent of patients before THEVA but in only 25 per cent after THEVA ( P = 0.02). The majority of chest tubes (75%) were removed within 4 days of the operation. Two patients required conversion to thoracotomy. THEVA done within 3 days of admission was associated with a lower operative difficulty score, shorter hospital stay, and a trend toward shorter intraoperative time compared with THEVA done after 3 days of admission. All patients had effective resolution of their radiographic opacities after THEVA. Three patients developed a complication (urinary tract infection, pneumonia, and persistent air leak). We conclude that patients with significant RPTH and without major physiologic compromise are appropriate candidates for THEVA. The procedure is safe, evacuates PRTH effectively, and improves the respiratory function of affected patients. Ideally it should be performed within 3 days of admission.
Around-the-dock Attending Radiology Coverage is Essential to Avoid Mistakes in the Care of Trauma Patients
Authors: Velmahos George C. , Fili Cleo , Vassiliu Pantelis , Nicolaou Nicolaos , Radin Randal , Wilcox Alison
Published: November 2022

Financial constraints due to increasing operating cost and decreased reimbursement do not allow many hospitals to maintain coverage by attending radiologists around the clock (CARAC). Preliminary film readings by radiology trainees may be inaccurate. In trauma, decisions are made fast and are often based on these preliminary readings. To examine whether there are significant discrepancies between preliminary readings (PRs) and final readings (FRs) of CT scans of trauma patients we prospectively recorded PRs (done immediately by radiology residents) and FRs (done the following working day by radiology attendings) over a period of 6 months for trauma CT scans done between 5 pm and 7 am on weekdays or weekends. A discrepancy was classified as significant if a change in management was instituted after FR. In 42 of 383 (11%) trauma patients there was a discrepancy between PR and FR. Patients with discrepancies had a higher Injury Severity Score, higher incidence of penetrating trauma, longer hospital stay, higher hospital charges, and higher mortality than patients without any discrepancy. Most of the discrepancies were found on abdominal CT scans. The lower the level of radiology resident doing the PR the higher the likelihood of a discrepancy. In 20 patients (5%) a significant discrepancy was found. We conclude that the absence of CARAC results in inaccurate FRs risking optimal trauma patient care. The institutional savings realized by avoiding CARAC may be offset by the cost of additional care provided to patients who have delayed diagnosis and treatment due to the lack of it.