bluuebunny/crossref_metadata_2025 huggingface dataset:
Changing Times and the Treatment of Liver Injury
Authors: Lucas Charles E. , Ledgerwood Anna M.
Published: November 2022

We hypothesized that the frequency, diagnosis and treatment of liver injury have changed dramatically in the past 30 years. Patients with liver injuries treated in an urban level I trauma center were analyzed for three separate time periods, namely, 1969–1970, 1981–1982, and 1997–1998. The injuries were categorized by etiology; Abbreviated Injury Score severity, and type of treatment, including observation (Ob), laparotomy without treatment of liver injury (OR No Rx), suture repair (Sut), tractotomy with intraperipheral hemostasis (Tr), dearterialization (HAL), and resection (Re) (See Table, below). There were 249 patients in 1969–1970, 70, 79 in 1981–1982, and 116 in 1997–1998. Stab wounds and gunshot wounds decreased from 235 patients in 1969–1970 to 61 patients in 1997–1998. Blunt injuries increased from 14 patients in 1969–1970 to 55 patients in 1997–1998. Major injuries (Abbreviated Injury Score 4–5) fell from 104 to 25 to 20 during the decade. Laparotomy was done in all patients in 1969–1970 and 1981–1982, whereas most blunt injuries were observed in 1997–1998; only 9 of 65 blunt injuries in 1997–1998 required hemostasis.
Further Evaluation of Colostomy in Penetrating Colon Injury
Authors: Gonzalez Richard P. , Falimirski Mark E. , Holevar Michele R.
Published: November 2022

Our objective was to compare, in a randomized prospective format, complication rates associated with primary repair versus fecal diversion in penetrating colon injury. During a 72-month period, 181 patients with penetrating colon injuries were entered in a randomized prospective study at an urban Level I trauma center. After intraoperative identification of colon injuries, patients were randomized to a primary repair or a diversion group. Randomization was independent of previously identified risk factors, including severity of colon injury, presence of hypotension, blood loss, extent of fecal contamination, and time from injury to operation. Five patients initially entered in the study protocol were removed because they died in the immediate postoperative period (< 24 hours). One hundred seventy-six patients were studied, of which 89 were randomized to primary repair and 87 to diversion. The average age in the diversion group was 26.4 years and it was 28.0 years in the primary repair group ( P > 0.05). The average Penetrating Abdominal Trauma Index for the diversion group was 22.3, and it was 23.7 for the primary repair group ( P > 0.05). There were 18 (21%) septic related complications in the diversion group and 16 (18%) in the primary repair group ( P > .05). With respect to risk factors, complication rates were not higher in one study group versus the other. We conclude that, in the civilian population, all penetrating colon injuries should be managed with primary repair.
Human Endothelial Cell Cultures from Progenitor Cells Obtained by Leukapheresis
Authors: Hernandez Diego A. , Townsend Laurace E. , Uzieblo Maciej R. , Haan Mark E. , Callahan Rose E. , Bendick Phillip J. , Glover John L.
Published: November 2022

Although improved prosthetic graft patency with endothelial cell (EC) seeding has been shown in animal models, the clinical application of this technique requires a convenient source of ECs. We have evaluated EC cultures derived from the mononuclear cell (MNC) fraction obtained during large-volume leukapheresis and compared this with cultures grown from peripheral blood cells obtained by phlebotomy. Leukapheresis was performed in healthy adult volunteers (n = 7) using software designed to increase the percentage of MNCs harvested. Blood (40–293 mL) was drawn from a peripheral vein in healthy adult volunteers (n = 13), and the MNCs were obtained by differential centrifugation using a Lymphoprep gradient. Significantly more MNCs were obtained by leukapheresis than by phlebotomy. Each leukapheresis procedure yielded 12.5 to 23 mL, which contained 2.29 ± 0.35 x 109 MNCs, compared with 2.16 ± 0.50 x 108 MNCs, for each phlebotomy ( P < 0.001). EC colonies developed in significantly more cultures from leukapheresis-derived MNCs (6 of 7) than phlebotomy-derived MNCs (4 of 13; P = 0.008). Leukapheresis-derived cells developed EC morphology at 15.5 ± 2 days compared with 21 ± 3.4 days for cells obtained by phlebotomy ( P = not significant). EC were identified by positive factor VIII and vascular endothelial growth factor receptor immunostaining. Leukapheresis significantly increases the number of progenitor cells available for differentiation into EC compared with phlebotomy and avoids the need for any surgical procedure to harvest a peripheral vein as a direct source of ECs.
The Role of Hepatic Resection in the Management of Bile Duct Injuries following Laparoscopic Cholecystectomy
Authors: Lichtenstein Sonja , Moorman Donald W. , Malatesta Jeannie Q. , Martin Maureen F.
Published: November 2022

The creation of a specialized hepatobiliary surgery unit at our medical center has resulted in referral of 16 patients with bile duct complications following laparoscopic cholecystectomy over the last 18 months. No patient required conversion to open cholecystectomy. Although no injury was recognized at the time of surgery, 15 of 16 patients became symptomatic within the first 30 days. Two patients died from sepsis and multisystem organ failure after protracted hospital courses. Endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography determined diagnosis and level of injury. Six of seven patients with cystic duct leak underwent successful endoscopic stent placement and one patient sealed spontaneously after percutaneous drainage of a large biloma. Nine patients required surgery that included hepaticojejunostomy (five), T-tube insertion and drainage of abscess (two), or segmental hepatic resection (two). Timely recognition of bile duct complications following laparoscopic cholecystectomy is critical to a successful long-term outcome. Although the majority of cystic duct leaks can be managed with endoscopic stenting, patients with ductal injuries require hepaticojejunostomy. Segmental liver resection may serve an important role in the management of carefully selected patients with high intrahepatic injuries to avoid long-term transhepatic stenting and complications such as episodic cholangitis and late stricture formation.
Preoperative Chemoradiation and Coloanal J Pouch Reconstruction for Low Rectal Cancer
Authors: Chaudhry Vivek , Nittala Murali , Prasad Madhava L.
Published: November 2022

Our objective was to determine clinical outcomes of treatment of low rectal adenocarcinoma with neoadjuvant chemoradiation, rectal excision, and coloanal J pouch reconstruction. A retrospective review of 69 patients with stage B2 or higher lesions was performed. Preoperative chemoradiation was followed by low anterior resection and coloanal J pouch anastomosis, with end loop ileostomy. Data were analyzed using the SPSS computer software. There were 46 males and 23 females, with a median age of 63 years. Pathologic staging showed no tumor in the specimen, i.e.: stage 0,14 per cent; stage A, 14 per cent; stage B, 53 per cent; stage C, 18 per cent; and stage D, 1.4 per cent. Postoperative mortality was 2.8 per cent, and the pelvic leak rate was 4.3 per cent. After curative resection, 89 per cent patients are alive and 83 per cent are disease free with a mean follow-up of 50 months. The local recurrence rate is 7.2 per cent. Nodal status was the most important predictor of survival and disease-free survival. Most (96%) have fewer than two bowel movements a day and are satisfied with the functional results. We conclude that preoperative chemoradiation and coloanal J pouch reconstruction can achieve low recurrence rates and prolonged survival for most patients with low rectal cancer with an acceptable quality of life.
Do Angiogenesis and Growth Factor Expression Predict Prognosis of Esophageal Cancer?
Authors: Millikan Keith W. , Mall Julian W. , Myers Jonathan A. , Hollinger Edward F. , Doolas Alexander , Saclarides Theodore J.
Published: November 2022

A retrospective study of surgically resectable esophageal cancers was undertaken to determine the relationship between angiogenesis score and growth factor expression with tumor size, histology, degree of differentiation, depth of invasion, nodal disease, and the presence of Barrett's esophagus. The office and hospital charts of 27 patients who had esophageal resection for carcinoma between 1990 and 1995 at Rush-Presbyterian-St. Luke's Medical Center were reviewed. Data collection included patient demographics, survival, tumor size, histology, differentiation, depth of invasion, nodal metastases, and the presence of Barrett's esophagus. The pathology specimens were immunostained for von Willebrand factor (factor VIII-related antigen). Immunostaining was also performed for vascular endothelial growth factor and transforming growth factor at. Twenty normal esophageal specimens served as controls. Angiogenesis score was determined by counting vessels under conventional light microscopy at x200 magnification, and growth factor expression was graded on a scale of 1 to 4. Cancers had higher angiogenesis and growth factor expression than controls ( P = 0.01). Patient age, tumor size, histology, differentiation, depth of invasion, and Barrett's esophagus did not correlate with angiogenesis score or tumor growth factor expression. Lymph node status did correlate with both angiogenesis score and growth factor expression ( P ≤ 0.02). We conclude that high angiogenesis score and growth factor expression correlate with the presence of lymph node metastases. This may help select patients for preoperative radiation and chemotherapy or determine the extent of surgery performed for esophageal carcinoma.
Liver Resection for Colorectal Cancer: Liver Metastases in the Aged
Authors: Brand Marc I. , Saclarides Theodore J. , Dobson H. Drexel , Millikan Keith W.
Published: November 2022

The purpose of this study was to determine the morbidity and mortality in elderly patients undergoing liver resections for metastatic colon cancer and compare them with those of a control group of younger patients. The charts of all patients undergoing liver resection for colon cancer were retrospectively reviewed. Patients less than 70 years of age (Group A) were compared with patients 70 years of age or older (Group B). Between 1971 and 1995, 167 liver resections were performed for metastatic colorectal cancer. Of these, 41 patients were in Group A and 126 patients were in Group B. The mean age of Group A was 74.5 years, and that of Group B was 57 years. American Society of Anesthesiologists (ASA) classification was similar for both groups (Groups A and B were 75.6% and 81.1% ASA class II, respectively). Anatomic resections were performed in 49 per cent and wedge resections in 51 per cent of patients in Group A, and 68 and 32 per cent in Group B, respectively. Estimated blood loss was slightly less for Group A (1575 vs 1973 cm3), as was operative time (4.0 vs 4.7 hours). In-hospital mortality rate was 7.3 per cent for Group A and 2.4 per cent for Group B. The major morbidity rates were 29 and 17.5 per cent, respectively. Intensive care unit care was necessary in 73 per cent (mean length of stay 3.9 days) for Group A and 62.6 per cent (mean length of stay 2.0 days) for Group B. The average length of hospitalization was 13.1 days for Group A and 16.6 days for Group B. The recurrence rates were similar for the two groups [56% (Group A) vs 66% (Group B)], but mean survival was longer for younger patients (22.9 vs 33.5 months). We conclude that liver resection for colorectal cancer liver metastases in properly selected patients older than 70 years of age can be performed with acceptable morbidity and mortality rates. The long-term survival for older patients is less than that for younger patients, but is still a significant length of time. Therefore, we conclude that age alone is not a contraindication to liver resection for colorectal cancer metastases in patients older than 70.
Adjuvant Radiation after Modified Radical Mastectomy for Breast Cancer Fails to Prolong Survival
Authors: Geisler D.P. , Boyle M.J. , Malnar K.F. , Melichar R.M. , Mcgee J.M. , Nolen M.G. , Broughan T.A.
Published: November 2022

Recent literature has reported improved local disease control and overall survival in premenopausal node-positive (stage II, and HI) breast cancer patients undergoing modified radical mastectomy (MRM) using radiation therapy (RT) combined with chemotherapy. To assess the efficacy of postoperative RT in our own community, we analyzed all patients undergoing MRM for carcinoma utilizing an extensive database from the three major teaching hospitals in Tulsa, OK, between 1965 and 1993. A total of 5257 patients underwent MRM during this time period. One hundred thirty-seven patients were excluded for insufficient data or because they were found to be at stage IV, leaving a total study population of 5125. Overall survival (OS), overall mean survival (MS), disease-free survival (DFS), and locoregional DFS (LRDFS) were analyzed for all patients and were further analyzed according to stage, lymph node involvement, and menopausal status. Median follow-up was 103 months. Statistical analysis was performed using Kaplan-Meier and t-tests. The DFS at 10 years was 65 per cent in the RT group and 80 per cent in the patients who did not receive RT ( P = 0.00). No improved DFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. Similarly, the LRDFS at 10 years was 91 per cent in the RT group and 96 per cent in the patients who did not receive RT ( P = 0.00). No improved LRDFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. The overall MS was 97 months in the RT group and 104 months in the patients who did not receive RT ( P = 0.00). Comparisons of overall MS rates revealed apparent survival benefits from RT in the premenopausal node-negative group, postmenopausal one to four-positive-node group, and all stage I patients. This apparent survival advantage was not confirmed by Kaplan-Meier curves of OS. No other overall MS differences were detected according to stage, lymph node, or menopausal status. Using Kaplan-Meier survival curves, the OS in the RT group at 10 years was 46 per cent, and 63 per cent in the patients who did not receive RT ( P = 0.00). No improved OS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. These findings from a large breast cancer database failed to demonstrate any meaningful benefit from RT after MRM and serve to further question the efficacy of this treatment modality in postmastectomy breast cancer patients.
Suppression of the Invasive Capacity of Human Breast Cancer Cells by Inhibition of Urokinase Plasminogen Activator via Amiloride and B428
Authors: Evans Douglas M. , Sloan-Stakleff Kimberly
Published: November 2022

Inhibition of urokinase plasminogen activator (uPA) has been shown to suppress cancer cell invasion and metastasis in the laboratory setting by numerous investigators. Most studies have used murine cell lines implanted in syngeneic rodents or transfected human cell lines grown in immunocompromised laboratory hosts. In this study using Matrigel invasion chambers and two separate uPA inhibitors, amiloride and B428, the invasive capacity of unaltered human breast cancer cells was significantly suppressed. Cell proliferation was also suppressed to a lesser degree. These findings suggest that uPA inhibition may be a valid clinical approach to the control of the invasion and metastasis of human cancers.
How Well Do Third-Year Medical Students Learn Key Objectives in a Case-Based Surgical Lecture Series ?
Authors: Sheehan Maureen K. , Gabram Sheryl G.A. , Minks Kenneth D. , Fisher Susan G. , Aranha Gerard V. , Gamelli Richard L.
Published: November 2022

Faculty members were asked to list major and minor concepts of their case-based session presented during the 12-week 3rd-year surgical clerkship. After each session, students were queried to list the key concepts presented. Data were collected from two groups: one at the end of an academic year and a second at the beginning of the next academic year. Faculty members listed a median of 10 major and 15 minor concepts. The mean number of matched major concepts ranged from 0.2 to 4, and from 0.2 to 3.4 for minor concepts. In a comparative analysis, the end-of-the-year students listed a higher number of matched concepts for 17 of the 20 sessions than the beginning of the year students (8 sessions reached statistical significance, P < 0.05). The current case-based teaching method is not effective in emphasizing key concepts to students. Reformatting cases to better align with key concepts may be one solution to enhance a student's ability to grasp key concepts. Students at the end of the academic year outperformed those at the beginning of the year. This additional variable needs to be considered by faculty and incorporated into their teaching techniques.
Prognostic Variables in Male Breast Cancer
Authors: Clark John L. , Nguyen Phuong L. , Jaszcz Waclaw B. , Jatoi Aminah , Niehans Gloria A.
Published: November 2022

The prognostic role of ploidy status, S phase fraction, estrogen and progesterone receptor status, and the expression of p53 and erbB-2 protein in male breast carcinoma (MBC) remains controversial. The primary objective of this study was to determine which of the common prognostic factors for female breast cancer predict prognosis in MBC. A secondary objective was to assess the impact of comorbid illnesses on survival. A retrospective review of demographic data, surgical treatment, pathological staging, adjuvant treatment and follow-up was completed for 16 patients with MBC (1 intraductal and 15 invasive). Formalin-fixed, paraffin-embedded tissue was processed for ploidy, S phase fraction, and immunohistochemical detection of estrogen and progesterone receptors plus expression of p53 and erbB-2 protein. Six of 15 patients with infiltrating ductal carcinoma are currently alive without evidence of disease and a median survival of 61 months. Nine patients died after a median survival of 52 months, with 6 patients having no evidence of recurrent breast cancer. Two of 3 deaths secondary to advanced breast cancer occurred in patients who initially presented with T4 lesions and were staged IIIB. Two of 15 tumors were erbB-2 positive, whereas only 1 tested weakly positive for p53 protein. We observed that MBCs express erbB-2 and p53 proteins infrequently. Neither ploidy status, S phase fraction, nor erbB-2/ p53 status provided any apparent improvement in establishing prognosis beyond routine pathological staging. Advanced TNM stage was associated with diminished survival. The majority of MBCs express estrogen and progesterone receptors. Survivals in MBC were reduced in association with comorbid medical conditions.
Pathologic and Clinical Features Influencing Outcome of Thin Cutaneous Melanoma: Correlation with Newly Proposed Staging System
Authors: Finley J. William , Gibbs John F. , Rodriguez Luz M. , Letourneau Richard , Driscoll Deborah , Kraybill William
Published: November 2022

The incidence of malignant melanoma is increasing. Because of increased awareness, early recognition of malignant melanoma has become more common. In 1997, a new staging system for cutaneous melanoma was proposed, with reclassification of thin melanoma < 1 mm, with and without ulceration. This report evaluates the pathologic and clinical features of thin melanomas influencing recurrence and survival from a tertiary cancer center in an attempt to correlate findings with the proposed staging system. A review of the Roswell Park Cancer Institute tumor registry identified 352 patients with thin cutaneous melanomas (< 1.0 mm) seen during an 18-year period ending August 30, 1998. Overall survival was 93 and 87 per cent at 5 and 10 years, respectively. Disease-free survival was 94 and 93 per cent at 5 and 10 years, respectively. Local recurrence occurred in 3 per cent of patients, regional recurrence in 3 per cent, and metastatic disease in 3 per cent, for an overall recurrence of 7 per cent, with a median follow-up of 118 months. Only the presence of ulceration was a significant prognostic factor for recurrence by both univariate and multivariate analysis. Failure rates (any recurrence) by Clark levels I, II, and III/IV were 3, 5, and 10 per cent, respectively ( P = 0.14). Failure rates by tumor thickness (mm), for 0.0–0.24, 0.25–0.49, 0.50–0.74, and 0.75–0.99 were 3, 4, 7, and 10 per cent, respectively ( P = 0.49). Ten-year disease-free survival for ulceration versus no ulceration was 40 and 94 per cent, respectively ( P < 0.0001). We conclude that thin cutaneous melanoma carries an excellent prognosis with appropriate treatment. Our findings support inclusion of ulceration in a new staging system. Lesions 0.76 to 0.99 mm and Clark level III and IV may warrant close observation as a separate subgroup.
The Effect of Clinical Pathway Implementation on Total Hospital Costs for Thyroidectomy and Parathyroidectomy Patients
Authors: Markey Donna W. , Mcgowan Jim , Hanks John B.
Published: November 2022

Clinical pathways have long been used to guide the delivery of patient care in varied practice settings. There is little information in the literature to document the effectiveness of pathway implementation in general surgical populations. This study reports the effect of clinical pathway implementation in two general surgical patient groups, thyroidectomy and parathyroidectomy. Clinical pathways were implemented to serve patients undergoing thyroidectomy and parathyroidectomy surgery. The effects of both clinical pathways on total hospital costs, length of hospitalization, variances, and outcomes were collected and evaluated from July 1998 through July 1999. These data were compared to data from the previous year. The average length of stay for parathyroidectomy patients decreased from 2.4 to 1.5 days ( P = 0.26) for pathway patients as compared to prepathway patients. The average cost per case decreased from $5071 to $4291 ( P = 0.50) for parathyroidectomy pathway versus prepathway patients. The average length of stay decrease for thyroidectomy patients was 1.4 to 1.2 ( P = 0.16) for the pathway to prepathway comparison. The average cost per case decrease was minor at $4117 to $4111. Pharmacy costs and laboratory utilization were effectively reduced. Perioperative costs rose dramatically during this period, operating room/central sterile supply cost per case rose 12 per cent, anesthesia supply cost per case rose 15 per cent, and surgical pathology costs increased 110 per cent overall for both patient groups. Clinical pathway implementation has allowed us to reduce or maintain total hospital costs in the face of rising perioperative costs. We conclude that implementation of these clinical pathways has allowed us to improve consistency with which we deliver care while maintaining the quality of patient outcomes and reducing the costs of care and length of hospital stay.
Ileoanal Pouch versus Ileostomy: Is There a Difference in Quality of Life?
Authors: Seidel Scott A. , Newman Martin , Sharp Kenneth W.
Published: November 2022

Ileoanal pouch (IAP) construction is arguably the procedure of choice to follow proctocolectomy for ulcerative colitis (UC) or familial adenomatous polyposis (FAP). Patients with UC or FAP at our institution choose their operation after counseling with the surgeon, with an enterostomal therapist, and with patients who have undergone IAP and proctocolectomy with ileostomy (IL). We studied these patients who chose IAP and IL, to determine differences in outcome and quality of life (QOL) between those two groups. We assessed outcomes by evaluating clinic and hospital records and surveyed patients' QOL via a standardized questionnaire. During a retrospective 10-year study period, 86 patients underwent evaluation for IAP construction for UC (64) and FAP (22). Fifty-five patients underwent IAP construction, and 31 underwent IL. There were no operative deaths. Thirty-four patients sustained 69 early and late complications (40%). The IAP group experienced a higher complication rate, 53 per cent, compared with the IL group, 16 per cent. Forty-five patients (56%) have completed questionnaires. Eighty-seven per cent of IAP patients and 93 per cent of IL patients responded that their overall QOL is “always” better since their operation ( P = not significant). Both groups reported very favorable responses to questions regarding work, social life, family life, sleep, and relationships without statistically significant differences between the two groups. Despite a high complication rate, IAP is an excellent operation for many patients with UC or FAP, but patients who choose IL after preoperative counseling can be expected to have similar improvement in quality of life.
Appendicitis: Why So Complicated? Analysis of 5755 Consecutive Appendectomies
Authors: Pittman-Waller Virginia A. , Myers John G. , Stewart Ronald M. , Dent Daniel L. , Page Carey P. , Gray Gina A. , Pruitt Basil A. , Root Harlan D.
Published: November 2022

A perceived high rate of complicated (gangrenous or perforated) appendicitis, despite advances in laboratory and radiographic diagnostic modalities, prompted a review of our experience with appendicitis followed by a prospective analysis that examined the time course from presentation to definitive treatment in 218 consecutive patients. In 5755 appendectomies, our overall rate of complicated appendicitis was 32 per cent; higher in males, in the young, and in the elderly; and relatively stable over each year reviewed. Prospectively, we determined that of the various time intervals, the time from the onset of symptoms to first seeking medical attention is the only significant predictor of complicated appendicitis (39.8 vs 16.5 hours for acute appendicitis). On the other hand, the time from surgical evaluation to operative intervention was significantly shorter for complicated appendicitis (3.8 vs 4.7 hours for acute appendicitis). The high rate of complicated appendicitis with its subsequent sequelae of increased morbidity and resource expenditure is primarily the direct result of patient delay in seeking medical attention and not the result of diagnostic dilemma or surgical delay. Public education, specifically targeting those groups at risk, may provide a substantial and significant solution to the complicated appendix.
Appendicitis Due to Bird Shot Ingestion: A Case Study
Authors: Larsen Angie R. , Blanton Robert H.
Published: November 2022

Appendicitis due to foreign bodies is rare. Foreign bodies leading to appendicitis or perforation are usually sharp, pointed objects. Lead shot can become lodged in the appendix. Few prior cases have shown a causal relationship between the presence of pellets in the appendix and acute appendicitis. We present the case of a 9-year-old white boy who presented to the emergency room with a 36-hour history of right lower quadrant pain over McBurney's point accompanied by anorexia. The patient's history was significant for consumption of pheasant meat 4 days before onset of symptoms. The pheasant had been shot with a shotgun. X-ray of the child's abdomen-revealed a metallic foreign body in the right lower quadrant. Appendectomy was performed. Bird shot was found obstructing the lumen of the grossly inflamed appendix. Pathology was consistent with acute appendicitis. This case is presented as an interesting consequence of bird shot ingestion.
Gastric Adenocarcinoma of Meckel's Diverticulum as a Cause of Colonic Obstruction
Authors: Lin Peter H. , Koffron Alan J. , Heilizer Timothy J. , Theodoropoulus Philip , Pasikhov Demetri , Lujan Henry J.
Published: November 2022

A 45-year-old-female patient with no prior surgical history presented with bowel obstruction. At laparotomy, a bulky tumor arising from the ileum, which completely obstructed the sigmoid colon, was found. A left hemicolectomy followed by a transverse colostomy and a Hartman's pouch were performed. Pathological examination of the specimen revealed gastric adenocarcinoma arising from a Meckel's diverticulum in the ileum. Malignant transformation from a Meckel's diverticulum is an uncommon occurrence. This case illustrates that successful management of a symptomatic Meckel's diverticulum, even with malignant transformation, can be achieved by surgical resection.
Secondary Causes of Intestinal Obstruction: Rigorous Preoperative Evaluation is Required
Authors: Jenkins Joseph T. , Taylor Andrew J. , Behrns Kevin E.
Published: November 2022

The clinical presentation, management and outcome of patients with small intestinal and large bowel obstruction unrelated to adhesive or primary colonic neoplastic disease is not well described. The aim of this study was to determine the clinical presentation, evaluation, operative management, and outcome in patients with secondary causes of intestinal obstruction. The medical records of 200 patients who underwent an operation for intestinal obstruction from January 1995 through December 1997 were reviewed. Seventy-three patients (37%) had secondary causes of intestinal obstruction, and these records were reviewed in detail. The cohort included 37 men and 36 women with a mean age of 52 ± 2 years. The etiology of intestinal obstruction was metastatic neoplastic obstruction (19%), colonic volvulus (18%), Crohn's disease (14%), herniae (11%), diverticular disease (7%), and miscellaneous causes (31%). Six patients (8%) had intestinal motor disorders and a misdiagnosis of intestinal obstruction. The clinical presentation of patients with secondary causes of obstruction was similar to typical patients with adhesive small bowel obstruction. Preoperative evaluation included frequent use of CT (42%), but intestinal contrast studies were used in 13 (18%) patients only. Two-thirds of the patients required an intestinal resection, and 50 per cent of the patients with a misdiagnosis had a nontherapeutic celiotomy. Operative mortality and morbidity were 3 per cent and 48 per cent, respectively, and 15 per cent of patients required reoperation. Suspected intestinal obstruction from secondary causes requires rigorous preoperative evaluation with liberal use of intestinal contrast examinations to avoid misdiagnosis, operative complications, and reoperations.
Surgical Repair of Incisional Ventral Hernias: Tension-Free Technique Using Prosthetic Materials (Expanded Polytetrafluoroethylene Gore-Tex Dual Mesh)
Authors: Chrysos Emmanuel , Athanasakis Elias , Saridaki Zenia , Kafetzakis Alexandros , Dimitriadou Dimitra , Koutsoumpas Vasilios , Chalkiadakis George , Xynos Evangelos , Zoras Odysseas
Published: November 2022

Repairing an incisional ventral hernia is a major challenge for a surgeon. The high recurrence rates observed during hernia repair by tissue approximation led to development of tension-free procedures by using prosthetic materials. The purpose of this study is to report the results of a tension-free repair technique using expanded polytetrafluoroethylene Gore-Tex Dual Mesh (Gore-Tex Soft Tissue Patch, W.L. Gore and Associates Inc, Flagstaff, AZ) in patients with primary or recurrent incisional ventral hernias. Over 3 years, 52 patients with incisional hernias have undergone this procedure in our clinic. Fourteen of them had recurrent hernias which had been primarily repaired by Mayo hernioplasty. Six of our patients had irreducible hernias preoperatively. Twenty-five patients had hernias on midline incisions, and the rest of them had hernias on transverse abdominal incisions. The median patient age was 65 years, and all were operated on under general anesthesia. The majority of the patients had 4 to 6 days of hospitalization. A subcutaneous seroma developed in eight patients. They all were treated by multiple paracentesis. Four of our patients experienced wound infection and were treated by mesh removal. None of the patients presented with cardiovascular or pulmonary complications. During the follow-up period, no other hernia recurrence, except the cases with mesh removal, has been noticed. The tension-free incisional hernia repair using expanded polytetrafluoroethylene mesh is, to our experience, a safe and easy procedure with no major morbidity or recurrence.
Tuberculous Enteritis: A Case Report
Authors: Lane Joshua E. , Barron Timothy D. , Solis Maurice M. , Tench Daniel W. , Stephens Jeffrey L.
Published: November 2022

Tuberculous enteritis is an unusual diagnosis in the United States. Because this entity is rare and the symptoms are not specific, the physician must have a high index of suspicion. We report the case of a young man with tuberculous involvement of the gastrointestinal tract who required surgical intervention for small bowel obstruction.
Fatal Airway Compromise Due to Retropharyngeal Hematoma after Airbag Deployment
Authors: Tenofsky Patty L. , Porter Scott W. , Shaw John W.
Published: November 2022

In trauma patients it is possible for a hematoma to form in the potential space between the pharynx and cervical spine (the retropharyngeal space). Fewer than 30 cases of actual airway obstruction secondary to retropharyngeal hematomas have been reported. We present an unusual case of an elderly woman who was involved in a minor motor vehicle collision which deployed her airbag. She died as a result of anoxic injury to the brain. Autopsy results demonstrated transverse fractures through the bodies of C5 and C7 with associated significant retropharyngeal and mediastinal hematoma. Airbags have been shown to significantly decrease the mortality rate in frontal collisions; however, the potential for hyperextension injuries from airbag deployment exists, especially if the occupant is unrestrained, small, or sitting too close to the airbag. When this woman's airbag deployed, it most likely caused her vertebral fractures, hematoma, subsequent airway compromise, and anoxic brain injury. Whatever the mechanism of trauma, one must be cognizant of the potential risk for retropharyngeal hematoma and airway compromise when a patient presents with injury to the cervical spine.
Aneurysm of the Gastroduodenal Artery: An Unusual Cause of Obstructive Jaundice
Authors: Konstantakos Anastasios K. , Coogan Sheila M. , Husni Elias A. , Raaf John H.
Published: November 2022

Splanchnic artery aneurysms are among the most infrequent aneurysms that affect the arterial circulation. Aneurysms of the gastroduodenal artery are the rarest splanchnic artery aneurysms, comprising fewer than 10 per cent of all such lesions. The most typical presentations include abdominal pain and acute gastrointestinal bleeding. However, the diagnosis is often missed preoperatively. We report the successful surgical management of a patient with a gastroduodenal artery aneurysm who presented with isolated obstructive jaundice and review the literature on this unusual finding.
Brigadier General Theodore C. Lister, M.D.: Father of American Aviation Medicine
Authors: Barrios Joey , O'Leary J. Patrick
Published: November 2022

Aviation medicine came into existence as a recognized entity when certain standards were established during and shortly after World War I.1 During this time, accident rates were high.2 In fact, a larger number of pilots were dying in accidents than in combat. Figures from Great Britain's casualty list at the close of the first year of World War I indicated that for every 100 aviators killed, 60 died as a result of some individual physical defect, 30 from some form of recklessness or careless behavior, 8 as a result of some mechanical defect in the airplane, and only 2 at the hands of the enemy.3 Aviators were found to be in poor physical condition. Because there were no established regulations with regard to workloads, aviators were frequently found to have been flying to a point beyond exhaustion. Because of workload, chronic fatigue, and emotional stress, aviators were constantly called upon to perform superhuman feats when not in peak physical condition. Errors in judgement were common. The majority of pilots lost weight as a somatic sign of stress. This was recognized by Theodore Lister who had recently been appointed as the Chief Surgeon, Aviation Section of the U.S. Army. Such problems were not diagnosed by medical officers because they were not trained to recognize them.

Theodore Charles Lister was the son of Captain William J. and Martha Doughty Lister. He was an Army “brat” who entered the world on July 10, 1875. His childhood was spent in various posts around the country. At the age of 7, Lister contracted yellow fever while living in Fort Brown, TX. The boy was treated by William Gorgas, a young post surgeon. Gorgas was credited with the young boy's recovery. Later, Gorgas was to marry Lister's aunt making Lister his nephew by marriage. Having survived the yellow fever infection, young Lister had a lifelong immunity to the disease.
Pancreaticoduodenectomy for Lymphoepithelial Cyst of the Pancreas
Authors: Worrall Neil K. , Drebin Jeffrey A.
Published: November 2022

Lymphoepithelial tumors of the pancreas are rare cystic tumors characterized by the presence of a keratinizing squamous epithelium and a dense lymphoid infiltrate on histologic examination. This case report describes the first lymphoepithelial tumor to be resected from the pancreatic head by pancreaticoduodenectomy. This case is also the first in which the cyst was found to be secondarily infected. The radiologic and clinicopathologic features of these unusual tumors are discussed.
Stump Appendicitis
Authors: Mangi Abeel A. , Berger David L.
Published: November 2022

There has been a recent increase in interest in stump appendicitis with the rapid development of laparoscopic appendectomy. The objective of this study is to determine the frequency, management, and prevention of stump appendicitis in a retrospective review of 2185 cases of appendectomy and right colectomy at the Massachusetts General Hospital from 1960 to 1998. Three patients with stump appendicitis were identified. Patients presented with epigastric or periumbilical pain that radiated to the right lower quadrant. All had focal abdominal signs and a mild to moderate leukocytosis, and all underwent right colectomy. Pathology noted appendiceal stumps 5 mm deep. Two additional patients with chronic abdominal pain had cecal filling defects on barium enema. Endoscopically, these appendiceal stumps were 7 mm deep with impacted fecaliths and pathologic changes consistent with early inflammation. The stumps were resected by snare electrocautery. Stump appendicitis is a very rare entity. Its incidence may be minimized with accurate visualization of the appendiceal base and creation of an appendiceal stump less than 3 mm in depth. There is no correlation between simple ligation or inversion of the stump and stump appendicitis. There should not be a sudden increase in the incidence of this entity if laparoscopic appendectomy is performed properly.
Mammographic Considerations for Patients Undergoing Ancillary Surgical Procedures in the Breast: A Need for Pre- and Postoperative Mammograms
Authors: Heller Barbara , Stomper Paul C.
Published: November 2022

Mammographic evaluation of the pre- and postoperative breast has been primarily emphasized for patients undergoing diagnostic breast biopsies and breast-conserving surgery. There is limited literature addressing ancillary surgical procedures involving breast tissue that may complicate mammographic evaluation of the breasts during breast cancer screening. We present mammographic diagnostic dilemmas after ancillary surgical procedures in the breast. The placement and removal of devices, such as central venous access ports and pacemakers, may result in scarring that may appear suspicious for malignancy on mammography. In addition, the placement of devices can obscure lesions that are being followed mammographically. These cases illustrate the need for the application of a basic principle of breast surgery, that of pre- and postoperative mammography, to ancillary surgery of the breast to allow optimal mammographic evaluation of women who are breast screening candidates.
The Antiphospholipid Syndrome in a Teenager with Miscarriages, Thromboses, and Diabetes Mellitus
Authors: Best Irwin M. , Anyadike Njideka C. , Bumpers Harvey L.
Published: November 2022

The antiphospholipid syndrome has been associated with many clinical conditions since its description by GRV Hughes in 1983. The linkage to Type 1 diabetes mellitus has not been established. There have been no reports of deep venous thrombosis in association with antiphospholipid syndrome and diabetes mellitus. We present the case of an African-American teenager with multiple miscarriages, diabetic ketoacidosis, deep venous thromboses, and elevated immunoglobulin M and G anticardiolipin antibodies. We urge that clinicians consider testing for antiphospholipid antibodies when diabetic patients present with multiple miscarriages or deep venous thrombosis.
Postoperative Suppressive Therapy for Thyroid Adenomas
Authors: Krouse Robert S. , Mccarty Todd , Weiss Lawrence M. , Wagman Lawrence D.
Published: November 2022

Thyroid adenoma is a common disease. If partial thyroidectomy is performed, postoperative suppression therapy is often given to avoid nodule development in the remaining thyroid. It is unclear whether this treatment is warranted. Patients who underwent a partial thyroidectomy with a histologic diagnosis of follicular thyroid adenoma from January 1985 until February 1998 were studied retrospectively. Patients were analyzed on the basis of postoperative therapy, new thyroid nodule growth, and costs. Seventy-six patients were identified with a recurrence rate of 4 per cent (3/76). Sixty-one per cent (46/76) were treated with postoperative thyroid suppression therapy, and no difference in new nodule development was noted with at least 6 months of follow-up ( P = 0.274). No patients required reoperation. A large cost saving was shown for patients who were not treated with levothyroxine. We conclude that postoperative thyroid suppression may not be routinely indicated. A prospective, randomized study would be necessary to answer this question conclusively.
Transient Horner's Syndrome in a Trauma Patient with Thoracic Epidural Analgesia: A Case Report
Authors: Menendez Carolyn , Macmillan David T. , Britt L.D.
Published: November 2022

Horner's syndrome, which classically presents as ipsilateral ptosis, meiosis, and facial anhydrosis, may present as a consequence of thoracic epidural analgesia. Pain that limits the patient's ability to maintain adequate pulmonary mechanics may optimally be treated with a thoracic epidural. The importance of recognition of a Horner's syndrome in such a patient is critical in preventing unnecessary anxiety for the patient and potentially embarking on an unnecessary diagnostic workup. The following is a case presentation of a patient who sustained multiple rib fractures in an automobile accident. The patient presented with a Horner's syndrome after a thoracic epidural infusion had begun. This article highlights the importance of early recognition of this benign, transient syndrome and discusses the pathways and potential mechanism of this process.
The Use of the Valtrac Ring in the Upper and Lower Gastrointestinal Tract, for Single, Double, and Triple Anastomoses: A Report of 50 Cases
Authors: Cossu Maria Laura , Coppola Massimiliano , Fais Enrico , Ruggiu Matteo , Spartà Claudio , Profili Stefano , Bifulco Vincenzo , Meloni Giovanni B. , Noya Giuseppe
Published: November 2022

The Valtrac biofragmentable anastomotic ring (V-BAR) technique has been widely used in clinical practice, particularly in anastomoses of the colon. The success of this method encouraged some surgeons to use it also in anastomosis of the small intestine. We are convinced that the method can be used successfully also in anastomosis of the small intestine and the upper gastrointestinal tract, particularly in cases of technically difficult and high-risk anastomoses. Between 1995 and 1998, we used the V-BAR in 35 patients, performing a total of 50 anastomoses. In 13 patients a double anastomosis was created in the same operation, and in one patient a triple anastomosis was created. In all we performed one end-to-end esophagojejunostomy, one gastrojejunostomy, six gastroileostomies, two duodenojejunal anastomoses, 13 end-to-end duodenoileostomies, one jejuno-jejunal anastomosis, 18 end-to-side ileoileal anastomoses, one ileocolic anastomosis, and seven colocolic anastomoses. Follow-up at between 2 and 36 months showed good overall results with regard to resumption of intestinal transit and canalization, even in those cases in which a double and triple suture was performed using the Valtrac ring. In our experience, the V-BAR can be used in upper gastrointestinal surgery with excellent results. Compared with manual sutures, the ring allows better and faster resumption of transit and canalization.
Concomitant Renal Revascularization with Aortic Surgery: Are the Risks of Combined Procedures Justified?
Authors: Taylor Spence M. , Langan Eugene M. , Snyder Bruce A. , Cull David L. , Sullivan Timothy M.
Published: November 2022

Indications for concomitant renal revascularization during aortic surgery are not well established. Higher mortality and poorer results are often cited. To examine this, all combined aortic and renal revascularization procedures from August 1992 until May 1998 were reviewed. Of 2003 major arterial reconstructions performed on the Vascular Teaching Service, 45 patients (2%) underwent renal revascularization. Of these 31 patients (69%) had combined aortic and renal procedures. Aortic pathology in these 31 patients (54% male, 94% white, median age 64 years) included arterial occlusive disease (n = 21; 47%), abdominal aortic aneurysm (n = 6; 13%), and thoracoabdominal aortic aneurysm (n = 4; 9%). In all 31 cases the patient presented because of the aortic pathology. Indications for concomitant renal revascularization included renovascular hypertension (n = 21; 68%) and preservation of renal function (n = 10; 32%). Renal revascularization procedures included transaortic endarterectomy (n = 23; 74%), renal bypass (n = 7; 23%), and both bypass and endarterectomy (n = 1; 3%). Seven (22%) complications and two (6%) deaths (both patients operated on for renal salvage) occurred perioperatively. Complications included wound infection (n = 2; 6%), postoperative bleeding (n = 1; 3%), respiratory failure (n = 1; 3%), deep venous thrombosis (n = 1; 3%), cerebrovascular accident (n = 1; 3%), and pseudomembranous enterocolitis (n = 1; 3%). All patients either were cured of their hypertension (n = 5; 24%) or were improved (n = 16; 76%) at 3 months. No patient to date operated on for renal salvage progressed to chronic hemodialysis, but mortality was higher after renal revascularization for renal salvage versus hypertension (20% vs. 0; P = 0.034). There was no significant difference in mortality between the combined aortic/renal procedures versus aortic procedures alone. Despite adding complexity, renal revascularization in patients undergoing aortic surgery appears relatively safe and effective. These data favor an aggressive approach toward renal revascularization in selected patients needing aortic surgery.