bluuebunny/crossref_metadata_2025 huggingface dataset:
Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges
Authors: Shubinets Valeriy , Fox Justin P. , Lanni Michael A. , Tecce Michael G. , Pauli Eric M. , Hope William W. , Kovach Stephen J. , Fischer John P.
Published: June 2020

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.
Extremity Vascular Injury Management: Good Outcomes Using Selective Referral to Vascular Surgeons
Authors: Hafiz Shabnam , Zubowicz Elizabeth A. , Abouassaly Chadi , Ricotta John J. , Sava Jack A.
Published: June 2020

Revascularization after extremity vascular injury has long been considered an important skill among trauma surgeons. Increasingly, some trauma surgeons defer vascular repair in response to training or practice patterns. This study was designed to document results of extremity revascularization surgery to evaluate trauma surgeon outcomes and judicious referral of more complex injuries to vascular surgeons (VAS). The trauma registry of an urban level I trauma center was used to identify all patients from 2003 to 2013 who underwent an early (<24 hours) procedure for urgent management of acute injury to extremity vessels. Patients were managed by trauma (TRA) versus VAS based on the practice pattern of the on-call trauma surgeon. Injury and outcome variables were recorded. Of 115 patients, 84 patients were revascularized by trauma and 31 vascular surgeries. There was no difference in complication rates or frequency of any type of complication associated with repairs performed by VAS or TRA. There were similar rates between the two groups for patients with multiple injuries, such as venous, bone or tendon, and nerve injury to the affected extremity. One VAS patient and two TRA patients developed compartment syndrome. In appropriately selected patients, trauma surgeons achieve good outcomes after revascularization of injured extremities.
Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection
Authors: Ohtsuka Takao , Mori Yasuhisa , Fujimoto Takaaki , Miyasaka Yoshihiro , Nakata Kohei , Ohuchida Kenoki , Nagai Eishi , Oda Yoshinao , Shimizu Shuji , Nakamura Masafumi
Published: June 2020

The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with ( n = 10) and without ( n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer ( P < 0.01) and blood loss significantly greater ( P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent ( P = 0.02) and postoperative hospital stay was significantly longer ( P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study.
Genetic Testing for Hereditary Breast Cancer: The Decision to Decline
Authors: White V. Brook , Walsh Kendall K. , Foss Kimberly Showers , Amacker-North Lisa , Lenarcic Stacy , Mcneely Lindsay , White Richard L.
Published: June 2020

Genetic testing is important for comprehensive cancer care. Commercial analysis of the BRCA1/2 genes has been available since 1996, and testing for hereditary breast and ovarian cancer syndrome is well established. The National Comprehensive Cancer Network (NCCN) guidelines identify individuals for whom BRCA1/2 analysis is appropriate and define management recommendations for mutation carriers. Despite recommendations, not all who meet NCCN criteria undergo genetic testing. We assess the frequency that individuals meeting NCCN criteria decline BRCA1/2 analysis, as well as factors that affect the decision-making process. A retrospective chart review was performed from September 2013 through August 2014 of individuals who received genetic counseling at the Levine Cancer Institute. A total of 1082 individuals identified through the retrospective chart review met NCCN criteria for BRCA1/2 analysis. Of these, 267 (24.7%) did not pursue genetic testing. Of the Nontested cohort, 59 (22.1%) were disinterested in testing and 108 (40.4%) were advised to gather additional genetic or medical information about their relatives before testing. The remaining 100 (37.5%) individuals were insured and desired to undergo genetic testing but were prohibited by the expense. Eighty five of these 100 patients were responsible for the total cost of the test, whereas the remaining 15 faced a prohibitive copay expense. Financial concerns are a major deterrent to the pursuit of BRCA1/2 analysis among those who meet NCNN criteria, especially in patients diagnosed with breast or ovarian cancer. These findings highlight the need to address financial concerns for genetic testing in this high-risk population.
Incidence and Impact of Variant Celiacomesenteric Vascularization and Vascular Stenosis on Pancreatic Surgery Outcomes: Personal Experience
Authors: Sánchez Alejandro M. , Tortorelli Antonio P. , Caprino Paola , Rosa Fausto , Menghi Roberta , Quero Giuseppe , Doglietto Giovanni B. , Alfieri Sergio
Published: June 2020

Ischemic complications after pancreatic surgery can raise postoperative mortality from 4 to 83 per cent. Variants in vascular anatomy play a major role in determining such complications, but they have been only occasionally reported in the literature. We retrospectively analyzed 100 records of patients consecutively treated between January 2011 and December 2013 for resectable malignant diseases who underwent pancreaticoduodenectomy (PD) or total pancreatectomy to state the statistical impact of anatomical vascular variations in surgical outcomes (mean surgical timing, mean blood loss during surgery, and postoperative major complications onset) and to state whether preoperatively undetected vascular anomalies (VA) can raise the risk of postoperative ischemic complications. PD was performed in 89 patients, requiring multiorgan resections in three cases and total pancreatectomy was performed in 11 cases, which was associated to splenectomy in four patients. Incidence of VA was 25/100 (25%), whereas in 18/25 cases (72%) they were detected by preoperative radiologic setting. Their presence in patients undergoing PD significantly raised mean surgical timing ( P = 0.003) and increased mean blood loss ( P < 0.0001). Preoperatively undetected VA resulted in a major risk of postoperative acute liver ischemia ( P = 0.008). Celiacomesenteric aberrant anatomy was proven to be related to an increased risk of intraoperative complications. If undetected preoperatively, they can be associated with anastomotic complications and liver failure. Maximal efforts must be done to detect and to preserve vascular anatomy of celiacomesenteric district.
Head CT before Transfer Does Not Decrease Time to Craniotomy for TBI Patients
Authors: Tonui Peter M. , Spilman Sarah K. , Pelaez Carlos A. , Mankins Mark R. , Sidwell Richard A.
Published: June 2020

Rural trauma education emphasizes that radiologic imaging should be discouraged if it delays transfer to definitive care. With increased capacity for image sharing, however, radiography obtained at referring hospitals (RH) could help providers at trauma centers (TC) prepare for patients with traumatic brain injury. We evaluated whether a head CT prior to transfer accelerated time to neurosurgical intervention at the TC. The study was conducted at a combined adult Level I and pediatric Level II TC with a catchment area that includes rural hospitals within a 150 mile radius. The trauma registry was used to identify patients with traumatic brain injury who went to surgery for a neurosurgical procedure immediately after arrival at the TC. All patients were transferred in from a RH. Differences between groups were assessed using analysis of variance and chi-square. Fifty-six patients met study criteria during the study period (2010-2015). The majority (86%) of patients received head CT imaging at the RH, including a significant percentage of patients (18%) who presented with GCS ≤8. There was no statistically significant decrease in time to surgery when patients received imaging at the RH. CTimaging was associated with a delay in transfer that exceeded 90 minutes. Findings demonstrate that imaging at the RH delayed transfer to definitive care and did not improve time to neurosurgical intervention at the TC. Transfer to the TC should not be obstructed by imaging, especially for patients with severe TBI.
Follow-Up Imaging in Patients with Blunt Splenic or Hepatic Injury Managed Nonoperatively
Authors: Mebert R. Viola , SchnÜRiger Beat , Candinas Daniel , Haltmeier Tobias
Published: June 2020

Nonoperative management of blunt splenic and hepatic injuries has become the standard of care for hemodynamically stable patients. However, nonoperative management may lead to delayed complications and appropriate follow-up is therefore crucial. The aim of this systematic literature review was to assess the role of different imaging modalities in the follow-up assessment of patients with blunt splenic or hepatic injuries using the PubMed database. Eighteen studies were found to be relevant to the topic. A total of 2725 patients were enrolled in the included studies. Both retrospective and prospective studies, but no randomized controlled trials were found. In these studies, CT, ultrasound, and contrast-enhanced ultrasound were discussed. CT was the most commonly used imaging modality. Taking into account all studies included, only one patient underwent intervention due to a complication diagnosed by follow-up CTscan in the absence of clinical signs and symptoms. This equates to a total of 920 CT scans performed to diagnose one clinically nonevident complication that required intervention. Based on the reviewed literature, routine imaging follow-up CT scans may not be indicated in asymptomatic patients with lower grade blunt splenic or hepatic injuries. Contrast-enhanced ultrasound is a promising alternative imaging modality for the follow-up of these patients.
Clinicopathological Features and Management of Appendiceal Mucoceles: A Systematic Review
Authors: Morano William F. , Gleeson Elizabeth M. , Sullivan Sean H. , Padmanaban Vennila , Mapow Beth L. , Shewokis Patricia A. , Esquivel Jesus , Bowne Wilbur B.
Published: June 2020

Appendiceal mucoceles (AMs) are rare mucin-containing neoplasms with malignant potential. Lack of evidence-based data exists defining clinicopathological features for management. MEDLINE search between 1995 and 2015 was performed using search criteria “Appendix mucocele.” Systematic review of patient-, pathologic-, and treatment-related characteristics was performed and data analyzed. Among 276 cases of non-perforated AMs, 163 (59%) patients were female, with variable and nonspecific presentation. Patients were treated with appendectomy (52.1%), right hemicolectomy (17.6%), partial cecectomy (17.2%), and ileocecetomy (13.1%). Pathologic evaluation revealed the following: cystadenoma/low-grade appendiceal mucinous neoplasm (54%), unspecified/benign (25%), retention cyst (14.1%), cystadenocarcinoma (4.2%), and mucosal hyperplasia (2.9%). All 11 (4.2%) patients with cystadenocarcinoma were female ( P = 0.004), odds ratio for malignancy 1.07 times higher for women. Synchronous colonic malignancy was reported in three patients (27%) with cystadenocarcinoma ( P = 0.007), odds ratio of 12.1. AMs have low risk for malignancy. Treatment should begin with appendectomy-only and subsequently guided by pathologic diagnosis.
Helmets Matter: Kentucky All-Terrain Vehicle Crashes Seen at a Tennessee Trauma Center
Authors: Testerman George M. , Prior Daniel C. , Wells Tamie D. , Rollins Sarah E. , Oesch Stephen L.
Published: June 2020

All-terrain vehicle (ATV) safety laws, including helmet use, vary by state and are sporadically enforced. Kentucky state laws require safety helmets only for younger riders. We hypothesized that ATV riders injured in Kentucky and seen at a Tennessee trauma center would more likely be unhelmeted, have more severe head injuries, and have higher mortality rates than those injured in Virginia or Tennessee. A Trauma Registry review of 750 injured ATV riders from June 1, 2005, through June 1, 2015 examined state location of accident, helmet use, markers of injury severity, and outcomes. Multiple logistic regression analysis examined predictors of severe head injuries and death with P < 0.05 significant. Unhelmeted ATV rider status predicted more severe head injuries (relative risk 23.5, P < 0.001) and death (relative risk 4.6, P < 0.001). ATV riders injured in the state of Kentucky were twice as numerous. In addition, they were more likely than ATVriders injured in Tennessee or Virginia to be unhelmeted, to have severe head injuries, and to sustain fatal injuries (all P < 0.001). This single trauma center study lends support for maintaining and enforcing current universal helmet laws for ATVriders of all ages in states where they are in effect and highlights the need to upgrade helmet laws that apply only to some riders.
Prospective Analysis of Epigastric, Umbilical, and Small Incisional Hernia Repair Using the Modified Kugel Oval Patch
Authors: Wang Dianchen , Chen Jianmin , Chen Yake , Han Yuqian , Zhang Hongyue
Published: June 2020

The study was performed to determine the complication and recurrence rate using the modified Kugel oval patch for small ventral hernia repair. Another aim of the study was to find risk factors for recurrence in patients with this repair. Seventy-three patients underwent ventral hernia repair with the modified Kugel oval patch between April 2013 and February 2015. Prospective follow-up data (18 months postoperative) were collected and evaluated. A total of 58 primary (18 epigastric/40 umbilical) and 15 incisional ventral hernias were repaired with the modified Kugel oval patch (7.6/10.2 cm/8 x 12 cm). We found three patients suffered superficial wound infection and two participants got hernia recurrence. Placement of mesh was found to be a significant risk factor for hernia recurrence. Small ventral hernia repair using the modified Kugel oval patch is a novel and useful approach and we recommend placing the patch preperitoneally.
Laparoscopic Experience for Recurrent Inguinal Hernia Repair in a Single Center for 14 Years
Authors: Sun Jing , Wang Wenrui , Li Jianwen , Yue Fei , Feng Bo , Wang Ji , Wang Minggang
Published: June 2020

Laparoscopic techniques are now well pervading in the treatment of inguinal hernia. This study aims to investigate the laparoscopic strategy for recurrent inguinal hernia repair. Laparoscopic technique was retrospectively applied to 330 patients with 352 recurrent inguinal hernias in the past 14 years. The surgical strategies were further evaluated. There were 22 cases with bilateral recurrent hernias, whereas the rest 308 cases with unilateral disorders. Patients were further categorized by previous repair approaches as high ligation, sclerotherapy, conventional suture repair, Lichtenstein repair, plug and patch repair, and preperitoneal repair. All cases were successfully repaired by laparoscopic approaches including transabdominal preperitoneal (TAPP) (288 cases), totally extraperitoneal (50 cases), and intraperitoneal onlay mesh (14 cases). The median operation duration was 39.5 ± 13.4 minutes. The average Visual Analog Scales score on postoperative day 1 was 2.4 ± 1.1. The median follow-up time was 36 (14–61) months. There was one case of recurrence during the follow-ups. One severe complication, i.e., bowel injury, was observed and cured, whereas other complications were as follows: 22 seroma, 8 urinary retention, 3 transient paresthesia, and 1 ileus. Laparoscopic procedures for recurrence inguinal hernia are safe and applicable. A surgeon can choose to reinforce the myopectineal orifice or only fix the hernia defect accordingly. The strategy of choosing TAPP and/or totally extraperitoneal depends on the type of previous repair, the exact anatomical position of the previous implanted mesh, and more importantly, the surgeon's experience. Moreover, the intraperitoneal onlay mesh technique can be regarded as a backup option for TAPP in certain cases.
Nighttime Trauma Fellow Care Is Associated with Improved Outcomes after Injury
Authors: Beard Jessica H. , Martin Niels D. , Reilly Patrick M. , Seamon Mark J.
Published: June 2020

Time of admission and surgeon experience may explain variations in trauma outcomes. We hypothesized that earlier admission time by a more experienced trauma surgeon leads to improved outcomes after injury. We conducted a retrospective cohort study using trauma registry and performance improvement data at our Level 1 trauma center. Consecutive patients presenting at night from 2013 to 2014 were dichotomized into early (6:00 PM–12:00 AM) and late (12:01 AM–7:00 AM) cohorts. Second year trauma fellows acting as attendings and staff trauma surgeons were categorized as less and more experienced, respectively. The primary study outcome was any complication tracked by our state registry, missed injury, delay in diagnosis, or death. The influence of admission time and trauma surgeon experience on this endpoint was examined using multivariable logistic regression. A total of 2078 patients presented either during early (n = 1189) or late (n = 889) night. The cohorts were not different with respect to Deyo–Charlson index, systolic blood pressure, Glasgow Coma Scale, Injury Severity Core, admitting trauma surgeon age, experience, or unadjusted primary study outcome (early 14 vs late 16%; P = 0.206). Trauma surgeon experience was independently predictive of outcomes. Trauma patients admitted at night by fellows were 29 per cent less likely to sustain complications or death than those admitted by staff (adjusted odds ratio 0.71; 95% confidence interval: 0.54–0.92, P = 0.010). This protective effect of fellow care was found only in patients admitted after midnight ( P = 0.03). In conclusion, nighttime initial trauma care by fellows was associated with improved outcomes. Possible explanations include more oversight of nighttime fellow care, variations in daytime responsibilities between fellows and staff, and differential effects of sleep loss by age.
Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study
Authors: Al-Taki Muhyeddine , Sukkarieh Hamdi G. , Hoballah Jamal J. , Jamali Sarah F. , Habbal Mohamad , Masrouha Karim Z. , Abi-Melhem Racha , Tamim Hani
Published: June 2020

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89–0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14–1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10–1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08–1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04–1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96–1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.
Axillary Hidradenitis: Risk Factors for Recurrence after Surgical Excision in 214 Patients
Authors: Nweze Nkem , Parsikia Afshin , Ahuja Rakesh , Joshi Amit R.T.
Published: June 2020

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the apocrine sweat glands. Although the mainstay of surgical treatment is excision, the disease has a high tendency to recur, for reasons that are not well understood. We sought to better characterize the natural history of this disease, focusing on patients who required operative intervention. Two hundred and fourteen patients with axillary HS underwent 293 surgical procedures. We divided the cohort into two groups based on recurrence and then compared them to identify the factors most associated with recurrent axillary HS. Mean age of onset of HS was 32.1 years. The patients were overwhelmingly female (84.1%), black (93%), and obese (average body mass index = 33.4). Of them, 35.5 per cent of the patients had bilateral axillary disease and 8.4 per cent had extra-axillary disease. Of the 214 patients, 22 (10.3%) had recurrent disease. The vast majority of interventions included excision of disease (median area = 78.6 cm2). Closure versus nonclosure was not associated with a proclivity toward recurrence. The patients with HS were overwhelmingly obese and female, and many of them smoked. Surgical excision was the most common intervention and closure was used in roughly half of the patients. Recurrence after excision was not associated with extra-axillary disease and did not seem to correlate with the manner in which the wounds were managed after excision. Weight loss and smoking cessation may play a more significant role in the prevention of recurrence of HS than surgical treatment alone.
Outcomes after Ventral Hernia Repair Using the Rives-Stoppa, Endoscopic, and Open Component Separation Techniques
Authors: Muse Thomas O. , Zwischenberger Brittany A. , Miller M. Troy , Borman Daniel A. , Davenport Daniel L. , Roth J. Scott
Published: June 2020

Complex ventral hernias remain a challenge for general surgeons despite advances in minimally invasive surgical techniques. This study compares outcomes following Rives-Stoppa (RS) repair, components separation technique with mesh (CST-M) or without mesh (CST), and endoscopic components separation technique (ECST). A retrospective review of patients undergoing open ventral hernia repair between 2006 and 2011 was performed. Analysis included patient demographics, surgical site occurrences, hernia recurrence, hospital readmission, and mortality. The search was limited to open repairs, specifically the RS, CST-M, CST, and ECST with mesh techniques. A total of 362 patients underwent repair with RS (66), CST-M (126), CST (117), or ECST (53). The groups were demographically similar. ECST was more frequently used for patients with a history of two or more recurrences ( P < 0.001). The RS method had the lowest rate of recurrence (9.1%) compared with CST and CST-M with 28 and 25 per cent recurrences, respectively ( P = 0.011). The RS recurrence rate was not significantly different than ECST (15%). There were no significant differences between groups for surgical site occurrences ( P = 0.305), hospital read-mission ( P = 0.288), or death ( P = 0.197). When components separation is necessary for complex ventral hernia repair, ECST is a viable option without added morbidity or mortality.
Esophageal Achalasia: Pathophysiology, Clinical Presentation, and Diagnostic Evaluation
Authors: Schlottmann Francisco , Neto Rafael M. L. , Herbella Fernando A. M. , Patti Marco G.
Published: June 2020

Esophageal achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter to relax in response to swallowing. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with resulting food stasis. Most patients experience severe dysphagia, and regurgitation can lead to aspiration and respiratory problems. Consequently, the quality of life of patients affected by achalasia is severely impacted. A thorough evaluation with upper endoscopy, barium swallow, and esophageal manometry is mandatory to establish the diagnosis and plan the optimal treatment. In selected patients, an ambulatory pH monitoring is recommended to distinguish between gastroesophageal reflux disease and achalasia.
POEM for Achalasia
Authors: Kroch Daniel A. , Grimm Ian S.
Published: June 2020

In 2008, a new treatment modality for esophageal achalasia was introduced—peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.
Redefining the Surgical Council of Resident Education (SCORE) Curriculum: A Comparison with the Operative Experiences of Graduated General Surgical Residents
Authors: Strosberg David S. , Quinn Kristen M. , Abdel-Misih Sherif R. , Harzman Alan E.
Published: June 2020

Our objective was to investigate the number and classify surgical operations performed by general surgery residents and compare these with the updated Surgical Council on Resident Education (SCORE) curriculum. We performed a retrospective review of logged surgical cases from general surgical residents who completed training at a single center from 2011 to 2015. The logged cases were correlated with the operations extracted from the SCORE curriculum. Hundred and fifty-one procedures were examined; there were 98 “core” and 53 “advanced” cases as determined by the SCORE. Twenty-eight residents graduated with an average of 1017 major cases. Each resident completed 66 (67%) core cases and 17 (32%) advanced cases an average of one or more times with 39 (40%) core cases and 6 (11%) advanced cases completed five or more times. Core procedures that are infrequently or not performed by residents should be identified in each program to focus on resident education.
Bacteriology and Comorbidities in Patients Requiring Surgical Management of Empyema
Authors: Pinnola Aaron , Kuo Yen-Hong , Sciarretta Jason D. , Mcintyre Alexander , Messier Robert , Davis John M.
Published: June 2020

Concern over the changing bacteriology of empyema has led to numerous attempts to characterize the most common locoregional bacterial isolates. The purpose of this study is to better characterize the bacteriology and demographics in patients with community-acquired pneumonia (CAP) and hospital-acquired pneumonia requiring surgery for empyema. All patients diagnosed with empyema preoperatively and had either a video-assisted thoracoscopic or open decortication surgery from January 2010 to September 2015 were reviewed. Forty-seven patients were identified with a mean age of 54.7 ± 16.8 years (X ± SD). Sixty per cent of patients had CAP. Anaerobes were the most common isolate at 21 per cent, followed by Streptococcus species and Staphylococcus aureus (50% Methicillin Resistant). Coagulase-negative Staphylococcus species were the next most frequent at 13 per cent. Hospital-acquired pneumonia patients had a higher incidence of S. aureus infections ( P = 0.047). Cancer history had higher rates of both fungal ( P = 0.004) and gram-negative infections ( P = 0.03). Older patients had increased incidence of gram-negative infections ( P = 0.05). The median length of stay for CAP patient who were intravenous drug abusers (n = 3) were 31 days (95% confidence interval (CI) [15, NA]), which was significantly longer than the others (median 12 days, 95% CI: [9, 18], P = 0.014). Streptococcus pneumoniae was not found in any of the isolates. Our data reveal that anaerobes and Staphylococcus species have replaced S. pneumoniae as the major regional pathogens in surgically treated empyema. In addition, anaerobic isolates were found in higher incidence in CAP than previously reported.
Outcome and Cost Analysis of Hand-Sewn and Stapled Anastomoses in the Reversal of Loop Ileostomy
Authors: Nemeth Zoltan H. , Bogdanovski Dorian A. , Hicks Addison S. , Paglinco Samantha R. , Sawhney Rohan , Pilip Stefanie A. , Stopper Patricia B. , Rolandelli Rolando H.
Published: June 2020

Diverting loop ileostomies are common procedures for protecting high-risk anastomoses. There is little consensus on the most ideal technique both in terms of cost efficiency and outcome. Data for this study were collected from 101 patients who underwent loop ileostomy reversal between 2009 and 2014 at Morristown Medical Center. Of the 101 patients included in the review, 57 received a hand-sewn anastomosis (HS-A) and 44 received a stapled anastomosis (S-A). Average total hospital charges for stapled anastomoses were significantly greater than that for hand-sewn anastomoses, as were total operating room supply costs. When the total cost of the operation itself was considered, S-A cases were still found to be significantly greater than HS-A cases. Hospital room charges, total lab charges, pathology charges, and EKG/ECG charges were all greater for S-A cases than HS-A cases. Overall costs were greater for S-As than hand-sewn anastomoses and because of a lack of difference in procedure length, stapler supply costs were not offset. Complication rates and length of stay were also similar between the techniques. We found S-A cases to be more costly and have a greater cost/hour than HS-A cases.
What Is Most Important to the Endoscopist for Therapeutic Plan? Morphology versus Pathology: A Nationwide Multicenter Retrospective Study in Korea
Authors: Baek Il Hyun , Kim Kyoung Oh , Choi Min Ho , Jung Sung Won , Jang Hyun Joo , Min Kyeong Won
Published: June 2020

Histologic discrepancy may sometimes occur between biopsy and endoscopic resection. We investigated the discrepancy rate between the biopsy and the resection lesion in the Korean population. From January 2010 to October 2016, 268 patients with gastric endoscopic mucosal resection/endoscopic submucosal dissection history from nationwide hospitals were enrolled retrospectively. We compared the histologic discrepancy rates from the biopsy and the resection. The mean age was 63.2 years. Gastric adenomas occurred most frequently in the antrum. The pathology of the resected specimens classified 25 lesions (9.3%) as gastritis/hyperplasia, 146 lesions (54.5%) as low-grade dysplasia, 76 lesions (28.4%) as high-grade dysplasia (HGD), and 21 lesions (7.8%) as adenocarcinoma. The discrepancy rate between biopsy and resection was 23.1 per cent. Among the 44 cases of gastritis/hyperplasia, two cases (4.5%) were diagnosed as HGD and 11 cases (25.0%) were diagnosed as cancer after resection. Among the 182 cases of low-grade dysplasia, 33 cases (18.1%) were diagnosed as HGD and nine cases (5.0%) were diagnosed as cancer after resection. Gastritis/hyperplasia, ulceration, and lesions in the lower body location were significant factors related to the discrepancies. Especially, discrepancy occurred most frequently in gastritis/hyperplasia lesions with ulcer in the lower body. There was considerable histologic discrepancy between biopsy and resection. Ulcerative-type tumor morphology and biopsy diagnosis of gastritis/hyperplasia are suggestive factors predictive of discrepancy between biopsy and resection in terms of malignancy. Therefore, although the results of biopsy are gastritis/ hyperplasia, suspicious tumorous lesions with ulcer should be indicative of active endoscopic resection for diagnosis and treatment.
Role of Laparoscopic Surgery in the Current Management of Mirizzi Syndrome
Authors: Gelbard Rondi , Khor Desmond , Inaba Kenji , Okoye Obi , Szczepanski Crystal , Matsushima Kazuhide , Strumwasser Aaron , Rhee Peter , Demetriades Demetrios
Published: June 2020

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis caused by extrinsic biliary compression by stones in the gallbladder infundibulum or cystic duct. The purpose of this study was to evaluate the outcomes associated with a laparoscopic approach to this disease process. This is a 10-year, retrospective study conducted at two academic medical centers with established acute care surgery practices. Patients with a diagnosis of MS confirmed intraoperatively were included. Eighty-eight patients with MS were identified with 55 (62.5%) being type 1. Twenty six (29.5%) patients, all type 1, underwent successful laparoscopic cholecystectomy. Of the 62 patients that underwent open cholecystectomy, 27.3 per cent had a laparoscopy converted to open procedure. There was no significant difference in overall complications (19.2 vs 29%) among those undergoing laparoscopic versus open cholecystectomy. Length of stay was lower in patients that had a laparoscopic approach ( P = 0.001). Laparoscopic cholecystectomy can safely be attempted in type 1 MS and seems to be associated with fewer overall complications and shorter length of stay compared with an open approach.
Factors Influencing Time to Decrease in Intraoperative Parathyroid Hormone (ioPTH) Levels in Patients Undergoing Focused Parathyroidectomy (FP)
Authors: Bhutiani Neal , Graffree Beunca , Martin Robert C.G. , Quillo Amy R.
Published: June 2020

The aim of this study was to evaluate potential factors affecting the time period in which a 50 per cent parathyroid hormone (PTH) drop is observed. Eight-seven patients undergoing focused parathyroidectomy between 2011 and 2015, whose PTH values dropped to within normal range, were grouped according to whether they required > or ≤15 minutes after gland excision to achieve a 50 per cent PTH. Groups were compared according to preoperative PTH, calcium, age, glomer-ular filtration rate, and adenoma weight. Lower preoperative and preincision PTH levels were associated with requiring >15 minutes to achieve a >50 per cent drop in ioPTH. Time to >50 per cent ioPTH drop did not affect cure rates at one year, though a >15 minutes requirement was associated with higher serum calcium levels (P = 0.015). Lower baseline PTH and preincision PTH levels are significantly associated with a >15 minutes postexcision time to achieve a >50 per cent drop in ioPTH. Future analyses are warranted to determine whether a longer postexcision time threshold before proceeding with four-gland exploration is warranted in patients with primary hyperparathyroidism and mildly elevated preoperative PTH.
Incidence of Surgical Site Infections after Thyroid and Parathyroid Surgery: No Role for Antimicrobial Prophylaxis
Authors: Moskalenko Marina , Asai Megumi , Beem Karen , Pezzi Todd A. , Brophy Cynthia L. , Noonan Kristin , Pezzi Christopher M.
Published: June 2020

To better define the value of antimicrobial prophylaxis (AMP) and antiseptic skin preparation (ASP) in thyroid and parathyroid surgery, we examined the rate of surgical site infections (SSIs) with and without AMP. Retrospective analysis was performed using the National Surgical Quality Improvement Program database at a single institution. Patients undergoing thyroid or parathyroid surgery with data entered into the National Surgical Quality Improvement Program database at our institution between November 2007 and June 2015 were studied, including patient demographics, wound classification, other risk factors for SSI, and wound outcome. Charts were retrospectively reviewed for AMP, ASP, and use of drains. Of the 534 patients who underwent thyroid (n = 358) or parathyroid (n = 176) surgery, 58 (10.9%) were diabetic, 54 (10.1%) used tobacco, and 14 (2.6%) were on steroids. Most wounds were classified as “clean” (99.6%). Betadine was used for ASP in 96 per cent. AMP was given to 141 patients (26%) using cefazolin, vancomycin, or clindamycin. The remaining 393 patients (74%) received no AMP. Zero infections occurred in the group who did not receive AMP. One (0.7%) superficial, nonpurulent SSI occurred in the group that received AMP which was not statistically significantly different (P = 0.319). The rates of SSI after thyroid and parathyroid surgery are extremely low, around two per 1000 cases, and do not decrease with AMP. Therefore, AMP is not necessary in thyroid and parathyroid surgery and should be avoided to reduce costs, adverse reactions, and antibiotic resistance.
The South Carolina Surgical Quality Collaborative: A New Effort to Improve Surgical Outcomes in South Carolina
Authors: Lockett Marka , Turley Chris , Gibbons Lorri , Stinson Shawn , Adams James L. , Cole David , Baliga Prabhakar K.
Published: June 2020

Regional surgical quality Collaboratives are improving surgical quality and cutting costs by building regional relationships that leverage information sharing to improve outcomes. The South Carolina Surgical Quality Collaborative (SCSQC) is a new regional surgical quality Collaborative focused on improving general surgery outcomes in South Carolina. It is a joint effort which brings together the skills and resources of Health Sciences South Carolina, the South Carolina Hospital Association, and the Blue Cross Blue Shield of SC Foundation to create a web-based data collection system to provide real-time outcomes data to participating surgeons, and establishing a supportive network for sharing best practices and promoting data driven quality improvement. Members of the SCSQC abstracted more than 8000 general surgery cases from eight participating hospitals in its first year. These facilities are spread across the state of South Carolina and range from large academic referral centers to small community hospitals. The resulting data should be representative of much of the surgical care provided in South Carolina. Monthly conference calls and quarterly face-to-face meetings occur with site Surgeon Leads, site Surgical Clinical Quality Reviewer, and Collaborative leaders. Each site is pursuing a quality improvement project addressing issues identified from analysis of their initial data. Early results on these efforts are encouraging. The SCSQC is a new regional surgical quality Collaborative, which leverages multiple state resources, builds on the successes of similar Collaboratives in Michigan and Tennessee, with the goal to improve the quality and value of general surgical care for South Carolinians.
The Impact of Mesh Reinforcement with Components Separation for Abdominal Wall Reconstruction
Authors: Razavi Seyed Amirhossein , Desai Karan A. , Hart Alexandra M. , Thompson Peter W. , Losken Albert
Published: June 2020

The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.
Wiser with Age? Increased Per-Surgeon Elderly Patient Volume is Associated with Lower Postinjury Complications
Authors: Warnack Elizabeth , Simon Joshua , Dang Quoc , Catino Joseph , Bukur Marko
Published: June 2020

We hypothesize that higher elderly patient volume per trauma surgeon is associated with fewer clinical complications. This is a retrospective cohort study which included elderly patients admitted to trauma surgery service within a five-year period, from 2009 to 2013, at two Level I trauma centers in Florida. Trauma surgeons were stratified into three groups depending on patient volume. Primary outcomes were postinjury complications and in-hospital mortality, and secondary outcomes were hospital length of stay (LOS), intensive care unit LOS, and ventilator days. A total of 2379 elderly patients were included in this study. Elderly patient volume per surgeon did not significantly differ based on years in practice after fellowship (P = 0.88). The higher volume group had lower incidence of complications (15% complication rate, P = 0.02), compared with the average and low-volume group (18.1 and 21%, respectively), and had significantly lower rates of acute respiratory failure (P = 0.04) and acute renal failure (P = 0.004). In-hospital mortality was not affected by volume. Hospital LOS was decreased in the higher volume group (mean LOS 7.4 days, P < 0.001). There appears to be a relationship between elderly patient volume and outcome, independent of surgeon years of experience.
Correlating Geographic Location with Incidence of Motor Vehicle–Induced Pedestrian Injury
Authors: Bhutiani Neal , Miller Keith R. , Benns Matthew V. , Nash Nicholas A. , Franklin Glen A. , Smith Jason W. , Harbrecht Brian G. , Bozeman Matthew C.
Published: June 2020

To date, no studies have examined the relationship between geographic and socioeconomic factors and the frequency of pedestrians sustaining traumatic injuries from a motor vehicle. The objective of this study was to analyze the impact of location on the frequency of pedestrian injury by motor vehicle. The University of Louisville Trauma Registry was queried for patients who had been struck by a motor vehicle from 2010 to 2015. Demographic and injury information as well as outcome measures were evaluated to identify those impacting risk of pedestrian versus motor vehicle accidents. Number of incidents was correlated with lower median household income. There was also a moderate correlation between the number of incidents and population density. Multivariable analysis demonstrated a significant association between increased median household income and distance from downtown Louisville and decreased risk of death following pedestrian versus motor vehicle accident. Incidence of pedestrian injury by motor vehicles is influenced by regional socioeconomic status. Efforts to decrease the frequency of these events should include further investigation into the mechanisms underpinning this relationship.
Are Lymph Node Characteristics on Axillary Ultrasound Associated with ≥3 Positive Lymph Nodes in Patients Managed by the American College of Surgeons Oncology Group Z0011 Trial Criteria?
Authors: Rooney Emma G. , Fleming Margaret M. , Patel Jay G. , Clifford Kelly , Kim Chaejin , Chen Zhengjia , Gillespie Theresa W. , Arciero Cletus A. , Subhedar Preeti D.
Published: June 2020

Patients often receive axillary ultrasound-biopsy (AUS-B) before clinical evaluation. One positive biopsy in the absence of palpable disease rarely indicates additional nodal involvement, but it eliminates patients from being managed by the American College of Surgeons Oncology Group Z0011 trial criteria. To determine which patients may benefit from AUS-B, we analyzed whether characteristics on AUS were associated with large-volume axillary disease and, thus, the need for axillary lymph node (LN) dissection. A retrospective review identified patients who met Z0011 criteria and underwent AUS. Clinicopathologic and ultrasound characteristics were compared between patients with ≤2 versus ≥3 positive LNs. Two hundred and seven patients with cT1-2N0 tumors underwent preoperative AUS and breast-conserving surgery. On multivariate analysis, three AUS combinations were associated with ≥3 positive LNs: cortical thickness (CT) > 4 mm + loss of fatty hilum + round shape (P = 0.0218), CT > 4 mm + loss of fatty hilum (P = 0.0211), and CT > 4 mm + round shape (P = 0.0155). Preoperative axillary LN biopsy in patients with a single abnormal LN characteristic on AUS may be unnecessary because a positive finding will eliminate management according to Z0011 criteria. Cortical thickness >4 mm combined with any other abnormal characteristic was associated with ≥3 positive LNs, supporting the performance of AUS-B in this population.