bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of a Trauma Service Activation and Admission Policy for Very Elderly Trauma Patients: Impact on Hospital Efficiency and Patient Outcomes
Authors: Kalina Michael
Published: June 2020

Very elderly trauma patients (VETs) were routinely admitted to nonsurgical services at our institution; therefore, a trauma service activation and admission policy was implemented. Our goal was to determine policy success and impact on efficiency and outcomes. VETs, defined as trauma patients aged >89 years, admitted before and after policy implementation were reviewed. Demographics included age, gender, Injury Severity Score, Glasgow Coma Score, admission diagnosis, mechanism of injury, admission service, and comorbidities. Efficiency included intensive care unit length of stay (ICU-LOS) and hospital length of stay (H-LOS). Outcomes included complications, discharge disposition, and mortality. Statistical analysis included Chi square, Fisher's exact test, and regression analyses, significance denoted by P < 0.05. 375 VETs were investigated. Demographic analysis revealed differences in Injury Severity Score (9.4 + 5.4 vs 7.2 + 4.0, P < 0.001), coronary artery disease (2.1% vs 38.2%, P < 0.001), neurologic disease (7.4% vs 28.24%, P < 0.001), and intracranial hemorrhage (15.6% vs 6.1%, P = 0.01). The most common mechanism of injury and admission diagnosis was fall and femur fracture. VETs admitted to the trauma service increased from 28.3 per cent to 40.5 per cent, P = 0.02. Efficiency analysis revealed differences in ICU-LOS (4.0 + 4.2 days vs 0.7 + 1.3 days, P < 0.001) and H-LOS (7.3 + 4.9 days vs 6.3 + 5.5 days, P = 0.005). Outcomes analysis revealed differences in pneumonia (0.8% vs 5.3%, P = 0.01), acute respiratory distress syndrome (0% vs 2.3%, P = 0.04), discharge to skilled nursing facility (75.8% vs 57.3%, P < 0.001), but no difference in mortality. Regression analyses revealed that trauma service admission was associated with decreased ICU-LOS and H-LOS. The trauma service activation and admission policy for VETs led to improved hospital efficiency.
Outcomes of Endoscopic Stenting for Traumatic Biliary and Pancreatic Fistulae
Authors: Richey John S. , Manning Benjamin M. , Jones Wesley B.
Published: June 2020

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the trauma patient is limited. Therefore, reporting of outcomes is sparse in the literature. The purpose of this study was to review outcomes of patients who underwent ERCP for traumatic biliopancreatic injury. We retrospectively reviewed 1550 ERCPs, from a prospectively maintained database, performed by a single surgical endoscopist consulted by the trauma surgical service for the management of traumatic fistulae. Referral was made for patients with high output (greater than 200 mL/d) and/or persistent (failure to resolve within 30 days) fistulae and traumatic biliary stricture. Primary end point was postprocedural complications. Secondary end points included patient characteristics, stents placed, and duration of stenting. Seventeen patients underwent a total of 31 ERCPs for biliary and/or pancreatic injury resulting from abdominal trauma (eight penetrating, nine blunt). Fourteen patients had ERCP after laparotomy, with a mean interval to ERCP of 74 days. In three patients, ERCP was the only intervention required. Fourteen biliary stents were placed, seven of which were metallic. Ten pancreatic stents were placed; one proximally migrated but was successfully retrieved. Four patients had both ducts simultaneously stented. The mean duration of stenting was 158 days. All fistulae resolved after stenting. There were no serious complications.
Identifying Effectors of Outcomes in Patients with Large Umbilical Hernias
Authors: Groene Steven A. , Heniford Davis W. , Prasad Tanushree , Lincourt Amy E. , Augenstein Vedra A.
Published: June 2020

Quality of life (QOL) has become an important focus of hernia repair outcomes. This study aims to identify factors which lead to ideal outcomes (asymptomatic and without recurrence) in large umbilical hernias (defect size ≥9 cm2). Review of the prospective International Hernia Mesh Registry was performed. The Carolinas Comfort Scale was used to measure QOL at 1-, 6-, and 12-month follow-up. Demographics, operative details, complications, and QOL data were evaluated using standard statistical methods. Forty-four large umbilical hernia repairs were analyzed. Demographics included: average age 53.6 ± 12.0 and body mass index 34.9 ± 7.2 kg/m2. The mean defect size was 21.7 ± 16.9 cm2, and 72.7 per cent were performed laparoscopically. Complications included hematoma (2.3%), seroma (12.6%), and recurrence (9.1%). Follow-up and ideal outcomes were one month = 28.2 per cent, six months = 42.9 per cent, one year = 55.6 per cent. All patients who remained symptomatic at one and two years were significantly symptomatic before surgery. Symptomatic preoperative activity limitation was a significant predictor of nonideal outcomes at one year ( P = 0.02). Symptomatic preoperative pain was associated with nonideal outcomes at one year, though the difference was not statistically significant ( P = 0.06). Operative technique, mesh choice, and fixation technique did not impact recurrence or QOL. Repair of umbilical hernia with defects ≥9 cm2 had a surprising low rate of ideal outcomes (asymptomatic and no recurrence). All patients with nonideal long-term outcomes had preoperative pain and activity limitations. These data may suggest that umbilical hernia should be repaired when they are small and asymptomatic.
Is there an Optimal Surgical Approach to Neuroendocrine Tumors of the Ampulla? A Single Institution Experience over 15 Years
Authors: Baptiste Gillian G. , Postlewait Lauren M. , Ethun Cecilia G. , Le Nina , Russell Maria C. , Kooby David A. , Staley Charles A. , Maithel Shishir K. , Cardona Kenneth
Published: June 2020

Neuroendocrine tumors (NETs) of the ampulla of Vater are rare neoplasms accounting for a small fraction of gastroenteropancreatic NETs. The optimal surgical approach remains controversial. This study aimed to define the optimal approach in patients with ampullary NETs. Patients who underwent resection of ampullary NETs from 2000 to 2014 were analyzed. Fourteen patients with well-differentiated, nonfunctional NETs were identified. The mean age was 60 ± 15 years, and nine (64%) were male. The mean tumor size was 1.6 ± 0.9 cm and the majority (61%) had an advanced tumor-node-metastasis stage. Eight (57%) patients underwent pancreaticoduodenectomy (PD) and six (43%) underwent transduodenal ampullectomy (TA). Although the mean tumor size was similar (1.7 vs 1.5 cm), the majority (75 vs 20%) of PD patients demonstrated a trend toward more aggressive tumors, characterized by advance T stage in 25 vs 0 per cent, lymph node positivity in 88 vs 17 per cent, and elevated proliferative index (Ki-67) in 25 vs 0 per cent. Complete resection (R0) was achieved in all PD patients versus 75 per cent in TA patients. There was no difference in major complication rate (50 vs 33%). In the TA group, one (17%) patient recurred and two (33%) patients died, whereas only one (13%) patient died in the PD group and no patients recurred. In conclusion, ampullary tumors can be aggressive tumors characterized by high regional lymph node involvement. A transduodenal approach may provide an inadequate oncological resection and thus has the potential to understage ampullary NETs. In the era of increasing therapeutic options for gastroenteropancreatic NETs, accurate staging is crucial and appropriate oncologic resection via PD for ampullary NETs should be considered.
Unnecessary Transfers for Acute Surgical Care: Who and Why?
Authors: Broman Kristy Kummerow , Poulose Benjamin K. , Phillips Sharon E. , Ehrenfeld Jesse M. , Sharp Kenneth W. , Pierce Richard A. , Holzman Michael D.
Published: June 2020

Interhospital transfers for acute surgical care occur commonly, but without clear guidelines or protocols. Transfers may subject patients and delivery systems to significant burdens without clear clinical benefit. The incidence and factors associated with unnecessary transfers are not well described. We conducted a retrospective cohort study of patient transfers within a regional referral network to a tertiary center for nontrauma acute surgical care from 2009 to 2013. Clinically unnecessary transfers were defined as transfers that resulted in no intervention (operation, endoscopy, or interventional radiology procedure) and discharge to home within 72 hours. We performed bivariate and multivariate logistic regression analyses. The study population included 2177 patient transfers, 19 per cent of which were determined to be clinically unnecessary. After adjustment, clinically unnecessary transfers were more commonly performed for patient request (odds ratio = 2.52, 95% confidence interval = 1.60–3.99), continuity of care (1.87, 1.44–2.42), and care by urologic (1.50, 1.06–2.13) and vascular services (1.44, 1.03–2.01). Patients with higher comorbidity and severity of illness scores were less likely to have unnecessary transfers. The burden of unnecessary transfers could be mitigated by identifying appropriate transfer candidates through mutually developed guidelines, interfacility collaboration, and increased use of remote care to provide surgical subspecialty consultation and maintain continuity.
Indications for Surgical Resection in Low-Grade Pancreatic Neuroendocrine Tumors
Authors: Fitzgerald Timothy L. , Mosquera Catalina , Vora Haily S. , Vohra Nasreen A. , Zervos Emmanuel E.
Published: June 2020

The role of surgical resection in low-grade pancreatic neuroendocrine tumors (P-NET) is unclear. The patients diagnosed with low-grade P-NET from 1988 to 2012 were identified in SEER. Five hundred and sixty-one patients met the inclusion criteria. A majority were white (82.9%), and node negative (69.9%). Univariate analysis revealed that tumor size (<2 cm 8.3%, 2–4 cm 38.5%, and >4 cm 40.3%; P < 0.0001) and surgery (30.9% vs 25.3%; P = 0.0014) were associated with the risk of lymph node metastases (LNM). In contrast, age ( P = 0.8360), gender ( P = 0.4903), and race ( P = 0.4235) were not. Five-year disease-free survival was associated with size (<2 cm 89.4%, 2–4 cm 80.0%, and >4 cm 74.5%; P = 0.0089), LNM (72.4% vs 82.9%; P = 0.0025), and surgery (84.3% vs 47.5%; P < 0.0001). Cox regression model showed that the association with LNM ( P = 0.0025) and surgery ( P < 0.0001) was significant. Surgery was associated with an improved disease-free survival for tumors >2 cm (2–4 cm, 84.4% vs 26.0% at five years; P = 0.0003, and >4 cm, 80.5% vs 49.5% at five years; P < 0.0001) but not for those with tumor size <2 cm ( P = 0.4525). In conclusions, low-grade P-NETs in patients with tumor size >2 cm showed an increased risk of LNM and improved survival with resection.
Venovenous Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure
Authors: Ham P. Benson , Hwang Brice , Wise Linda J. , Walters K. Christian , Pipkin Walter L. , Howell Charles G. , Bhatia Jatinder , Hatley Robyn
Published: June 2020

Conventional treatment of respiratory failure involves positive pressure ventilation that can worsen lung damage. Extracorporeal membrane oxygenation (ECMO) is typically used when conventional therapy fails. In this study, we evaluated the use of venovenous (VV)-ECMO for the treatment of severe pediatric respiratory failure at our institution. A retrospective analysis of pediatric patients (age 1–18) placed on ECMO in the last 15 years (1999–2014) by the pediatric surgery team for respiratory failure was performed. Five pediatric patients underwent ECMO (mean age 10 years; range, 2–16). All underwent VV-ECMO. Diagnoses were status asthmaticus (2), acute respiratory distress syndrome due to septic shock (1), aspergillus pneumonia (1), and respiratory failure due to parainfluenza (1). Two patients had severe barotrauma prior to ECMO initiation. Average oxygenation index (OI) prior to cannulation was 74 (range 23–122). No patients required conversion to VA-ECMO. The average ECMO run time was 4.4 days (range 2–6). The average number of days on the ventilator was 15 (range 4–27). There were no major complications due to the procedure. Survival to discharge was 100%. Average follow up is 4.4 years (range 1–15). A short run of VV-ECMO can be lifesaving for pediatric patients in respiratory failure. Survival is excellent despite severely elevated oxygen indices. VV-ECMO may be well tolerated and can be considered for severe pediatric respiratory failure.
Timing of Adjuvant Radioactive Iodine Therapy Does Not Affect Overall Survival in Low- and Intermediate-Risk Papillary Thyroid Carcinoma
Authors: Suman Paritosh , Wang Chi-Hsiung , Moo-Young Tricia A. , Prinz Richard A. , Winchester David J.
Published: June 2020

There is no consensus regarding the timing of adjuvant radioactive iodine therapy (RAI) therapy in low- and intermediate-risk papillary thyroid carcinoma (PTC). We analyzed the impact of adjuvant RAI on overall survival (OS) in low- and intermediate-risk PTC. The National Cancer Data Base was queried from 2004 to 2011 for pN0M0 PTC patients having near/subtotal or total thyroidectomy and adjuvant RAI. Tumors ≤1 cm with negative margins were low risk while 1.1- to 4-cm tumors with negative margins or ≤1 cm with microscopic margins were termed intermediate risk. RAI in ≤3 months and between 3 and 12 months was termed as early and delayed, respectively. Survival analysis was performed after adjusting for patient and tumor-related variables. There were 7,306 low-risk and 16,609 intermediate-risk patients. Seventeen per cent low-risk and 15 per cent intermediate-risk patients had delayed RAI. Kaplan-Meier analysis did not show a difference in OS for early versus delayed RAI administration in low- (10-year OS 94.5% vs 94%, P = 0.627) or intermediate-risk (10-year OS 95.3% vs 95.9%, P = 0.944) patients. In adjusted survival analysis, RAI timing did not affect OS in all patients (hazard ratios = 0.98, 95% confidence interval = 0.71–1.34, P = 0.887). In conclusion, the timing of postthyroidectomy adjuvant RAI therapy does not affect OS in low- or intermediate-risk PTC.
The Goalposts Have Moved: Can Surgery Residents Meet Updated Quality Benchmarks for Adenoma Detection Rate in Colonoscopy?
Authors: Ortolani John B. , Tershak Daniel R. , Ferrara John J. , Paget Charles J.
Published: June 2020

The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology Task Force (ACGTF) on Quality in Endoscopy released updated quality benchmarks for colonoscopy in 2015. Our initial study concluded that surgery residents could perform safe and competent screening colonoscopy within a structured endoscopy curriculum. In this follow-up study, we sought to determine whether surgery residents could achieve the increased adenoma detection rate (ADR) benchmarks endorsed by the ASGE/ACGTF. An Institutional Review Board-approved prospective analysis of colonoscopies performed by five postgraduate year 2 and 3 general surgery residents from 2013 to 2015 was completed. All colonoscopies were performed under the direct supervision of surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following ASGE/ACG quality metrics were recorded: bowel preparation quality; cecal intubation rate; polyp and ADRs; and, complications. Power analysis determined that 108 procedures were required for an 80 per cent probability of data analysis accuracy. About 135 screening and diagnostic colonoscopies were performed. Bowel prep was considered “adequate” in 90 per cent of cases. The cecum was reached independently in 95 per cent of cases. Polyp(s) were visualized and removed in 39 per cent of patients. The overall ADR was 31.8 per cent (>25%). Male ADR was 38.7 per cent (>30%). Female ADR was 26.0 per cent (>20%). Average polyp size was 8.7 mm (range: 1–22 mm). One patient was readmitted for post-polypectomy syndrome, and successfully managed nonoperatively. In conclusion, using our structured endoscopy curriculum, surgery residents achieved ADRs fully consistent with the updated benchmark values endorsed by the ASGE/ACGTF.
Admission Variables Associated with a Favorable Outcome after Mild Traumatic Brain Injury
Authors: Schwed Alexander C. , Boggs Monica M. , Watanabe Drew , Plurad David S. , Putnam Brant A. , Kim Dennis Y.
Published: June 2020

Consensus is lacking for ideal management of mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH). Patients are often monitored in the intensive care unit (ICU) without additional interventions. We sought to identify admission variables associated with a favorable outcome (ICU admission for 24 hours, no neurosurgical interventions, no complications or mortality) to divert these patients to a non-ICU setting in the future. We reviewed all patients with mTBI [Glasgow Coma Scale (GCS) = 13–15] and concomitant ICH between July 1, 2012, and June 30, 2015. Variables collected included demographics, vital signs, neurologic examination, imaging results, ICU course, mortality, and disposition. Of 201 patients, 78 (39%) had a favorable outcome. On univariate analysis, these patients were younger, more often had an isolated subarachnoid hemorrhage, and were more likely to have a GCS of 15 at admission. On multivariate regression analysis, after controlling for admission blood pressure, time to CT scan, and Marshall Score, age <55, GCS of 15 on arrival to the ICU, and isolated subarachnoid hemorrhage remained independent predictors of a favorable outcome. Patients meeting these criteria after mTBI with ICH likely do not require ICU-level care.
Influence of Weight Loss Attempts on Bariatric Surgery Outcomes
Authors: Deb Sayantan , Voller Lindsey , Palisch Chase , Ceja Omar , Turner Wes , Rivas Homero , Morton John M.
Published: June 2020

Many payors require an additional attempt at nonsurgical weight loss before approval of bariatric procedures. This study evaluates this requirement by characterizing the prior weight loss attempts (WLAs) undergone by bariatric surgery patients and correlating those attempts to postoperative weight loss outcomes. Number and duration of WLAs were obtained from a preoperative clinic assessment. Body mass index (BMI) and percentage of excess weight loss (%EWL) were used to assess weight loss. Kruskal-Wallis and Spearman Correlation tests were performed to analyze data using GraphPad Prism 6. Mean number of WLAs before surgery was 3.5 ± 0.2 attempts, with an average duration of 15.2 ± 1.1 years. There was a significant negative correlation between duration of WLAs and preoperative BMI ( r = -0.2637, P = 0.0025). No significant difference was found for preoperative BMI or mean 12-month %EWL among any WLA groups. The number and duration of dietary attempts before surgery do not significantly affect long-term weight loss outcomes after bariatric surgery. Given these data, an additional preoperative WLA may not be efficacious in improving patients’ chances at weight loss.
Predictors of Mortality in Trauma Patients Aged 80 years or Older
Authors: Mock Kyle , Keeley Jessica , Moazzez Ashkan , Plurad David S. , Putnam Brant , Kim Dennis Y.
Published: June 2020

The population of the United States is predicted to age dramatically over the next few decades; as such older patients will comprise an increasing proportion of the injured populations. Due to multiple comorbidities and frailty, the old and very old are at greater risk for mortality than younger patients. To identify predictors of inhospital mortality in these patients, we performed a retrospective cohort study at our Level 1 trauma center. Between April 2009 and October 2014, we identified 193 trauma patients aged 80 years and older admitted to the intensive care unit. The mean age was 86 years old (4.9) and a majority of patients were white (57%) and male (54%). Univariate analysis found Injury Severity Score ( P < 0.01), initial Glasgow Coma Scale ( P < 0.01), admission pH ( P = <0.01), admission lactate ( P < 0.01), the need for mechanical ventilation ( P < 0.01), and Geriatric Trauma Outcome Score ( P < 0.01) to be predictors of mortality. Multivariate analysis identified length of mechanical ventilation [odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.60–0.90, P < 0.01], admission lactate (OR = 1.74, 95% CI = 1.21–2.51, P < 0.01), and the need for mechanical ventilation (OR = 18.2, 95% CI = 3.33–99.8, P < 0.01) as independent predictors of mortality. These predictors can help guide clinical decisions and should prompt early discussion of goals of care. The association between mechanical ventilation and mortality is confounded by withdrawal of care.
Factors Associated with a Short (<2 Days) or Long (>10 Days) Length of Stay after Colectomy: A Multivariate Analysis of over 400 Patients
Authors: Cologne Kyle G. , Byers Sean , Rosen David R. , Hwang Grace S. , Ortega Adrian E. , Ault Glenn T. , Lee Sang W.
Published: June 2020

A prospectively maintained database of 415 patients undergoing colectomy was evaluated. We performed a logistic regression analysis to identify factors associated with 1) length of stay (LOS) of 2 days or less and 2) LOS of 10 days or more. Investigated variables included demographics, American Society of Anesthesiology (ASA) score, diagnosis, operative procedure, approach and time, transfusion requirements, and occurrence of any complications. Factors associated with a LOS of two days or less included ASA [odds ratio (OR): 0.34, 95% confidence interval (CI): 0.208–0.576], use of transversus abdominis plane block (OR: 5.259, 95% CI: 2.825–9.791), and operative time (OR: 0.98, 95% CI: 0.974–0.986). Age >65 had an OR of 1.73, though this did not reach statistical significance. Factors associated with LOS >10 days included ASA (OR: 2.152, 95% CI: 1.245–3.721), anastomotic leak (OR: 2.163, 95% CI: 1.486–3.148), ileus (OR: 8.790, 95% CI: 4.501–17.165), and surgical site infection (OR: 5.846, 95% CI: 2.764–12.362). Cancer and transfusion status were associated but did not reach statistical significance. Although operative time was longer in left-sided resections, no differences in LOS were observed. In conclusion, numerous factors are associated with short or long LOS and may help stratify resource utilization after colectomy. Further study is needed to confirm our findings.
Racial and Gender Differences in Arterial Anatomy of the Arm
Authors: Pham Xuan-Binh D. , Kim Jerry J. , Parrish Aaron B. , Tom Cynthia , Ihenachor Ezinne J. , Mina David , De Virgilio Christian
Published: June 2020

Prior studies have shown racial and gender differences with respect to maturation of arteriovenous fistulas. Women and minorities have lower maturation rates for unclear reasons. Small arterial diameter and high brachial artery bifurcation (HBB) are also implicated in reduced maturation rates. We sought to correlate differences in upper extremity arterial anatomy to race and gender. All upper extremity vascular mapping ultrasounds from 2013 to 2014 were retrospectively reviewed. A total of 509 arms in 284 patients were evaluated. Men had significantly higher mean arterial diameters than women at the elbow brachial (4.7 vs 3.9 mm, P < 0.01) and wrist radial arteries (2.1 vs 1.9 mm, P = 0.03). There were 20 (7%) patients with HBB of at least one arm, and 7 (2.5%) patients with bilateral HBB. African-American patients had significantly higher rates of both unilateral HBB (15.9% vs 5.4%, P = 0.02) and bilateral HBBs (9.1% vs 1.3%, P = 0.01). In conclusion, men had significantly larger arteries than women, and African-Americans had a higher rate of HBB than non-African-Americans. Consideration should be given for routine preoperative ultrasound to assess arterial anatomy before arteriovenous fistulas creation, particularly in women and in African-Americans.
Staging Rectal Cancer: The Utility of Chest Radiograph and Chest Computed Tomography
Authors: O'Leary Michael P. , Parrish Aaron B. , Tom Cynthia M. , Maclaughlin Brian W. , Petrie Beverley A.
Published: June 2020

The National Comprehensive Cancer Network recommends that patients who are newly diagnosed with rectal cancer undergo staging CT scan of the chest. It is unclear whether posteroanterior and lateral chest radiography (X-ray) alone would provide adequate staging for most of these patients. A retrospective review was performed on all patients who had a two-view chest X-ray along with a chest CT for rectal cancer staging from 2007 to 2015. A total of 74 patients had both modalities. Sixty-three (85%) had a normal chest X-ray and 11 (15%) had an abnormal chest X-ray. Of the 63 patients with a normal chest X-ray, 40 (63%) had a corresponding normal chest CT and 23 (37%) had a lesion only noted on chest CT. Four patients (17%) in the latter group had metastatic cancer to the lung at the time of workup and four out of five of the tumors found to metastasize were within 5 cm from the anal verge. Our data suggest that a staging chest X-ray is unlikely to diagnose metastatic lungs lesions from a primary rectal cancer. Conversely, staging chest CT will accurately stage metastatic disease but will also reveal benign lung lesions in this patient population.
Appendicitis in Cancer Patients is often Observed and Can Represent Appendiceal Malignancy
Authors: Santos David , Chiang Yi-Ju , Badgwell Brian
Published: June 2020

Appendectomy is standard of care for uncomplicated appendicitis, but cancer patients may not be optimal surgical candidates. Interval appendectomy is controversial, and appendiceal malignancy is rare. Study objectives were to review the role of surgery, observation, and interventional radiology (IR)-guided drainage in patients with appendicitis and advanced malignancy. Retrospective review was performed on cancer patients presenting to a tertiary academic cancer center from January 1, 2001 to December 31, 2014. Patients diagnosed with appendicitis were assigned to observation, surgery, and IR drainage after surgical evaluation. Success rates of initial treatment strategies were calculated. Rates of interval appendectomies and pathology were reviewed. Of 72 consults, 32 patients were included. Median age was 53 years, 50 per cent (16/32) were male, 50 per cent (16/32) had chemotherapy less than six weeks to presentation, and 63 per cent (20/32) had advanced stage malignancy. Of the 62.5 per cent (20/32) observed, 25 per cent (8/32) received immediate surgery, 12.5 per cent (4/32) required IR drainage, and 69 per cent (22/32) of patients were initially managed without surgery. Interval appendectomy rate was 19 per cent (6/32). Pathology confirmed appendiceal malignancies in 9.3 per cent (3/32). Cancer patients with acute appendicitis are frequently observed. High incidence of appendiceal malignancy may be due to the older median age. Interval appendectomy should be considered in this population.
National Disparities in Surgical Approach to T1 Rectal Cancer and Impact on Outcomes
Authors: Gabriel Emmanuel , Thirunavukarasu Pragatheeshwar , Al-Sukhni Eisar , Attwood Kristopher , Nurkin Steven J.
Published: June 2020

This study investigated disparities between patients who had local excision versus radical resection for T1 rectal cancer. A retrospective analysis was performed using the National Cancer Data Base, 2004 to 2011. Inclusion criteria consisted of patients with T1, N0 rectal adenocarcinoma that were <3 cm, well or moderately differentiated without perineural invasion. Patients were stratified based on local excision and radical surgery. The primary outcome was overall survival (OS). Secondary outcomes included 30-day mortality, unplanned readmission rates, and postoperative length of stay. A total of 2235 patients were identified; 1335 (59.7%) underwent local excision and 900 (40.3%) had radical surgery. Overall, radical surgery was associated with an improved 5-year OS rate compared to local excision (0.86 vs 0.78, P = 0.009), increased unplanned readmission (6.5% vs 2.7%, P < 0.001), and longer postoperative length of stay (6.9 days vs 3.1 days, P < 0.001). For patients who had local excision, insurance status was an independent predictor of OS. Compared to patients with private insurance, those with government plans or no insurance had poorer OS (hazard ratio = 1.77 and 17.45, respectively, P = 0.006). Further study is warranted to understand the reasons accounting for this disparity in surgical approach to T1 rectal cancer.
Limited Resection of the Duodenum for Nonampullary Duodenal Tumors, with Review of the Literature
Authors: Hashimoto Daisuke , Arima Kota , Chikamoto Akira , Taki Katsunobu , Inoue Risa , Kaida Takayoshi , Higashi Takaaki , Imai Katsunori , Beppu Toru , Baba Hideo
Published: June 2020

The surgical management of duodenal pathology is challenging because of its retroperitoneal position and shared blood supply with the pancreas. We present three types of limited resection of the duodenum for the removal of superficial or small nonampullary duodenal (NADL) lesions, and also a review of the English literature regarding management, such as endoscopic resection and limited duodenal resection. Ten cases underwent limited resections of the duodenum for superficial or small NADL lesions from 2011 to 2015. Pancreas-preserving segmental duodenectomy was performed in three cases, local full-thickness resection was performed in three and transduodenal submucosal dissection was performed in four. One patient experienced pancreatic fistula as a postoperative complication. Postoperative pathological diagnosis were adenoma (n = 2), mucosal adenocarcinomas (n = 5), and neuroendocrine tumor (n = 3). Surgical margin was negative in all cases, and no patient has experienced postoperative recurrence or metastasis. Limited resections of the duodenum were feasible and safe procedures for patients with superficial or small NADL lesions. Laparoscopic surgery may be considered in treatment for these tumors. However, the optimal surgical management for superficial or small nonampullary duodenal lesions remains controversial.
Development and Validation of a Risk Calculator for Renal Complications after Colorectal Surgery Using the National Surgical Quality Improvement Program Participant Use Files
Authors: Ramonell Kimberly M. , Fang Shuyang , Perez Sebastian D. , Srinivasan Jahnavi K. , Sullivan Patrick S. , Galloway John R. , Staley Charles A. , Lin Edward , Sharma Jyotirmay , Sweeney John F. , Shaffer Virginia O.
Published: June 2020

Postoperative acute renal failure is a major cause of morbidity and mortality in colon and rectal surgery. Our objective was to identify preoperative risk factors that predispose patients to postoperative renal failure and renal insufficiency, and subsequently develop a risk calculator. Using the National Surgical Quality Improvement Program Participant Use Files database, all patients who underwent colorectal surgery in 2009 were selected (n = 21,720). We identified renal complications during the 30-day period after surgery. Using multivariate logistic regression analysis, a predictive model was developed. The overall incidence of renal complications among colorectal surgery patients was 1.6 per cent. Significant predictors include male gender (adjusted odds ratio [OR]: 1.8), dependent functional status (OR: 1.5), preoperative dyspnea (OR: 1.5), hypertension (OR: 1.6), preoperative acute renal failure (OR: 2.0), American Society of Anesthesiologists class ≥3 (OR: 2.2), preoperative creatinine >1.2 mg/dL (OR: 2.8), albumin <3.5 g/dL (OR: 1.8), and emergency operation (OR: 1.5). This final model has an area under the curve (AUC) of 0.79 and was validated with similar excellent discrimination (area under the curve: 0.76). Using this model, a risk calculator was developed with excellent predictive ability for postoperative renal complications in colorectal patients and can be used to aid clinical decision-making, patient counseling, and further research on measures to improve patient care.
William Arbuthnot Lane (1856–1943): Surgical Innovator and His Theory of Autointoxication
Authors: Morris Mackenzie , Price Thea , Cowan Scott W. , Yeo Charles J. , Phillips Benjamin
Published: June 2020

William Arbuthnot Lane contributed to the advancement of many fields of orthopedics, otolaryngology, and general surgery. He is credited for his “no-touch technique” and the invention of long-handled instruments, some of which are still in use today, to minimize tissue handling. He is most well known for his hypothesis that slowing of gastric contents could cause a variety of ailments and this became known as Lane's disease. Although his surgical treatment of Lane's disease is now defunct, it advanced the surgical technique in colorectal surgery. It seems likely that some of Lane's “autointoxication” patients would be classified today as patients with colonic inertia, diverticulitis, colonic volvulus, and megacolon or, which are all treated with colectomy. Lane was a pioneer in multiple fields and a true general surgeon. He advanced colorectal surgery immensely and propelled the field of surgery into a new era.
The Development of Total Parenteral Nutrition
Authors: Nakayama Don K.
Published: June 2020

The first patient to receive complete nourishment of a patient by intravenous infusion independent of the alimentary tract was an infant girl born with near-total small bowel atresia. Total parenteral nutrition, the intravenous infusion of nutrients, has been attempted since Harvey's description of the circulatory system in the early 17th century. The modern era of parenteral nutrition began in the early 20th century, when infusions of glucose, plasma, and emulsified fat into humans proved feasible. Robert Elman, working in the 1930s and 1940s, demonstrated that carefully prepared protein hydrolysates could be safely infused intravenously and incorporated by the body. Stanley Dudrick and Douglas Wilmore, surgeon researchers at the University of Pennsylvania, worked through the many details of preparation, administration, and clinical monitoring in beagle puppies before testing them on adult patients malnourished from a variety of surgical complications and gastrointestinal conditions. They applied their techniques and formulations on a newborn wasting away from congenital absence of the small bowel, the baby growing and developing for several months while being nourished completely by total parenteral nutrition. Their techniques, inspired by patients with progressive malnutrition from devastating intestinal conditions and malformations, form the basis of the practice of intravenous nutrition practiced today.
Impact of Timing of Conversion to Open Surgery on Short-Term and Oncologic Outcomes in Patients Undergoing Minimally Invasive Surgery for Colorectal Cancer
Authors: Kim Ik Yong , Kim Bo Ra , Kim Young Wan
Published: June 2020

To evaluate the influence of timing of open conversion on short-term and oncologic outcomes after minimally invasive surgery for colorectal cancer. Six hundred forty-six consecutive patients were enrolled. All patients converted to open surgery were classified into early (n = 10) or late (n = 67) groups based on conversion timing using a 60-minute cutoff. A comparison of early conversion and nonconverted groups showed that history of prior abdominal surgery and pT4 tumor was more common in the early conversion group. Mean operative time was longer in the early conversion group. Rates of 30-day postoperative complications (30% vs 27%), time to soft diet (5 days vs 5 days), and hospital stay (12 days vs 12 days) were not different. A comparison of the late and nonconverted groups showed that history of prior abdominal surgery was more common in the late conversion group. Mean operative time was longer in the late conversion. Rates of 30-day postoperative complications (42% vs 27%), Clavien–Dindo score ≥3 (22% vs 11%), intensive care unit care (31% vs 15%), and transfusion (37% vs 21%) were significantly higher in the late conversion group. Time to soft diet (6 days vs 5 days) and hospital stay (15 days vs 12 days, P = 0.037) were longer in the late conversion group. Cancer-specific and recurrence-free survival rates did not differ among the early, late conversion, and nonconverted groups. Decisions about open conversion need be made within 60 minutes of the beginning of surgery as early conversion does not worsen short-term and oncologic outcomes.
A Multi-Institutional Study Comparing the Use of the American Joint Committee on Cancer 7th Edition Esophageal versus Gastric Staging System for Gastroesophageal Junction Cancer in a Western Population
Authors: Adeshuko Folashade A. , Squires Malcolm H. , Poultsides George , Pawlik Timothy M. , Weber Sharon M. , Schmidt Carl , Votanopoulos Konstantinos , Fields Ryan C. , Maithel Shishir K. , Cardona Kenneth
Published: June 2020

Controversy exists over the staging of gastroesophageal junction (GEJ) adenocarcinomas. The aim of our study was to assess the adequacy of the American Joint Committee on Cancer 7th edition esophageal (E7) and gastric (G7) staging systems for GEJ tumors in a western population. All patients with GEJ adenocarcinoma who underwent curative resection from 2000 to 2012 were identified from the United States Gastric Cancer Collaborative database and assessed according to the E7 and G7 systems. Fifty-one patients were identified. Neither the E7 nor G7 system adequately stratified patients by Tor N stage with a loss of distinctiveness between T1 to 4 and N0 to 3 tumors. On final stage analysis, the outcomes were similar between both systems; however, neither system, with the exception of the G7 stage I versus II, adequately stratified patients by stage (E7: I vs II, P = 0.07; II vs III, P = 0.23; G7: I vs II, P = 0.02; II vs III, P = 0.13). Histologic grade was not associated with survival (P = 0.27) and did not improve the ability to stratify patients in the E7 system. Our study identifies limitations in the proper stratification of patients with GEJ adenocarcinoma using either the American Joint Committee on Cancer 7th esophageal or gastric systems. The classification of GEJ adenocarcinoma within either system needs to be further studied in a larger patient population.
A Defined Esophagectomy Perioperative Clinical Care Process Can Improve Outcomes and Costs
Authors: Cooke David T. , Calhoun Royce F. , Kuderer Valerie , David Elizabeth A.
Published: June 2020

Esophagectomy (EG) is a high-risk therapy for esophageal cancer and end-stage benign disease. This study compares the results of EG before and after implementation of a perioperative clinical care process including a health provider education program (EP) and institutional uncomplicated postoperative clinical pathway (POP) for purpose quality improvement. This is a single institution retrospective cohort study. The EP was provided to critical care and telemetry unit nurses and the POP was imbedded in the electronic health record. Patients undergoing elective EG with reconstruction with the stomach for benign disease or cancer were included from 2005 to 2011. Cohorts were pre- and postimplementation (PreI and PostI) of an EP and 8-day POP (August 2008). Patient, tumor and peri/postoperative-specific variables were compared between cohorts, as well as resource utilization and hospital costs. We identified 33 PreI and 41 PostI patients. Both cohorts had similar patient demographics, preoperative comorbidities, majority cancer diagnosis, and for cancer patients, majority adenocarcinoma and IIB/III pathologic stage. Both groups had one death and similar rate of discharge to home. The PostI cohort demonstrated reduced 30-day readmission rate (2.4% vs 24.2%); P < 0.05. In regard to clinical outcomes, the PostI group exhibited reduced deep venous thrombosis/pulmonary emboli (2.4% vs 18.2%); P < 0.05. The PostI group demonstrated significantly reduced radiographic test utilization and costs, as well as total overall 30-day readmission costs. A defined perioperative clinical process involving educating the patient care team and implementing a widely disseminated POP can reduce complications, 30-day readmission rates, and hospital costs after EG.
The Efficacy of Dextran-40 as a Venous Thromboembolism Prophylaxis Strategy in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
Authors: Foster Jason M. , Sleightholm Richard , Watley Duncan , Wahlmeier Steven , Patel Asish
Published: June 2020

The incidence of venous thromboembolism (VTE) in peritoneal malignancies can approach 30 to 50 per cent without prophylaxis. Prophylaxis in cytoreductive surgeries (CRS) presents a challenge to preoperative heparin-based therapy because of an increased risk of coagulopathy and potential for bleeding. Herein, we report the large series of CRS and hyperthermic intraperitoneal chemotherapy receiving dextran-40 prophylaxis. Retrospective chart review of peritoneal malignancies patients undergoing CRS at University of Nebraska Medical Center identified 69 individuals who received dextran-40 between 2010 and 2013. The incidences of VTEs, perioperative bleeding, complications, morbidity, and mortality were determined in-hospital and at 90 days. Of the 69 patients treated, the 30-day VTE rate was 8.7 per cent, and no pulmonary embolisms, bleeding, anaphylactoid reaction, or mortality were observed with dextran usage. The specific VTE events included three upper extremity and three lower extremity VTEs. No additional VTE events were identified between 30 and 90 days. In conclusion, dextran-40 prophylaxis was not associated with any perioperative bleeding events, and the observed incidence of VTE was comparable to reported heparin-based prophylaxis in CRS/hyperthermic intraperitoneal chemotherapy patients. This data supports further exploration of dextran-40 as a VTE prophylactic agent in complex surgical oncology cases.
Choosing Surgery: Identifying Factors Leading to Increased General Surgery Matriculation Rate
Authors: Pointer David T. , Freeman Matthew D. , Korndorffer James R. , Meade Peter C. , Jaffe Bernard M. , Slakey Douglas P.
Published: June 2020

Tulane graduates have, over the past six years, chosen general surgical residency at a rate above the national average (mean 9.6% vs 6.6%). With much of the recent career choice research focusing on disincentives and declining general surgery applicants, we sought to identify factors that positively influenced our students’ decision to pursue general surgery. A 50-question survey was developed and distributed to graduates who matched into a general surgery between the years 2006 and 2014. The survey evaluated demographics, exposure to surgery, and factors affecting interest in a surgical career. We achieved a 54 per cent (61/112) response rate. Only 43 per cent considered a surgical career before medical school matriculation. Fifty-nine per cent had strongly considered a career other than surgery. Sixty-two per cent chose to pursue surgery during or immediately after their surgery clerkship. The most important factors cited for choosing general surgery were perceived career enjoyment of residents and faculty, resident/faculty relationship, and mentorship. Surgery residents and faculty were viewed as role models by 72 and 77 per cent of responders, respectively. This study demonstrated almost half of those choosing a surgical career did so as a direct result of the core rotation experience. We believe that structuring the medical student education experience to optimize the interaction of students, residents, and faculty produces a positive environment encouraging students to choose a general surgery career.
Analysis of Mortality in Traumatically Injured Patients Based on Body Mass Index and Mechanism Reveals Highest Mortality among the Underweight in Comparison with the Ideal Weight Patients
Authors: Treto Kevin , Safcsak Karen , Chesire David , Bhullar Indermeet S.
Published: June 2020

The purpose of this study was to evaluate the effect of body mass index (BMI) on mortality after traumatic injury. The records of patients from 2012 to 2015 were retrospectively reviewed. The patients were stratified into the following groups based on admission BMI (kg/m2): underweight (UW) (BMI <19), ideal weight (IW) (BMI = 19–24.9), overweight (OW) (BMI = 25–29.9), obese (OB) (BMI = 30–39.9), and morbid obese (MO) (BMI >40). The groups were well matched with no significant differences in demographics and Injury Severity Score. Morality for the IW group was compared with the remaining BMI groups. A total of 6049 patients were identified. In comparison with IW group, the UW mortality was significantly higher (IW vs UW, 4.1% vs 8.8%, P = 0.001); however, the there was no significant difference with remaining groups. There was also no significant difference in mortality between IW and the remaining groups for patients that went directly to the operating room or for patients that had penetrating trauma (stab wounds and gunshot wounds). However, for blunt trauma, the mortality was significantly higher for UW (IW vs UW, 4.3% vs 9.4%, P = 0.001), no different for IW vs OW (4.3% vs 3.7%, P = 0.3), and significantly lower for IW vs OB (4.3% vs 2.8%, P = 0.04) and for IW vs MO (4.3% vs 1.0%, P = 0.03). After traumatic injuries, it is the underweight patients (BMI <19) and not the obese, that are at a significantly higher risk for overall mortality; this difference is especially evident after blunt trauma where obesity may actually confer a protective role.
The Role of Doctors and Patients in Appendicitis Perforation
Authors: ÖZtÜRk Alaattin , Korkmaz Mevlit , Atalay Talha , KarakÖSe YÜKsel , Faruk Akinci ÖMer , Bozer Mikdat
Published: June 2020

In this study, we aimed to determine factors that cause appendix perforations and to identify the role of physicians and patients in contributing to the cause of these perforations. This study was conducted between April 2010 and May 2015 and included 64 patients with perforated appendicitis. Patients’ medical records were examined for factors that might have contributed to perforation, and the roles of patients and physicians in perforation appendicitis were evaluated. The perforation rate of patients with appendicitis was 16.0 per cent. The average duration from symptom onset to hospital admission was 4.4 days (29 patients were admitted to hospital within two days, 35 were admitted later). In total, 38 patients had visited a different hospital before admission. Furthermore, six out of 26 patients who had not visited any other hospital had consumed analgesics. Factors contributing to appendix perforation included misdiagnosis at the patient's initial visit (56.0%), delayed admission to hospital (11.0%), and use of analgesics (9.0%). The cause of perforation was mostly physician-related in children and adults, and patient-related in older adults.
Impact of Multimodality Pain Regimens on Elective Colorectal Surgery Outcomes
Authors: Kaplan Jennifer A. , Finlayson Emily , Auerbach Andrew D.
Published: June 2020

Trials of enhanced recovery programs suggest that multimodality pain regimens improve outcomes after colorectal surgery. We sought to determine whether patients receiving postoperative multimodality pain regimens would have shorter lengths of stay without an associated increase in readmission rate as compared to those receiving opioid-based pain regimens. Retrospective cohort study of adults who underwent elective colorectal surgery between January 1, 2006, and December 31, 2012, in a national hospital network participating in the Premier Perspective database. Patients were grouped into multimodality or opioid-based using postoperative medication charges. Primary outcome measures included length of stay and 30-day readmission rate. Among 91,936 patients, 38 per cent received multimodality pain regimens and 61 per cent received opioid-based regimens. After adjustment for patient and surgical characteristics, there was no difference in length of stay or cost, odds of readmission were 1.2 (95% confidence interval = 1.2–1.3, P < 0.001), and odds of mortality were 0.8 (95% confidence interval = 0.6–0.9, P < 0.001) in the multimodality group compared to nonopioid sparing. Our results were consistent in secondary analyses using propensity matching. Fewer than half of patients undergoing elective colorectal surgery in our cohort received multimodality pain regimens, and receipt of these medications was associated with mixed benefits in terms of length of stay, readmission, and mortality.