bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical Treatment of Severe Colonic Inertia with Restorative Proctocolectomy
Authors: Thakur Anjani , Fonkalsrud Eric W. , Buchmiller Terry , French Samuel
Published: November 2022

Patients with severe constipation due to colonic inertia who remain symptomatic after extensive medical therapy or partial colonic resection have occasionally been treated with ileostomy as a last resort. The hospital records of five patients with persistent symptomatic idiopathic colonic inertia were reviewed. Each of the patients had undergone extensive medical management, and eventually four underwent one or more colonic resections to relieve the recurrent abdominal distention and pain. Three of the patients eventually received a distal ileostomy, which functioned well. Anorectal manometric studies were within normal range for each of the five patients. Restorative proctocolectomy (J pouch) was therefore performed for each. With a mean follow-up of 42 months after restorative proctocolectomy each of the five patients was relieved of constipation and small bowel distention. The average number of bowel movements per 24 hours at 6 months was 4.8. All patients were able to discriminate flatus from stool, could hold back for up to 1.5 hours after the initial urge to defecate, and had total daytime continence. Each returned to work or school within 3 months, and each reported greater satisfaction with bowel function than with the ileostomy. Restorative proctocolectomy with a J pouch provides a satisfactory option for the management of patients with persistent abdominal distention and pain due to idiopathic colonic inertia.
Does Cell-Saver Blood Administration and Free Hemoglobin Load Cause Renal Dysfunction?
Authors: Klodell Charles T. , Richardson J. David , Bergamini Thomas M. , Spain David A.
Published: November 2022

Our aim was to evaluate the impact of cell-saver volume and free hemoglobin load on renal dysfunction. Intraoperative blood salvage was conducted in standard fashion, and in each case a sample of the blood was removed for testing. Outcome data on individual patients were collected during a 6-year period (1992–1998). The total amount of free hemoglobin each patient received was calculated. Renal dysfunction was defined as a rise in creatinine level of 1.0 mg/dL above baseline. There were a total of 125 patients who received salvaged blood. The free hemoglobin concentration ranged from 19 to 304 mg/dL (mean, 87.5 mg/dL). Patients were stratified into groups on the basis of the total free hemoglobin received, and the Kruskal-Wallis test demonstrated a difference between groups in the prevalence of renal dysfunction ( P < 0.001). A total of 15 patients (12%) had significant postoperative renal dysfunction. There was an association between the amount of free hemoglobin load and subsequent renal dysfunction. This may warrant further study toward establishing policies and limits regarding maximal free hemoglobin blood.
The Ascendance of Laparoscopic Splenectomy
Authors: Walsh R. Matthew , Heniford B. Todd , Brody Fredrick , Ponsky Jeffrey
Published: November 2022

The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50–800). The mean morcellated weight of the entire group was 411 g (33–3300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (293–3300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 1–5). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.
Comparison of Safety and Cost of Percutaneous versus Surgical Tracheostomy
Authors: Bowen Carol P.R. , Whitney Larry R. , Truwit Jonathon D. , Durbin Charles G. , Moore Marcia M.
Published: November 2022

Tracheostomy continues to be a standard procedure for the management of long-term ventilator-dependent patients. Traditionally the procedure has been performed by surgeons in the operating theater using an open technique. This routine practice has recently been challenged by the introduction of bedside percutaneous dilatational tracheostomy (PDT), which has been reported to be a cost-effective alternative. The purpose of this study is to evaluate and compare the safety, procedure time, cost, and utilization of percutaneous and surgical tracheostomies at a university hospital. A retrospective medical chart review was performed on all ventilator-dependent intensive care unit patients at the University of Virginia Medical Center undergoing tracheostomy during a 23-month period beginning December 26, 1996. Of the 213 patients identified for review, 74 and 139 patients received percutaneous and surgical tracheostomies, respectively. Of 74 percutaneous tracheostomies, 73 reviewed were performed by general surgeons, pulmonary physicians, or anesthesiologists in the intensive care unit; all open tracheostomies were performed by surgeons in the operating room, and one percutaneous procedure was performed in the operating room. Perioperative complications occurred in five of 74 patients (6.76%) during PDT; of these, three patients (4.1%) experienced major complications requiring emergent operative exploration of the neck. Three patients (2.2%) experienced perioperative complications during surgical tracheostomy. The mean procedure time was significantly shorter for the percutaneous procedure. Average charges per patient in an uncomplicated case including professional fees, inventory, bronchoscopy (if performed), and operating room charges were $1753.01 and $2604.00 for percutaneous and standard tracheostomies, respectively. These charges do not include the charges associated with surgical intervention after PDT complications. In contrast to previously published reports showing complications clustered during a physician's first 30 percutaneous cases, our study demonstrated no relationship between complication occurrence and physician experience. That is, no learning curve associated with performing PDT was evident. In addition there was no association seen between physician specialty and complication rate. PDT in the intensive care unit costs less than surgical tracheostomy performed in the operating room and can be performed in less time. Several other studies have recommended that bronchoscopy during PDT provides additional safety; however, in our series all three major complications took place during bronchoscopy-assisted percutaneous procedures. Our series suggests that PDT carries an appreciable risk of major complications. Careful patient selection and additional experience with the procedure may decrease complication rates to an acceptable level.
Aerodigestive Injuries of the Neck
Authors: Vassiliu Pantelis , Baker Jay , Henderson Shawn , Alo Kathy , Velmahos George , Demetriades Demetrios
Published: November 2022

Cervical aerodigestive trauma is rare and most centers have a limited experience with its management. The purpose of this review was to study the epidemiology, diagnosis, and problems related to the early evaluation and management of these injuries. This was a retrospective study based on trauma registry and on chart, operative, radiological, and endoscopic reports. There were 1560 admissions with blunt or penetrating trauma to the neck. The overall incidence of aerodigestive trauma was 4.9 per cent (10.2% for gunshot wounds, 4.6% for stab wounds, and 1.2% for blunt trauma). All patients with aerodigestive trauma had suspicious signs or symptoms on admission. The most common life-threatening problem in the emergency room and directly related to the aerodigestive trauma was airway compromise. Twenty-nine per cent of patients with laryngotracheal trauma required an emergency room airway establishment because of threatened airway loss. Although rapid sequence induction was successful in the majority of cases, in 11.9 per cent there was loss of airway and a cricothyroidotomy was necessary. Overall, 9 per cent of cases with aerodigestive injuries were successfully treated nonoperatively. Thirty-six per cent of patients with laryngotracheal trauma and surgical repair were successfully treated without a protective tracheostomy. There was no mortality due to the aerodigestive injuries. Cervical aerodigestive trauma is rare. In conclusion, all patients with significant aerodigestive injuries requiring treatment had suspicious signs and symptoms. Airway compromise was a common problem in the emergency room. Loss of airway after rapid sequence induction is a potentially lethal complication and the trauma team should be ready for a surgical airway. Repair of laryngotracheal injuries without a protective tracheostomy is safe in selected cases.
Identification of Early Predictors for Post-Traumatic Pneumonia
Authors: Croce Martin A. , Fabian Timothy C. , Waddle-Smith Linda , Maxwell Robert A.
Published: November 2022

We demonstrated that the standard clinical criteria of fever, leukocytosis, purulent sputum, and infiltrate on chest radiograph are nonspecific for the diagnosis of post-traumatic pneumonia, and only ∼50 per cent of patients with these conditions have pneumonia. Quantitative cultures of bronchoalveolar lavage effluent will differentiate pneumonia (requiring antibiotic therapy) from systemic inflammatory response syndrome (not requiring antibiotics). Early identification of patients at risk for pneumonia can target populations for clinical research. Because risk factors for pneumonia when diagnosed by quantitative cultures have not been defined we reviewed our recent experience to identify variables predictive of pneumonia. Patients over a 22-month period who survived >48 hours were identified from the trauma registry. Pneumonia was defined as growth of ≥105 organisms per milliliter in the bronchoalveolar lavage effluent. Risk factors evaluated included injury severity and severity of shock. There were 7503 patients (75% with blunt and 25% with penetrating injuries). The incidence of pneumonia was 6 per cent (7% of patients with blunt and 2% of patients with penetrating injuries). Logistic regression analysis identified age; Glasgow Coma Scale score; Injury Severity Score; transfusion requirements during resuscitation; spinal cord injury; chest injury severity; and emergent femur fixation, craniotomy, and laparotomy as being independent predictors of pneumonia. We conclude that multiple risk factors, which are all able to be determined early after injury, are predictive of post-traumatic pneumonia. Prompt identification of this high-risk group of patients allows prognostic considerations relative to patient management schemes and targets populations for prophylactic measures or immunomodulation.
Follow-Up Abdominal Computed Tomography after Splenic Trauma in Children May Not be Necessary
Authors: Rovin Joshua D. , Alford Bennett A. , Mcilhenny Joan , Burns R. Cartland , Rodgers Bradley M. , Mcgahren Eugene D.
Published: November 2022

Nonoperative management of splenic injuries in children is well accepted. However, the need for follow-up abdominal CT to document splenic healing has not been well studied. We retrospectively reviewed initial and follow-up abdominal CT examinations of pediatric patients admitted to our institution with documented splenic trauma who were managed nonoperatively. Eighty-four patients were admitted to our pediatric surgical service with splenic injury documented by CT from 1994 through 1998. The standard approach for splenic injury was bedrest for 5 to 21 days and limited activity for up to 90 days at the discretion of the attending surgeon. Thirty-five of the 84 had follow-up CTs during outpatient follow-up to evaluate and document splenic healing by CT criteria. The initial and follow-up studies were randomized and read blindly by pediatric radiologists using a modified American Association for the Surgery of Trauma grading system (I–V). The age range of the patients was 6 months to 17 years (mean ± SE; 11 ± 1 years). Nineteen (54%) were male and 16 (46%) were female. Causes of splenic trauma included motor vehicle accident (22), fall (seven), assault (four), pedestrian versus vehicle (one), and sports injury (one). Eight children (23%) had grade II injuries, 14 (40%) had grade III injuries, and 13 children (37%) had grade IV injuries on initial CT scan. Seven (88%) of the grade II splenic injuries were healed by 64 ± 11 days. The remaining grade II injury had healed by 210 days. Thirteen (93%) of the grade III splenic injuries were healed by 76 ± 7 days. The remaining grade III injury was healed by 140 days. Spleens in 10 (77%) of the 13 patients with grade IV injuries were healed by 81 ± 8 days. Of the three remaining grade IV injuries two were healed by 173 ± 14 days. The remaining patient's spleen was radiologically considered to have a grade III defect 91 days from the time of injury, and no further CTs were obtained. Of the 34 patients who underwent follow-up CT imaging until splenic healing was demonstrated the mean time to complete healing was 87 ± 8 days postinjury (range 11–217 days). These data suggest that routine follow-up abdominal CTs may not be necessary to allow children to resume their normal activities after an appropriate time of restricted activity.
Rectourethral Fistula and Massive Rectal Bleeding from Iodine-125 Prostate Brachytherapy: A Case Report
Authors: Cherr Gregory S. , Craig Hall M.D. , Pineau Benoit C. , Waters Gregory S.
Published: November 2022

Iodine-125 brachytherapy is an effective well-tolerated treatment for localized prostate cancer. Gastrointestinal complications of brachytherapy (minor rectal bleeding or tenesmus) are uncommon. Rectal ulceration or rectourethral fistulas after prostate brachytherapy are rare. We present a case of massive refractory rectal bleeding and rectourethral fistula, a complication of prostate brachytherapy never before reported. As a result of the patient's life-threatening symptoms aggressive surgical therapy was necessary.
Gastrointestinal Stromal Tumors: Analysis of Clinical and Pathologic Factors
Authors: Kim Christina J. , Day Scott , Yeh Karen A.
Published: November 2022

Gastrointestinal mesenchymal tumors have been classified as benign (leiomyoma) or malignant (leiomyosarcomas). More recently, these tumors have been termed gastrointestinal stromal tumors (GISTs). GISTs have a highly variable clinical course. This review analyzes the clinical presentation, pathologic examination, and long-term follow-up of patients with GIST. A retrospective analysis of the clinical course of patients with GIST at a single institution from 1986 to 1998 was performed. Nineteen patients with GIST (12 gastric, two duodenal, three jejunal, and two rectal) were treated. The most common clinical presentation was gastrointestinal bleed. CT scans, contrast studies, and endoscopy were used to identify a tumor mass. Diagnosis of GIST was made in only two patients preoperatively. Tumor size ranged from 0.8 to 23 cm. Histology of the tumors was variable. All patients underwent surgical resection with curative intent. Follow-up ranged from 2 to 55 months. There were two perioperative deaths. Local recurrence occurred in one patient. GISTs are uncommon. Preoperative diagnosis can be difficult, and often the diagnosis is made at the time of surgery. With complete resection of the tumor the clinical course is favorable with very few local recurrences. Therefore complete resection of the tumor is recommended.
Nonoperative Management of Pediatric Blunt Hepatic Trauma
Authors: Leone Richard J. , Hammond Jeffrey S.
Published: November 2022

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children ≤16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean ± standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 ± 1.0 years (range 3–16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 ± 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.
Embolization for Management of Hepatic Hemangiomas
Authors: Deutsch Geoffrey S. , Yeh Karen A. , Bates William B. , Tannehill William B.
Published: November 2022

Hemangiomas represent the most common primary tumor of the liver. Clinically the significance of these lesions is highly variable. The management of hemangiomas is controversial and is intimately related to the size, symptoms, and associated comorbidities of the patients who harbor these benign tumors. Series suggest that the vast majority of hemangiomas are less than 4 cm, asymptomatic, and clinically incidental findings. Symptomatic hemangiomas are large and associated with a constellation of vague upper abdominal complaints including pain, mass, distention, early satiety, and weight loss. A number of small series of surgically treated symptomatic hemangiomas have demonstrated enucleation as a safe and effective intervention. We report a collection of case reports using embolization as a primary treatment of symptomatic hemangiomas. The first patient is a 73-year-old black man previously treated for prostate cancer by radical prostatectomy and radiation. He developed weight loss, abdominal fullness, and early satiety. His symptoms were attributed to a large left lateral segmental liver mass that was biopsy proven to be a hemangioma. The second patient is a 49-year-old black women who complained of weakness, fatigue, night sweats, and anemia. The only abnormality discovered was a large right posterior hemangioma. The third patient is a 49-year-old black women with unexplained right upper quadrant pain and anemia who was found to have a 19 x 11 x 7.5-cm left hepatic hemangioma by CT. All three patients underwent elective treatment of their hemangiomas with highly selective hepatic embolization. There were no significant complications related to the procedures. Symptoms resolved for all patients acutely after treatment. The use of embolization for hepatic hemangiomas provides safe and effective treatment of the patient's symptoms while avoiding operative intervention, extended hospitalization, or postoperative recuperation. This treatment modality should be considered for the symptomatic hemangioma under elective conditions.
Pseudohyperkalemia Secondary to Postsplenectotny Thrombocytosis
Authors: Johnson Colleen M. , Hughes K. Michael
Published: November 2022

Hyperkalemia is a regularly encountered electrolyte abnormality. Less commonly recognized is pseudohyperkalemia. In vitro clotting results in the release of potassium from the formed elements of blood; this falsely elevates the serum potassium concentration. Usually attributed to thrombocytosis, leukocytosis, or hemolysis it is rarely reported in the postsplenectomy trauma patient. A 49-year-old man underwent splenectomy for a grade IV splenic injury. He developed an elevated serum potassium on postoperative day 16. His renal function remained normal, and an active search for causes of hyperkalemia failed to delineate a source for his elevated potassium. Pseudohyperkalemia was proposed as an etiology and confirmed by analyzing simultaneous serum (5.9 mEq/L) and plasma potassium levels (3.9 mEq/L). The serum potassium showed a concomitant rise with the evolution of the patient's postsplenectomy thrombocytosis. This is a case report of our patient and a literature review of this rarely reported and underestimated cause of a potentially serious electrolyte abnormality. We found through our patient that pseudohyperkalemia does occur in the postsplenectomy population and that this should be included in the differential diagnosis of any patient with an elevated serum potassium level and thrombocytosis.
Benign and Solid Tumors of the Liver: Relationship to Sex, Age, Size of Tumors, and Outcome
Authors: Reddy K. Rajender , Kligerman Seth , Levi Joe , Livingstone Alan , Molina Enrique , Franceschi Dido , Badalamenti Salvatore , Jeffers Lennox , Tzakis Andreas , Schiff Eugene R.
Published: November 2022

From 1983 through 1997, our center diagnosed 130 cases of benign neoplasms: 27 with focal nodular hyperplasia (FNH), 25 with hepatic adenoma, 71 with cavernous hemangioma, and seven with mixed tumors of different diagnoses. Most often these lesions were seen in females [female-to-male ratio (f/m): 5.5/1]. Hepatic adenomas and mixed tumors were seen exclusively in females and FNH predominantly in females (f/m: 26/1). Hemangiomas, however, were not uncommon in men (f/m: 52/19) relative to the other tumors ( P < 0.001). Furthermore patients with hemangioma were older (mean age: 49 years) whereas patients with hepatic adenoma, FNH, and mixed tumors were often younger (mean age: 33, 35, and 44 years respectively; P < 0.004). Oral contraceptive steroid use was related by 21 of 25 patients (84%) with hepatic adenoma, 22 of 26 (85%) females with FNH, five of seven (71%) females with mixed tumors, and 10 of 52 (19%) patients with hemangioma. Ninety-five of the 130 patients (73%) had one or more symptoms. There was no statistically significant correlation between symptoms and the size of the lesion, the final diagnosis, and whether there were solitary or multiple masses. Three of 25 (12%) with hepatic adenoma presented with rupture, and one of 27 (4%) with FNH had such a consequence. None of the hemangiomas presented with rupture or progressed to such a state. One patient with hepatic adenoma (4%) had a focus of malignancy. Surgical removal of benign tumors was performed in 82 of 130 patients (63%), and there was one operative mortality (1.2%) in a patient who had a caudate lobe FNH. The types of surgical procedures included segmentectomy (62%), lobectomy (34%), and trisegmentectomy (4%). In two of 84 patients who had undergone laparotomy resection was not technically possible. Resection is recommended in all cases of hepatic adenoma because of fear of rupture or associated focus of malignancy. FNH was not observed to undergo a malignant transformation and will rarely rupture. Surgery is only recommended for symptomatic hemangioma, and size of the lesion is not a criterion for excision.
Wires Should Not be Used Routinely on Skin Scars for Mammograms after Breast-Conserving Surgery
Authors: Proulx Gary M. , Heller Barbara , Stomper Paul C.
Published: November 2022

The accuracy of skin wire markers on surgical incision scars during mammography to locate the primary tumor excision site was prospectively determined for 100 women. The shortest distance between the excision site and skin scar wire on either the craniocaudal or mediolateral oblique projection was 10 mm or greater in 48 per cent of patients and 20 mm or greater in 30 per cent of patients. Wire markers placed on skin incision scars during mammography after breast-conserving surgery are inadequate for the localization of the primary excision site and should not be used routinely.
Necrotizing Fasciitis Developing from a Brown Recluse Spider Bite
Authors: Majeski James
Published: November 2022

A 20-year retrospective case series was analyzed to identify the brown recluse spider bite as a cause of necrotizing fasciitis. Data from 31 consecutive patients with necrotizing fasciitis were analyzed. Of the 31 patients with necrotizing fasciitis a brown recluse spider bite was found to be the initial cause in two patients. Both patients with spider bites delayed in obtaining medical treatment, and secondary infection of the necrotic tissue occurred. One patient was diagnosed by frozen section tissue biopsy, and the second patient was diagnosed by clinical examination. All patients in this series had immediate aggressive operative debridement. Both patients survived with functional limbs. There were no deaths in this large series. Necrotizing fasciitis can be caused by a secondarily infected brown recluse spider bite. Successful treatment of necrotizing fasciitis from any cause is associated with early diagnosis, immediate surgical debridement, and supplemental enteral or parenteral nutrition.
Ultrasound Evaluation of the Magnitude of Pneumothorax: A New Concept
Authors: Sargsyan Ashot E. , Hamilton Douglas R. , Nicolaou Saavas , Kirkpatrick Andrew W. , Campbell Mark R. , Billica Roger D. , Dawson David , Williams David R. , Melton Shannon L. , Beck George , Forkheim Kevin , Dulchavsky Scott A.
Published: November 2022

Pneumothorax is commonly seen in trauma patients; the diagnosis is confirmed by radiography. The use of ultrasound where radiographic capabilities are absent, is being investigated by the National Aeronautics and Space Administration. We investigated the ability of ultrasound to assess the magnitude of pneumothorax in a porcine model. Sonography was performed on anesthetized pigs in both ground-based laboratory (n = 5) and microgravity conditions (0 x g) aboard the KC-135 aircraft during parabolic flight (n = 4). Aliquots of air (50–100 cm3) were introduced into the chest to simulate pneumothorax. Results were videorecorded and digitized for later interpretation. Several distinct sonographic patterns of partial lung sliding were noted including the combination of a sliding zone with a still zone and a “segmented” sliding zone. These “partial lung sliding” patterns exclude massive pneumothorax manifested by a complete separation of the lung from the parietal pleura. In 0 x g, the sonographic picture is more diverse; one x g differences between posterior and anterior aspects are diminished. Modest pneumothorax can be inferred by the ultrasound sign of “partial lung sliding.” This finding, which increases the negative predictive value of thoracic ultrasound, may be attributed to intermittent pleural contact, small air spaces, or alterations in pleural lubricant. Further studies of these phenomena are warranted.
Interkukin-10 Attenuates Proinflammatory Cytokine Production and Improves Survival in Lethal Pancreatitis
Authors: Cook James W. , Karakozis Stavros , Kim Donald , Provido Haydee , Gongora Enrique , Kirkpatrick John R.
Published: November 2022

Given that interleukin (IL)-10 (IL-10) serves as a potent down-regulator of specific proinflammatory cytokines we reasoned that its administration should improve outcome in situations in which the biological response to a severe inflammatory challenge is the critical determinant of survival. To test our hypothesis we administered IL-10 in the setting of lethal pancreatitis to determine its effect on proinflammatory cytokine production and survival. We divided Sprague-Dawley rats into three groups. Controls (Group 1, n = 5) received a sham laparotomy. We induced pancreatitis in Group 2 (n = 9) and Group 3 (n = 9) via laparotomy and intrapancreatic infiltration of one mL of 5 per cent sodium taurocholate. Group 2 was treated only with saline, whereas Group 3 was treated with 10,000 units of IL-10 (in saline) at 30 minutes, 3.5 hours, and 6.5 hours after induction of pancreatitis. Serial blood samples were obtained at 6.5 hours for measurement of amylase, IL-1, and IL-6. The Kaplan-Meier method, Wilcoxon test, and Student's t test were used for analysis. Seven-day survival was 100, 0, and 45 per cent in Groups 1, 2, and 3, respectively. Production of amylase, IL-1, and IL-6 was lower in the IL-10-treated group (Group 3) compared with the group treated with saline alone (Group 2, P < 0.05). We conclude that administration of IL-10 in the setting of otherwise 100 per cent lethal experimental pancreatitis significantly reduces production of amylase, IL-1, and IL-6 and improves survival.
Evaluation of Serum Calcium Levels in Predicting Hypoparathyroidism after Total/Near-Total Thyroidectomy or Parathyroidectomy
Authors: Bentrem David J. , Rademaker Alfred , Angelos Peter
Published: November 2022

Hospital stays for thyroid and parathyroid surgery have decreased significantly with selected patients staying under 8 hours. Strategies to recognize hypocalcemia postoperatively vary. We examined timed postoperative calcium levels to determine how long one needs to monitor patients for hypoparathyroidism. We analyzed 120 consecutive patients having total/near-total thyroidectomy and/or parathyroidectomy between April 1998 and October 1999. Total and ionized serum calcium levels were obtained at 8, 16, and 22 hours postoperatively. Strict criteria for significant hypoparathyroidism were defined as a symptomatic patient, a total calcium value of less than 7.2 mg/dL, or an ionized calcium value of less than 1.0 mmol/L. Eighteen patients (15%) met criteria for hypocalcemia. The 8-hour ionized calcium level identified 40 per cent of those that needed supplementation. With the inclusion of the 16-hour ionized calcium value 94.5 per cent of patients who met criteria were identified. Of the 74 patients who had not previously received calcium at 22 hours after surgery only one patient with hypocalcemia was identified. Serial calcium values postoperatively add to the costs associated with an overnight hospital stay. In addition to clinical examination an ionized calcium level 16 hours postoperatively is sufficient to identify significant hypoparathyroidism in the majority of patients.
Retrospective Study of Neostigmine for the Treatment of Acute Colonic Pseudo-Obstruction
Authors: Abeyta Brandon J. , Albrecht Roxie M. , Schermer Carol R.
Published: November 2022

Acute colonic pseudo-obstruction (ACPO) typically develops postoperatively or after severe illness. Studies suggest that pharmacologic manipulation with intravenous (IV) neostigmine (NSM) may be an effective and less invasive treatment modality for ACPO with minimal side effects. The purpose of this study was to retrospectively assess the efficacy and incidence of complications of an IV NSM bolus in patients with ACPO. Eight patients with ten episodes of ACPO were treated with a bolus dose of NSM. Rapid and effective decompression of the colon was achieved in six episodes after a single dose of NSM at a mean of 22.8 ± 13.5 minutes. In three episodes decompression occurred after a second dose of NSM at a mean of 44.7 ± 37.7 minutes. One patient failed NSM treatment but responded to a Cystografin enema. One patient experienced significant bradycardia. NSM is a simple, safe, and effective treatment for ACPO and based on result comparison of this study and previous studies both bolus and slow infusion dosing practices of NSM are effective. The NSM bolus dosing side effect profile has been shown to include significant bradycardia, whereas when NSM was infused over one hour significant bradycardic episodes requiring treatment have not been encountered. We propose that a prospective study evaluating NSM dosing as an IV bolus versus an IV infusion would be useful in determining whether NSM infusion can be proven safer than bolus dosing for the treatment of ACPO.
Age is Not a Contraindication to Pancreaticoduodenectomy
Authors: Hodul Pamela , Tansey Joseph , Golts Eugene , Oh Daniel , Pickleman Jack , Aranha Gerard V.
Published: November 2022

The incidence of pancreatic cancer has increased threefold over the last 40 years with the greatest rate of growth occurring in the elderly. In the past it was suggested that elderly patients tolerated pancreaticoduodenectomy less well than younger patients with higher mortality rates. This single-institution experience examines the question of whether age is a significant factor in relation to morbidity and mortality in patients undergoing pancreaticoduodenectomy. Between 1994 and 1999 outcomes of 122 patients who underwent pancreaticoduodenectomy were reviewed. There were 48 patients 70 years of age and older and 74 patients less than 70 years of age. Both groups were compared with respect to preoperative clinical prognostic determinates and perioperative factors affecting morbidity and mortality. There was no significant difference between the two groups comparing their comorbidities, use of preoperative antibiotics, intraoperative blood loss, or length of hospital stay (11.9 and 10.8 days respectively). The two groups were also similar with regard to pathologic diagnosis with pancreatic adenocarcinoma being the most frequently encountered neoplasm. There was one death in the less-than-70-year-old group and none in the older group. No significant difference in the rate of complications was appreciated. These data demonstrate that pancreaticoduodenectomy can be performed safely in patients 70 years of age and older with morbidity and mortality rates similar to those of younger individuals.
Intraoperative and Early Postoperative Gastric Intramucosal pH Predicts Morbidity and Mortality after Major Abdominal Surgery
Authors: Theodoropoulos George , Lloyd Larry R. , Cousins Geoffrey , Pieper David
Published: November 2022

The present study was undertaken to investigate the correlation between the intraoperative and postoperative gastric intramucosal pH (pHi) with important perioperative variables and to explore any potential relationship of the measured pHi with the patients’ postoperative course. A prospective study was carried out in a group of 48 patients who underwent major abdominal operations over an 8-month period at St. John Hospital and Medical Center. An automated air tonometer was used for gastric pHi monitoring. Twenty-eight elective and 20 emergency abdominal operations were performed in 23 men and 25 women. Twenty-six patients (54%) required postoperative hospitalization in the Intensive Care Unit (ICU). Seventeen patients (35%) developed early postoperative complications. The non-ICU and ICU mortality rates were 4.5 and 19.2 per cent respectively. The mean intraoperative pHi (pHiOR) and postoperative pHi (pHiPO) ranged between 7.03 and 7.58 (7.38 ± 0.12) and 6.89 and 7.56 (7.35 ± 0.12) respectively (mean ± standard deviation). There was a significant decrease of the gastric pHi at the first hour intraoperatively compared with the pHi after induction to anesthesia (7.44 vs 7.38 ± 0.14, P < 0.001). Patients who underwent emergent abdominal procedures were characterized by lower pHiOR and pHiPO values (7.43 ± 0.08 vs 7.30 ± 0.13 and 7.39 ± 0.84 vs 7.30 ± 0.15, P < 0.001 and P < 0.05). Similarly patients who required surgical ICU admission had significantly lower pHiOR and pHiPO measurements (7.3 ± 0.12 and 7.28 ± 0.12) compared with the rest (7.46 ± 0.06 and 7.43 ± 0.06; P < 0.001). Overall, lower pHiOR and pHiPO values were associated with the occurrence of postoperative complications ( P < 0.001), the postoperative mortality ( P < 0.001), the requirement for postoperative mechanical ventilator ( P < 0.001) and its duration ( P < 0.001), longer ICU stay ( P < 0.001), and prolonged hospitalization ( P < 0.05). Evidence of intraoperative and early postoperative gastric mucosal ischemia (pHiOR and pHiPO ≤ 7.32) was observed in 12 (25%) and 15 (31%) patients respectively. The incidence of postoperative complications and the mortality rate were higher in this group of patients ( P < 0.001). At a cutoff point of 7.32 gastric pHiOR gave a sensitivity of 69 per cent and specificity of 97 per cent for predicting postoperative complications as well as a sensitivity and specificity of 67 per cent and 81 per cent for predicting death. Intraoperative and early postoperative gastric pHi is a reliable predictor of patient outcome after major abdominal operations. Splanchnic ischemia may play an important role in determining early complications and survival; therapy guided by the gastric pHi might improve outcome.
Decreased Recurrent Carotid Stenosis by Routine Patching and Intraoperative Scanning
Authors: Mansour M. Ashraf , Webb K. Michael , Kang Steven S. , Morasch Mark D. , Littooy Fred N. , Labropoulos Nicos , Baker William H.
Published: November 2022

Our objective was to review the results of carotid endarterectomies (CEAs) with Dacron patch angioplasty and intraoperative color-flow duplex scanning (CFS). In a 3-year period, patients who underwent CEA with Dacron patch angioplasty and intraoperative CFS were studied. We excluded patients who had primary closure, vein patch, and redo endarterectomy. Serial CFS was obtained first in the early postoperative period (one day to 3 weeks), then at 6 months, and then yearly. Intraoperative CFS abnormalities were classified as major, requiring immediate revision, or minor, which were observed. The diagnosis of recurrent stenosis by US was based on the detection of an increased peak systolic frequency (>8000 MHz) or velocity (>250 cm/second) in the internal carotid artery. There were 212 CEAs performed in 200 patients (128 men and 84 women) included in this study. Three patients (1.4%) awoke with a stroke, two (0.94%) had transient ischemic attacks, and three (1.4%) developed transient hypoglossal nerve paresis. Intraoperative CFS showed a major defect that required an immediate revision in six patients (2.8%). Minor abnormalities were detected in another 41 patients (19.3%), but no revision was necessary. In follow-up three patients were identified with a severe recurrent carotid stenosis (>80%) and they underwent redo CEA. This rate of recurrence (1.4%) is significantly lower than the rate we had previously reported in a larger study (82 of 1209, 6.8%; P = 0.003). We conclude that the combined use of Dacron patch angioplasty and intraoperative CFS after CEA is associated with a low perioperative morbidity and a low incidence of recurrent stenosis in the first 2 years after operation.
Emergency Cricothyrotomy: Long-Term Results
Authors: Isaacs John H.
Published: November 2022

In 1996 we reviewed the literature and reported on our own series of emergency cricothyrotomy (EC) patients. The success rate in obtaining an airway was very good. The survival rate was also acceptable. However, there have been no reports of long-term results of EC. We retrospectively reviewed the long-term results in 27 survivors of 65 original EC patients. The average length of follow-up was 37 months (1–77 months). In 13 patients no airway problems were found. The remaining 14 patients had only minor problems such as hoarse voice and mild untreated stenosis. Of these 27 patients, however, only seven were doing well. Five patients had relatively minor problems such as the need for a gastrostomy tube, minor shortness of breath, or minor neurological problems. Fifteen patients had major problems: cervical spine injuries, changes in mental status, need for permanent nursing home care, seizure disorders, or injuries that precluded their working. In most cases these problems were due to the underlying disease process. EC is effective in obtaining an airway with a low incidence of later severe airway problems. However, many of these patients do poorly overall.
Defining the Learning Curve for the Focused Abdominal Sonogram for Trauma (FAST) Examination: Implications for Credentialing
Authors: Gracias Vicente H. , Frankel Heidi L. , Gupta Rajan , Malcynski John , Gandhi Rajesh , Collazzo Lisa , Nisenbaum Harvey , Schwab C. William
Published: November 2022

Focused Abdominal Sonogram for Trauma (FAST) examination is being used increasingly for the torso evaluation of injured patients. In a controlled setting using peritoneal dialysis patients as models for injured patients with free fluid we hypothesized that more experienced providers would perform FAST with greater accuracy. Twelve fellow or attending level trauma surgeons, two radiologists, and one ultrasound technician were studied for their ability to detect intraperitoneal fluid (0–1600 cm3) in nine peritoneal dialysis patients with two different volumes of dialysate/patient. FAST experience with injured patients was defined as minimal (<30 patients examinations), moderate (30–100), or extensive (>100). All surgeons had participated in a didactic/practical course before the study. Test results were reported as “+” or “-” by the participant; “+” results were further quantified by volume. The sensitivity of those in the minimal-, moderate-, and extensive-experience to detect <1 L was 45, 87, and 100 per cent, respectively; the accuracy in detecting dialysate volume within 250 cm3 was 38, 63, and 90 per cent, respectively. In this controlled setting the accuracy of FAST particularly in diagnosing smaller volumes, as well as the ability to quantify volume, improves with experience. The learning curve for FAST starts to flatten out at 30 to 100 examinations. Training and credentialing policies should consider these findings to optimize patient care.
Effect of Pneumoperitoneal Pressure on Tumor Dissemination and Tumor Recurrence at Port-Site and Midline Incisions
Authors: Moreira Helio , Yamaguchi Takuyu , Wexner Steven , Singer Lisa , Zhao Ronghua , Baig Mirza Khurrum , Mack Judith A. , Xiong Hui , Abramson Susan
Published: November 2022

Over the past several years numerous cases of port site tumor recurrence after laparoscopic resection of a cancerous tissue have been reported. Possible mechanisms for tumor seeding include tumor removal, contaminated instruments, pneumoperitoneum, and aerosolization of tumor cells. This experiment examined the relationship among trocar contamination, aerosolization, and tumor recurrence with increasing pneumoperitoneal pressure using a hamster model. Increased pneumoperitoneal pressure significantly increased both instrument contamination and tumor recurrence at midline and port site incisions. Interestingly, increasing pneumoperitoneal pressure had no significant effect on the number of aerosolized tumor cells. The results reaffirm that the use of a reduced pneumoperitoneum or gasless laparoscopy may significantly lower port site tumor recurrence.
Idiopathic Spontaneous Intraperitoneal Hemorrhage: A Clinical Update on Abdominal Apoplexy in the Year 2001
Authors: Carr Shamus R. , Dinsmore Robert C. , Wilkinson Neal W.
Published: November 2022

Idiopathic spontaneous intraperitoneal hemorrhage is a rare and often fatal condition that has been historically referred to as abdominal apoplexy. The presentation varies widely, and preoperative diagnosis is seldom obtained. Immediate surgical exploration remains the treatment of choice. At the time of exploration a through examination of the visceral arteries and solid organs should be done, as these are common sites for intra-abdominal bleeding. Often the site of hemorrhage cannot be localized at time of surgery despite thorough exploration. Today a postoperative diagnosis can often be confirmed and treated with interventional radiology. In rare cases the site of bleeding remains unknown despite intraoperative exploration and radiographic studies.
Liver Infarction after Laparoscopic Cholecystectomy Injury to the Right Hepatic Artery and Portal Vein
Authors: Wong Marco D. , Lucas Charles E.
Published: November 2022

A 66-year-old woman presented with fever and right upper quadrant pain 5 weeks after laparoscopic cholecystectomy. Angiogram revealed occlusion of the right hepatic artery and right portal vein which necessitated a right hepatic lobectomy. To our knowledge this has not been previously reported. The patient recovered uneventfully.
Neoadjuvant Chemotherapy for Chinese Women with Locally Advanced Breast Cancer
Authors: Chow Louis W.C. , Day Weida , Kenneth C.K.
Published: November 2022

Locally advanced breast cancer carries a poor prognosis and is still prevalent in developing countries. The current management usually involves administration of neoadjuvant chemotherapy (NCT). From March 1990 through December 1997, 173 Chinese patients with tumor size greater than 4 cm were treated; 38 received NCT and the other 135 postoperative adjuvant chemotherapy. The regimens for NCT were FEC (5-fluorouracil 600 mg/m2, epirubicin 50 mg/m2, and cyclophosphamide 600 mg/m2) for 29 patients and Adriamycin 75 mg/m2 for the rest of the group. Postoperatively the NCT patients received the standard CMF regimen (oral cyclophosphamide 100 mg/m2 for 14 days and intravenous methotrexate 40 mg/m2 and 5-fluorouracil 600 mg/m2 on days one and eight of each cycle). The postoperative adjuvant chemotherapy group received only the CMF regimen. Tumor response after NCT was measured clinically and histologically. The response rate was 75 per cent with 13.2 per cent being complete response. Although there is no difference in response rate the actual reduction in size was greater for patients receiving Adriamycin than FEC ( P = 0.001). The only predictive factor of response to NCT was the type of chemotherapy administered. None of the tumor characteristics such as size, nodal status, histological grading, lymphovascular permeation, hormonal receptor status, and c- erb-B2 expression were found to be significant. The overall 5-year probability of survival was 0.44, and there was no difference between groups. The factor important for prognosis was axillary nodal status on histology. The use of NCT did not improve outcome. In summary our results showed that NCT was feasible for Chinese women and good response could be achieved. However, it is the axillary nodal status that determines the final outcome.
Isolated Colon Cancer Metastasis to the Spleen
Authors: Place Ronald J.
Published: November 2022

Splenic metastases from colon carcinoma are rare. If present they generally occur in concert with disseminated disease. Six cases have been previously reported. The patient presented here is a 51-year-old black man who presented with an enterocutaneous fistula as a complication from prior pelvic radiation. Workup included an abdominal CT and needle biopsy, which confirmed the splenic metastasis from a sigmoid colon cancer 6 years after the original diagnosis. The patient had an unevenful splenectomy. Although no long-term follow-up data are as yet available splenectomy including removal of hilar lymph nodes appears to be the treatment of choice. A case report and review of the literature are presented.