bluuebunny/crossref_metadata_2025 huggingface dataset:
Basic Ultrasound Training Can Replace Chest Radiography for Safe Tube Thoracostomy Removal
Authors: Lavingia Kedar S. , Soult Michael C. , Collins Jay N. , Novosel Timothy J. , Weireter Leonard J. , Britt L. D.
Published: June 2020

An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray (CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX) associated with TT removal after basic US training. Patients included had TT managed by the surgical team between October 2012 and May 2013. Bedside US was performed by a variety of members of the trauma team before and after removal. All residents received, at minimum, a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes occurred secondary to having incomplete imaging, charting, or death before having TT removed. Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40 years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%), hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were correctly identified by residents using US. This was confirmed on CXR with appropriate changes made. US was able to successfully predict the safe TT removal and patient discharge at all residency levels after receiving a basic US training program.
False-negative Results with the Bethesda System of Reporting Thyroid Cytopathology: Predictors of Malignancy in Thyroid Nodules Classified as Benign by Cytopathologic Evaluation
Authors: Richmond Bryan K. , Judhan Rudy , Chong Benny , Ubert Adam , Aburahma Zachary , Mangano William , Thompson Stephanie
Published: June 2020

The benign category of the Bethesda System for reporting thyroid cytopathology (BSRTC) predicts an incidence of malignancy from zero to three per cent. However, recent series report higher rates of malignancy ranging from eight to 14 per cent. Surgery is often performed for reasons other than their fine needle aspiration biopsy (FNAB) such as symptoms, nodule enlargement, or worrisome imaging. We hypothesized that an analysis of patients who underwent thyroidectomy despite a benign FNAB would identify predictors of malignancy, an area not currently addressed by American Thyroid Association guidelines. We performed a retrospective analysis of patients with benign FNAB results who underwent thyroidectomy from October 2007 to October 2012. Data collected included symptoms, imaging findings, FNAB results, and operative and histopathology results, all of which were obtained by chart review. Findings were compared between patients with and without a diagnosis of malignancy. Statistical significance was set as P < 0.05. Of 3839 FNABs, 2838 were benign. Of these, 180 underwent surgery for indications other than the FNAB category. Twenty-four (13.4%) malignancies were identified: 12 (6.7%) incidental microcarcinomas and 12 (6.7%) significant cancers (papillary greater than 1.0 cm, any nonpapillary histology). No patient's symptoms or signs reached significance as a predictor of malignancy. Suspicious ultrasound appearance was significantly associated with an underlying carcinoma ( P = 0.004). The false-negative result with benign FNAB is higher in surgical series than suggested by the BSRTC. Patients with tolerable symptoms may be observed in the face of a benign FNAB. Additionally, despite a benign FNAB, recommendations for closer follow-up or surgical intervention are warranted if the ultrasound appearance is suspicious.
Parathyroid Hormone Levels Predict Posttotal Thyroidectomy Hypoparathyroidism
Authors: Rivere Amy E. , Brooks Ashton J. , Hayek Genevieve A. , Wang Heng , Corsetti Ralph L. , Fuhrman George M.
Published: June 2020

We hypothesized that parathyroid hormone (PTH) determination would be the most effective strategy to identify posttotal thyroidectomy hypoparathyroidism (PTTHP) compared with other clinical and laboratory parameters. We retrospectively reviewed our recent experience with total thyroidectomy. We recorded demographics, malignancy, thyroid weight, parathyroid autotransplantation, hospital stay, use of postoperative calcium and hormonally active vitamin D3 (calcitriol), and postoperative serum calcium and PTH levels. Patients were divided into two groups depending on whether supplemental calcitriol was required to maintain eucalcemia and therefore reflecting the diagnosis of PTTHP. From October 2010 to June 2013, a total of 202 total thyroidectomies were performed. Twenty-four patients (12%) developed PTTHP and required calcitriol replacement. Logistic regression analysis revealed that only postoperative calcium levels ( P = 0.02) and PTH levels ( P < 0.0001) statistically significantly predicted PTTHP. Twenty-two of 29 patients with PTH 13 pg/mL or less had PTTHP. Only two of 173 patients with a PTH level greater than 13 pg/mL were diagnosed with PTTHP. We recommend using PTH levels after total thyroidectomy to determine which patients will have hypoparathyroidism requiring calcitriol therapy. An early determination of PTTHP allows for prompt management that can shorten hospital stay and improve outcomes.
Referral Patterns in Pediatric Burn Patients
Authors: Doud Andrea N. , Swanson John M. , Ladd Mitchell R. , Neff Lucas P. , Carter Jeff E. , Holmes James H.
Published: June 2020

Though multiple studies have demonstrated superior outcomes amongst adult burn patients at verified burn centers (VBCs) relative to nondedicated burn centers (NBCs), roughly half of such patients meeting American Burn Association (ABA) referral guidelines are not sent to these centers. We sought examine referral patterns amongst pediatric burn patients. Retrospective review of a statewide patient database identified pediatric burn patients from 2000 to 2007 using International Classification of Disease (ICD-9) discharge codes. These injuries were cross-referenced with ABA referral criteria to determine compliance with the ABA guidelines. 1831 children sustained burns requiring hospitalization during the study period, of which 1274 (70%) met ABA referral criteria. Of 557 treated at NBCs, 306 (55%) met criteria for transfer. Neither age, gender, nor payer status demonstrated significant association with treatment center. VBCs treated more severely injured patients, but there was no difference in survival or rate of discharge home from NBCs versus VBCs. Studies to evaluate differences in functional outcomes between pediatric burn patients treated at VBCs versus NBCs would be beneficial to ensure optimization of outcomes in this population.
Appendicostomy for Intraluminal Antibiotic Administration and Extracorporeal Membrane Oxygenation Support in Severe Hirschsprung's Enterocolitis
Authors: Phillips Michael R. , Erickson Kimberly M. , Adamson William T. , McLean Sean E.
Published: June 2020

A term male infant with Hirschsprung's disease underwent an uncomplicated laparoscopic-assisted endorectal pull-through procedure. Four weeks after discharge, the patient developed severe Clostridium difficile enterocolitis with hemodynamic instability and peritonitis. Bedside laparotomy confirmed intestinal viability and accommodated an appendicostomy for antegrade vancomycin colonic irrigations. The patient required venoarterial extracorporeal membrane oxygenation for physiological support for more than six days. Transition to conventional support was successful with survival and discharge from the hospital free from hemorrhagic complications. The patient is now developmentally appropriate for his age.
Trauma System Overtriage: Are We on Track?
Authors: Fullerton Zoe , Donald Graham W. , Cryer Henry G. , Lewis Catherine E. , Cheaito Ali , Cohen Marilyn , Tillou Areti
Published: June 2020

The American College of Surgeons (ACS) recommends trauma overtriage rate (OT) below 50 per cent to maximize efficiency while ensuring optimal care. This retrospective study was undertaken to evaluate OT rates in our Level I trauma center using the most recent criteria and guidelines. OT rates during a 12-month period were measured using six definitions based on combinations of Injury Severity Score (ISS), length of hospital stay (LOS, in days), procedures, and disposition after the emergency department. Reason for trauma activation was 55 per cent criteria, 16 per cent guidelines, 11 per cent paramedic judgment, five per cent no reason, and 13 per cent no documentation. OT rates ranged from 22.6 per cent (ISS less than 9, LOS 1 day or less, no consults) to 48.2 per cent (ISS less than 9, LOS 3 days or less, with procedures/consults) and were in compliance with ACS recommendations. Physiologic assessment criteria and anatomic injury had the lowest OT rates and contained all mortalities. Passenger space intrusion (PSI), pedestrian versus automobile (criterion and guideline), and extrication (guideline) all had consistently high rates of OT. We conclude that PSI should be reduced to a guideline, the pedestrian versus automobile criterion and guideline should be combined, and extrication could be removed from the triage scheme.
Effect of Marijuana Use on Outcomes in Traumatic Brain Injury
Authors: Nguyen Brian M. , Kim Dennis , Bricker Scott , Bongard Fred , Neville Angela , Putnam Brant , Smith Jennifer , Plurad David
Published: June 2020

Traumatic brain injury (TBI) is associated with significant morbidity and mortality. Several studies have demonstrated neuroprotective effects of cannabinoids. The objective of this study was to establish a relationship between the presence of a positive toxicology screen for tetrahydrocannabinol (THC) and mortality after TBI. A 3-year retrospective review of registry data at a Level I center of patients sustaining TBI having a toxicology screen was performed. Pediatric patients (younger than 15 years) and patients with a suspected nonsurvivable injury were excluded. The THC(+) group was compared with the THC(-) group with respect to injury mechanism, severity, disposition, and mortality. Logistic regression was used to determine independent associations with mortality. There were 446 cases meeting all inclusion criteria. The incidence of a positive THC screen was 18.4 per cent (82). Overall mortality was 9.9 per cent (44); however, mortality in the THC(+) group (2.4% [two]) was significantly decreased compared with the THC(-) group (11.5% [42]; P = 0.012). After adjusting for differences between the study cohorts on logistic regression, a THC(+) screen was independently associated with survival after TBI (odds ratio, 0.224; 95% confidence interval, 0.051 to 0.991; P = 0.049). A positive THC screen is associated with decreased mortality in adult patients sustaining TBI.
One-year Outcomes of Laparoscopic Sleeve Gastrectomy versus Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity
Authors: Young Monica T. , Gebhart Alana , Khalaf Racha , Toomari Nojan , Vu Stephen , Smith Brian , Nguyen Ninh T.
Published: June 2020

Sleeve gastrectomy is emerging to be the procedure of choice in the management of severe obesity. The aim of this study was to analyze outcomes between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic adjustable gastric banding (LAGB). A retrospective matched cohort analysis was performed between 150 patients who underwent LSG versus 150 patients who underwent LAGB. The cohorts were matched for age, gender, body mass index (BMI), and preoperative comorbidities. Length of hospital stay (1.6 vs 1.1 days, P < 0.01) was longer in the LSG group. Perioperative complications were similar between groups (4.6% for LSG vs 2.0% for LAGB) but the late complication rate was significantly lower in the LSG group (1.3 vs 8.0%). The 30-day reoperation (0 vs 0.7%) and readmission (1.3 vs 1.3%) rates were similar between groups. There were no 90-day mortalities in the study. The mean reduction in BMI was significantly higher for LSG (-11.9 kg/m2 for LSG vs -6.2 kg/m2 for LAGB, P < 0.01) at 1-year follow-up. The number of medications used to control all comorbidities was significantly lower at follow-up compared with baseline for both groups. The mean reduction in the number medications used to control hypertension was greater in the LSG group (-1.00 ± 0.70 vs -0.35 ± 0.70 medications, P < 0.01). LSG has a perioperative safety profile comparable to that of LAGB but achieved significantly better weight loss and control of hypertension with a lower rate of late complications.
Hypocaloric Enteral Nutrition Protects against Hypoglycemia Associated with Intensive Insulin Therapy Better than Intravenous Dextrose
Authors: Kauffmann Rondi M. , Hayes Rachel M. , Van Laeken Amanda H. , Norris Patrick R. , Diaz Jose J. , May Addison K. , Collier Bryan R.
Published: June 2020

Intensive insulin therapy treats hyperglycemia but increases the risk of hypoglycemia. Typically, intravenous dextrose is given to prevent hypoglycemia; however, enteral nutrition is preferred. We hypothesized that the provision of hypocaloric enteral nutrition would protect against hypoglycemia. A retrospective analysis was performed evaluating patients treated with intensive insulin therapy comparing the use of enteral nutrition versus a dextrose-only intravenous solution. Nutrition in the 2 hours before each blood glucose test was assessed, and the association with hypoglycemia (50 mg/dL or less) evaluated. Risk of hypoglycemia as a function of nutrition type and rate was estimated by multivariable regression. A total of 26,140 blood glucose tests were collected on 1289 patients. Hypoglycemia occurred in 6.4 per cent of patients. In regression models, enteral nutrition was the strongest protective factor against hypoglycemia ( P < 0.001) with the largest risk reduction (steepest portion of the curve) occurring at 60 per cent goal. Hypocaloric enteral nutrition showed a greater risk reduction than a peripheral dextrose-only intravenous solution alone. In the setting of intensive insulin therapy, the provision of enteral nutrition, even if hypocaloric, is sufficient to protect against hypoglycemia. Future prospective studies should evaluate the efficacy of enteral nutrition in reducing the risk of hypoglycemia and whether lower rates of hypoglycemia correspond to improved outcomes.
Increased Total Serum Random Cortisol Levels Predict Mortality in Critically Ill Trauma Patients
Authors: Pandya Urmil , Polite Nathan , Wood Teresa , Lieber Michael
Published: June 2020

Dysfunction in the hypothalamopituitary adrenal axis is thought to exist; however, there continues to be controversy about what level of serum cortisol corresponds to adrenal insufficiency. Few studies have focused on the significance of serum random cortisol in the critically ill trauma patient. Trauma patients with total serum random cortisol levels drawn in the intensive care unit within the first seven days of hospitalization were retrospectively reviewed. The primary outcome measured was in-hospital mortality. Two hundred forty-two patients were analyzed. Non-survivors had significantly higher mean cortisol levels than survivors (28.7 ± 15.80 mg/dL vs 22.9 ± 12.35 mg/dL, P = 0.01). Patients with cortisol 30 mg/dL or greater were more likely to die with odds ratio of 2.7 (95% confidence interval [CI], 1.5 to 5). The odds ratio increased to 4.0 and 3.8 (95% CI, 1.4 to 11.4 and 1.3 to 10.9) when cortisol was drawn on hospital Day 2 and Days 3 through 7, respectively. Among nonsurvivors, patients with an injury severity score less than 25 had significantly higher cortisol levels than patients with an Injury Severity Score 25 or higher (35.3 ± 19.21 mg/dL vs 25.7 ± 13.21 mg/dL, P = 0.009). Patients with massive transfusion, traumatic brain injury, spinal cord injury, or solid organ injury did not have significantly different cortisol levels. The covariate-adjusted area under the receiver operating characteristic curve indicated that cortisol level has a 77 per cent accuracy in differentiating survivors from nonsurvivors. Higher cortisol levels were predictive of mortality in critically ill trauma patients. Whether serum cortisol level is a marker that can be modified remains an area of interest for future study.
Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences
Authors: Fischer Peter E. , Colavita Paul D. , Fleming Gregory P. , Huynh Toan T. , Christmas A. Britton , Sing Ronald F.
Published: June 2020

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.
Impact of Gastric Prolapse after Laparoscopic Adjustable Gastric Banding for Morbid Obesity
Authors: Davis John P. , LaPar Damien J. , Schirmer Bruce D. , Hallowell Peter T.
Published: June 2020

Gastric prolapse (GP) after laparoscopic adjustable gastric banding (LAGB) remains a complication that has the potential to result in significant morbidities. The purpose of this study was to evaluate the incidence of GP after LAGB and to determine its impact on patient outcomes among the morbidly obese. From 2005 to 2012, 379 consecutive morbidly obese patients underwent LAGB procedures at a single institution. Patients were placed into two groups based on the occurrence of gastric prolapse (GP vs no GP). Patient demographics and risk factors, operative features, and postoperative outcomes were analyzed by univariate analyses to assess the impact of GP. Average patient age was 47 ± 29 years and patients were commonly female (80%) with a median body mass index (BMI) of 44 kg/m2. Incidence of GP was 4.2 per cent (n = 16). LAGB median BMIs at 1 month and 1 year were 41 and 36 kg/m2. There was no difference in 1-year weight loss (BMI GP: 36 kg/m2 vs no GP: 36 kg/m2, P = 0.617). Laparoscopic gastric banding results in significant weight reduction and a low incidence of gastric prolapse. Gastric prolapse has no difference in 1-year postoperative median BMI when compared with patients who did not prolapse.
Frequency of Lower Urinary Tract Injury after Gastrointestinal Surgery in the Nationwide Inpatient Sample Database
Authors: Sawkar Hari P. , Kim Dae Y. , Thum D. Joseph , Zhao Lee , Cashy John , Bjurlin Marc , Bhalani Vishal , Boller Anne-Marie , Kundu Shilajit
Published: June 2020

Bladder and ureteral injury are serious iatrogenic complications during abdominal and pelvic surgery but are poorly investigated in the general surgery literature. The objective of this study was to examine rates, trends, and patient and surgical characteristics present in lower urinary tract injuries during gastrointestinal surgery using the Nationwide Inpatient Sample (NIS) database. The NIS database was queried from 2002 to 2010 for gastrointestinal surgery procedures including small/large bowel, rectal surgery, and procedures involving a combination of the two. These were crossreferenced with bladder and ureteral injury using International Classification of Diseases, 9th Revision, Clinical Modification codes. Multivariate regression analysis was used to calculate odds ratios for hypothesized risk factors. From 2002 to 2010, total average rates of bladder injury and ureteral injury were 0.15 and 0.06 per cent, respectively. Small/large bowel procedures had lower annual rates of ureteral (0.05 to 0.07%) and bladder (0.12 to 0.14%) injuries compared with ureteral (0.11 to 0.25%) and bladder (0.27 to 0.41%) injuries in rectal procedures. Presence of metastatic disease was associated with the greatest risk for bladder (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.2) and ureteral (2.2; 1.9 to 2.5) injury in small/large bowel surgery, and for bladder (3.1; 2.5 to 3.9) and ureteral (4.0; 3.2 to 5.0) injury in combination procedures. Injury rates were significantly greater in open surgeries compared with laparoscopic procedures for both bladder injury (0.78 vs 0.26%, P < 0.0001) and ureteral injury (0.34 vs 0.06%, P < 0.0001). The incidence of genitourinary (GU) injury in gastrointestinal surgery is rare, less than 1.0 per cent, and is less than the incidence of GU injury reported in gynecologic surgery. This risk is increased by operations on the rectum and the presence of malignancy.
The Functional Outcomes of Coloanal and Low Colorectal Anastomoses with Reservoirs after Low Rectal Cancer Resections
Authors: Rubin FranÇ Ois , Douard Richard , Wind Philippe
Published: June 2020

Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.
Comparison of a Flexible-tip Laparoscope with a Rigid Straight Laparoscope for Single-incision Laparoscopic Cholecystectomy
Authors: Matsui Yoichi , Ryota Hironori , Sakaguchi Tatsuma , Nakatani Kazuyoshi , Matsushima Hideyuki , Yamaki So , Hirooka Satoshi , Yamamoto Tomohisa , Kwon A-Hon
Published: June 2020

This study assessed whether a flexible-tip laparoscope improves operative outcomes including operative length while performing single-incision laparoscopic cholecystectomy (SILC) compared with the use of a conventional straight laparoscope. The flexible-tip laparoscope decreased the operative time compared with the straight laparoscope. Although SILC has potential benefits, surgeons experience problems for in-line viewing through a laparoscope and from contact of instruments with the laparoscope, resulting in longer operative times and the need for additional ports. The aim of this study was to determine whether a flexible-tip laparoscope improves operative outcomes, including operative length and the rate of insertion of additional ports, while performing SILC compared with the use of a conventional rigid straight laparoscope. We reviewed data on patients for whom we performed SILC at the Department of Surgery, Kansai Medical University, for the period from November 1, 2009, to February 28, 2013. The information was assessed with respect to patient characteristics, types of laparoscope used, operative data as well as postoperative outcomes. Operating time for SILC using the flexible-tip laparoscope was significantly shorter than with the straight laparoscope (81.5 ± 23.2 vs 94.4 ± 21.1 minutes) as a result of a better view of the operating field without contact with working instruments. Although a trend was shown toward a reduced rate of the need for extra ports in the flexible-tip laparoscope group, the difference did not reach statistical significance. Using the flexible-tip laparoscope solved the problem of in-line viewing and decreased the operative time for SILC.
A Simplified Technique for Tumor Localization Using Preoperative Endoscopic Clipping and Radio-opaque Markers during Totally Laparoscopic Gastrectomy
Authors: Kim Beom Su , Yook Jeong Hwan , Kim Byung Sik , Jung Hwoon-Yong
Published: June 2020

Tumor localization during intracorporeal anastomosis after totally laparoscopic distal gastrectomy (TLDG) is challenging. The aim of this study was to assess the simplicity and feasibility of locating tumors in the stomach using radio-opaque markers and preoperative endoscopic clipping. The intra- and postoperative findings of 29 patients who underwent TLDG with intracorporeal anastomosis between January 2012 and March 2013 were reviewed. Preoperative endoscopic clips were applied just proximal to the tumor by specialized endoscopists, and surgical gauze with an attached radio-opaque marker (3 mm x 60 mm) was prepared. The marker was fixed to either the anterior or posterior of the stomach, above the predicted site of the tumor, using suture ties. Portable abdominal radiography was used during the laparoscopic surgery, and the stomach was resected using guidance by the radiomarker. The radio-opaque marker and the endoscopic clips were clearly visible by intraoperative abdominal radiography. All patients received curative resection. No complications or deaths were encountered. The mean distance between the endoscopic clips and the radiomarker by portable intraoperative radiography was 21.3 ± 18.3 mm, whereas the actual in situ mean distance was 20.7 ± 17.6 mm. This difference was not statistically significant ( P > 0.05). It is imperative that preoperative endoscopic clips are applied just proximal to the tumor by specialized endoscopists. The use of a radio-opaque marker is a simple and feasible way to locate tumors during totally laparoscopic gastrectomy.
The Burden of the U.S. Crisis in the Surgical Critical Care Workforce and Workflow
Authors: Sarani Babak , Toevs Christine , Mayglothling Julie , Kaplan Lewis J.
Published: June 2020

There will be a 46 per cent shortage of intensivists by 2030. Currently, only 3 per cent of U.S. critical care is provided by surgeon-intensivists. Measurement of the current workload is needed to understand the ramifications of the expected shortage of surgeon-intensivists. The purpose of this study is to evaluate the self-reported workload of U.S. surgeon-intensivists. Over a 2-month period, a voluntary and anonymous survey of the surgery section of the Society of Critical Care Medicine was performed using Survey Monkey. Only surgeons were invited to participate. We assessed personnel resources and surgeon-intensivists workload in the intensive care unit (ICU) and on their postcall day. Two hundred sixty-two persons responded. Sixty-nine per cent had administrative responsibilities and 42 per cent covered bed allocation/transfer center duties while in the ICU. Seventy-six per cent covered trauma and general surgery call and 72 per cent covered the outpatient clinic or had elective surgery cases while responsible for the ICU. Only 14 per cent had no other responsibilities. Twenty-one per cent did not round with residents and 50 per cent did not round with a fellow. Thirty-six per cent did not work with advanced practitioners. The majority of surgeon-intensivists have significant responsibilities in addition to providing ICU care. This workload should be factored into the expected shortage of surgical intensivists relative to the expected increase in critical care demand.
Subcutaneous Suture Can Accelerate Wound Healing of Lower Midline Incision: A Randomized Controlled Trial
Authors: Liang Xiao , Han-Xin Zhou , Chang-E Jin , Chao Wang , Juan Han , Guo-Quan Gao
Published: June 2020

Poor wound healing is one of the most common complications after laparotomy, especially in lower abdominal midline incisions. The aims of this trial are to assess the value of subcutaneous suture and identify risk factors to prevent poor wound healing. From October 2010 to October 2011, a total of 180 patients were randomized to the subcutaneous suture group (n = 89) or control group (n = 91) after laparotomy with a lower midline incision. Univariate and multivariate analyses were performed to determine the predictive significance of variables of poor wound healing. Patients’ demographics, preoperative laboratory values, and operative details were comparable between the two groups. The overall rate of poor wound healing was 16.7 per cent (30 of 180). Patients randomized to subcutaneous suture group (n = 89) had poor healing in 10.1 per cent (nine of 89) and those without suture (n = 91) in 23.1 per cent (21 of 91) ( P = 0.020). Multivariate logistic regression analysis revealed that American Society of Anesthesiologists (ASA) score (3 to 4) (odds ratio [OR], 2.933), subcutaneous suture (OR, 0.323), and blood loss (greater than 200 mL) (OR, 5.995) were independent risk factors for poor wound healing. Subcutaneous suture can effectively accelerate wound healing. Nonsubcutaneous suture, ASA score (3 to 4), and blood loss (greater than 200 mL) are independent risk factors for poor would healing.
Long-term Quality-of-life Improvement in Gastric Banding Patients from Body-contouring Surgery
Authors: Lanthaler Monika , Mattesich Monika , Nehoda Hermann , Puelzl Petra , Matiasek Johannes , Nitto Agnese , Pierer Gerhard , Kinzl Johann
Published: June 2020

Following my prior study of long-term results after laparoscopic gastric banding concerning operative outcome and complications involving the gastric band itself, I now focus on long-term quality-of-life improvement in the same study group after body-contouring surgery. As determined from our electronic patient data system, 72 patients from the former study group subsequently sought body-contouring surgery at our hospital after successful weight loss. Patients were enrolled in a telephone interview and asked about their expectations and body image before and after postbariatric aesthetic surgery and how it altered their well-being in addition to the weight loss achieved with the gastric band. All patients undergoing postbariatric aesthetic surgery felt extremely uneasy with the hanging skin resulting from weight reduction. Patients cannot imagine the degree of dissatisfaction they will experience from the sagging skin that comes with weight loss. Hardly any patient expected fewer scars than he ultimately had after body-contouring surgery and reported an extreme improvement in body image. Gastric banding should not be performed without informing patients about the need for postbariatric body-contouring surgery, because most patients not forewarned suffer greatly from their body image after weight loss.
Doing More: Trends in Breast Cancer Surgery, 2005 to 2011
Authors: Lucas Donald J. , Sabino Jennifer , Shriver Craig D. , Pawlik Timothy M. , Singh Devinder P. , Vertrees Amy E.
Published: June 2020

An increasing number of women may be choosing mastectomy over breast-conserving surgery for breast cancer as well as undergoing more bilateral resection, immediate reconstruction, and prophylactic operations. Women who had breast cancer operations between 2005 and 2011 were selected from the National Surgical Quality Improvement Program database. Annual trends were explored using robust Poisson multivariable regression as were predictors for mastectomy versus breast-conserving surgery. A total of 85,401 women were identified. Mastectomy increased from 2005 to 2011, starting at 40 per cent in 2005 and peaking at 51 per cent in 2008 ( P < 0.001). Bilateral resection, immediate reconstruction, and prophylactic mastectomy also increased (all P < 0.001). Independent predictors of mastectomy included young age, Asian race, invasive cancer (vs carcinoma in situ), bilateral resection, axillary dissection, higher American Society of Anesthesiologists class, and lower body mass index (all P < 0.001). There was an increase in mastectomy, bilateral resection, immediate reconstruction, and prophylactic mastectomy from 2005 to 2011.
Real-time Cadaveric Laparoscopy and Laparoscopic Video Demonstrations in Gross Anatomy: An Observation of Impact on Learning and Career Choice
Authors: Saberski Ean R. , Orenstein Sean B. , Matheson Dale , Novitsky Yuri W.
Published: June 2020

Medical curricula are continually evolving and increasing clinical relevance. Gross anatomy educators have tested innovations to improve the clinical potency of anatomic dissection and found that clinical correlations are an effective method to accomplish this goal. Recently, surgical educators defined a role for laparoscopy in teaching anatomy. We aimed to expand this role by using surgical educators to create clinical correlates between gross anatomy and clinical surgery. We held supplements to traditional anatomy open dissection for medical students, including viewing prerecorded operative footage and live laparoscopic dissection performed on cadavers. The main outcome measures were assessed through pre- and postsession surveys. Greater than 75 per cent of students found the demonstrations highly valuable, and students perceived a significant increase in their understanding of abdominopelvic anatomy ( P < 0.01). Additionally, 62 per cent of students with previous interest in surgery and 10 per cent of students without previous interest in surgery reported increased interest in pursuing surgical careers. Our demonstrations advance the use of minimally invasive surgical technology to teach gross anatomy. Live laparoscopic demonstrations augment traditional anatomic instruction by reinforcing the clinical relevance of abdominopelvic anatomy. Additionally, laparoscopic demonstrations generate interest in surgery that would otherwise be absent in the preclinical years.
Use of Acellular Dermal Matrix Combined with a Component Separation Technique for Repair of Contaminated Large Ventral Hernias: A Possible Ideal Solution for this Clinical Challenge
Authors: Yang Fei , Ji-Ye Li , Rong Li , Wen Tian
Published: June 2020

Repair of large contaminated ventral hernias is always challenging because of massive loss of muscular and fascial tissues, high risk of surgical infection and recurrence, and contraindication to use of a permanent prosthesis. This study reviewed retrospectively data of 35 patients with contaminated large ventral hernias who received repair using acellular dermal matrix combined with a component separation technique from 2009 to 2011. Twenty-one males and 14 females were identified with a mean age of 45.5 ± 12.5 years and a mean body mass index of 22.5 ± 5.8 kg/m2. Simultaneously, nine patients underwent bowel fistula resection, 13 patients underwent ostomy takedown, five patients underwent recurrent colon cancer dissection, and eight patients underwent infectious permanent mesh removal and wound débridement. Mean defect size was 125.0 ± 23.5 cm2. The aponeurosis of the external oblique muscle was transected and separated from internal oblique muscle to reach abdominal closure. A cellular dermal matrix was placed in an onlay fashion and mean mesh size was 300.0 ± 65.0 cm2. Thirty-five patients had a mean follow-up period of 36.5 ± 12.5 months. Wound bleeding and partial dehiscence occurred at 36 hours post-operatively. Five patients reported abdominal wall pain during the first postoperative month. Five patients developed surgical site infection. Four patients were detected to develop seroma with volume more than 20 mL by B-ultrasound examination. No recurrence and chronic foreign body sensation were followed up. Use of acellular dermal matrix combined with a component separation technique is safe and efficient management for repair of contaminated large ventral hernia, in which permanent prosthesis placement is contraindicated.
Surgical Aspects of Celiac Disease
Authors: Thompson Jon S. , Thompson David S. , Meyer Avishai
Published: June 2020

Celiac disease, characterized by intestinal inflammation and malabsorption, occurs in 1 per cent of the population and is often undiagnosed. These patients are at increased risk for surgical procedures resulting from symptoms, associated intestinal disorders, and malignancy. Our aim was to determine the incidence and outcome of abdominal operations in patients with celiac disease. Records of 512 adult patients with celiac disease evaluated over a 22-year period were reviewed. Operations were classified as related or unrelated to celiac disease. One hundred eighty-eight (36%) of 512 patients underwent abdominal operations. One hundred twenty-seven (68%) of the 188 patients had unrelated procedures. Sixty-one (32%) had operations considered related to celiac disease. Twenty-six (43%) of 61 with related procedures were diagnosed preoperatively. Procedures were performed for pain, obstruction, motility disorders, and malignancy. Six patients had recurrent pancreatitis. Seven patients underwent liver transplantation. Thirty-five (57%) related procedures led to the diagnosis of celiac disease including “unmasking” (n = 25) and diagnostic findings (n = 10). One-third of patients with celiac disease undergo abdominal operations of which one-third are related to celiac disease. Operations are related to complications of celiac disease and often lead to the initial diagnosis.
Impact of Implementing an Electronic Health Record on Surgical Resident Work Flow, Duty Hours, and Operative Experience
Authors: Wormer Blair A. , Colavita Paul D. , Yokeley William T. , Bradley Joel F. , Williams Kristopher B. , Walters Amanda L. , Green John M. , Heniford B. Todd
Published: June 2020

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means ( P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation ( P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation ( P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.
Solutions to Intraoperative Wound Classification Miscoding in a Subset of American College of Surgeons National Surgical Quality Improvement Program Patients
Authors: Turrentine Florence E. , Giballa Sarah B. , Shah Puja M. , Jones David R. , Hedrick Traci L. , Friel Charles M.
Published: June 2020

Intraoperative wound classification is a predictor of postoperative infection. Therefore, accurately assigning the correct classification to a surgical wound is of particular importance. Our institution participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a national outcomes database that collects wound classification for all qualifying operative procedures, and we noted discrepancies when comparing ACS NSQIP wound classification coding with perioperative coding in our electronic medical record. We tested the effectiveness of an intervention that included staff educational sessions, informational posters, and postoperative debriefings on improving the accuracy of documented intraoperative wound classification. The χ2 test was used to compare proportions of wound classification miscodings before and after educational sessions and debriefings commenced. Baseline data revealed misclassification of wounds occurred 21 per cent (30 of 141) of the time in predominately colorectal procedures performed by two surgeons from April through August 2012. Errors decreased to 9 per cent (13 of 147) from August to December 2012, after our intervention of education sessions with operating room staff and the surgeons incorporating a statement confirming the wound classification at the end of the case debriefing. The χ2 statistic was 8.7589. The P value was significant at 0.003. Ensuring concordance of classification between the surgeon and nurse during a post-procedure debriefing as well as education of perioperative nursing staff through posters and seminars significantly improved the accuracy of intraoperative wound classification coding.
Changes in Fecal and Colonic Mucosal Microbiota of Patients with Refractory Constipation after a Subtotal Colectomy
Authors: Feng Xiaobo , Su Yong , Jiang Jun , Li Ning , Ding Weiwei , Wang Zhiming , Hu Xionghui , Zhu Weiyun , Li Jieshou
Published: June 2020

The purpose of this study was to investigate the changes in gut microbiota of patients with refractory constipation 6 months after a subtotal colectomy. Feces and mucosal samples of five healthy volunteers and 17 patients with refractory constipation before and six months after subtotal colectomy were collected. Denaturing gradient gel electrophoresis (DGGE) and polymerase chain reaction techniques were used for quantitative analysis of main bacterial groups and archeal methanogens. No significant differences were found in the DGGE profiles among the three groups. After subtotal colectomy, a significantly decreased similarity coefficient was observed in the fecal. The Shannon diversity indices had no significant differences among the three groups. The numbers of predominant bacteria (Bacteriodetes, Clostridium coccoides group, and Clostridium leptum group) did not significantly change in patients before and after surgery compared with healthy control subjects, and the number of total bacteria, Firmicutes, Bacteriodetes, and Clostridium leptum group bacteria in the feces decreased after surgery. However, the numbers of these bacteria remained the same in mucosa from postoperative patients. The numbers of Bifidobacteria and Lactobacilli in feces and the number of Bifidobacteria in mucosa were significantly lower in preoperative compared with healthy control subjects and increased after the surgery. The number of methanogens in the mucosa was decreased in preoperative patients but returned to normal levels postoperatively. In conclusion, although there was no difference in the structure of the predominant bacteria between refractory constipated patients and healthy control subjects, the number of probiotics ( Bifidobacteria and Lactobacilli) was significantly lower in refractory constipated patients. However, subtotal colectomy can significantly normalize the number of intestinal flora.
Initial Experience with Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair: Lessons Learned and Technical Considerations to Achieve Success
Authors: Robie Daniel K.
Published: June 2020

The minimally invasive surgical (MIS) repair of esophageal atresia/tracheoesophageal fistula (EA/ TEF) is challenging and requires advanced endoscopic skills. The purpose of this study was to provide insight in successfully introducing the MIS repair based on the initial cases performed by a single pediatric surgeon and review of the experience of others. A retrospective review of all MIS TEF repairs performed by a single surgeon was conducted. Data gathered included patient demographics, technical details of repair including operative time, short- and long-term postoperative morbidity, length of stay, and follow-up. Eight cases (seven Type C, one Type D) were selected for MIS repair based on the judgment of the surgeon with consideration of adequate patient size, stability, type of associated anomalies, and expected length of esophageal gap. Operative time was an average of 207 minutes and there was one conversion to open for successful repair. There were no leaks and only one patient required a single anastomotic dilation at 19 months of age. There were two postoperative pneumothoraces of which one required bronchoscopic laser fistula ablation. Length of stay was an average of 16 days and length of follow-up is a median of 219 days. MIS repair of EA/TEF can be done successfully but requires careful patient selection, advanced MIS skills and meticulous attention to operative technique.
Perioperative and Oncologic Outcomes of Single-incision Laparoscopy Compared with Conventional Laparoscopy for Colon Cancer: An Observational Propensity Score-matched Study
Authors: Yun Jung-A , Kim Hee Cheol , Park Jong Seob , Cho Yong Beom , Yun Seong Hyeon , Lee Woo Yong
Published: June 2020

Single-incision laparoscopic (SIL) surgery is a recent advance in minimally invasive surgical techniques. From May 2011 to August 2012, 77 patients underwent primary SIL surgery for colon cancer by one colorectal surgeon. Among them, 61 patients were one-to-one-matched to control patients who had undergone conventional laparoscopic (CL) surgery with a propensity-matched score, and the outcomes were compared. Two hundred forty-seven patients with colon cancer underwent radical colectomy. Of these, 77 patients underwent SIL colectomy. After matching, there were no significant differences in the general characteristics between the patients undergoing the two types of surgery. Operation time was significantly longer in SIL surgery (139 vs 121 minutes, P = 0.001), but procedure time (107 vs 99 minutes, P = 0.069) was not significantly longer than CL surgery after eliminating closure time (31 vs 22 minutes, P < 0.001) from the operation time. There was no significant difference in postoperative complications between the two groups (3.3 vs 1.6%, P = 1.000). The mean number of harvested lymph nodes was 23 and 22 for SIL and CL surgery, respectively ( P = 0.332). The mean follow-up period was 15.7 for the SIL group and 21.4 months for the CL group ( P < 0.001) with two recurrences in the SIL group (3.3%) and three recurrences in the CL group (4.9%, P = 1.000). Disease-free survival at 20 months did not differ significantly between the two groups (93.3 vs 94.7%, P = 0.939). SIL for colonic malignancy can be safely applied for various types of operations and can provide equivalent oncologic resection and perioperative outcomes compared with CL surgery.