bluuebunny/crossref_metadata_2025 huggingface dataset:
Critical Role of c-Met and Ki67 in Progress of Biliary Carcinoma
Authors: Sanada Yuichi , Osada Shinji , Tokuyama Yasuharu , Tanaka Yoshihiro , Takahashi Takao , Yamaguchi Kazuya , Yoshida Kazuhiro
Published: June 2020

The purpose of this study was to evaluate the pattern of expression of c-Met and Ki67 in several components of biliary carcinoma. Fourteen surgically resected samples, including five intrahepatic cholangiocarcinomas, five gallbladder carcinomas, and four extrahepatic bile duct carcinomas, were subjected to immunohistochemistry with primary antibodies. In all 13 cases, intraductal neoplastic components showed diffuse staining for c-Met localized in the cell membrane, whereas 10 of the 14 cases lacked expression of c-Met in the corresponding invasive components. In four cases, invasive components composed of undifferentiated carcinoma (n = 2), signet-ring cell carcinoma (n = 1), and squamous cell carcinoma (n = 1) showed nuclear or perinuclear staining for c-Met. Conversely, 11 of the 13 cases did not express Ki67 in intraductal neoplastic components, whereas corresponding invasive components showed diffuse nuclear staining in all 14 cases. A comparison of the patterns of expression between c-Met and Ki67 at the boundary between intraductal and invasive components clearly demonstrated the complementary expression of c-Met and Ki67. Our results suggested that c-Met is involved in early events of carcinogenesis and Ki67 is involved in the formation of invasive carcinoma. However, exceptional cases were also observed, which might be associated with specificity for histologic subtypes and malignant potential.
Surgical Management of Abdominal Manifestations of Type 1 Neurofibromatosis: Experience of a Single Center
Authors: Cavallaro Giuseppe , Basile Ursula , Polistena Andrea , Giustini Sandra , Arena Rossella , Scorsi Alessandro , Zinnamosca Laura , Letizia Claudio , Calvieri Stefano , De Toma Giorgio
Published: June 2020

Neurofibromatosis type 1 (NF1) is a genetic disease characterized by neoplastic and nonneoplastic disorders involving tissues of neuroectodermal and mesenchymal origin. The mainly involved districts are skin, the central nervous system, and eye and there is a wide range of severity of clinical presentations. Abdominal manifestations of NF1 include five kinds of tumors: neurogenic tumors (neurofibromas, malignant peripheral nerve sheath tumors [MPNSTs], and ganglioneuromas); neuroendocrine tumors (pheochromocytomas and carcinoids); nonneurogenic gastrointestinal stromal tumors (GISTs); embryonal tumors; and miscellaneous. The present experience depends on the participation in the National Project for Diagnosis and Treatment of Rare Diseases. In the group of patients with a diagnosis of von Recklinghausen disease, 10 patients underwent surgical treatment for gastrointestinal and retroperitoneal tumors associated with NF1. Three patients underwent adrenalectomy for pheochromocytoma (in one case associated with jejunal wall neurofibroma); two patients were found to be affected by MPNST (recurrent and unresectable in one case). One patient was affected by giant gastric GIST and jejunal neurofibroma; two patients were affected by extraperitoneal neurofibroma (pararenal and pararectal position); one patient was affected by giant colic neurofibroma and one patient was affected by retroperitoneal bilateral plexiform neurofibromas. Early diagnosis of these abdominal manifestations is very important because of the risk of malignancy, organic complications (such as pheochromocytoma), or hemorrhagic–obstructive complications such as in case of tumors of the gastrointestinal tract (GISTs and neurofibromas). The importance of an annual clinical evaluation on the part of a multidisciplinary pool of clinicians in highly specialized centers allows early detection of complications and of neoplastic transformation. Genetic screening allows preclinical diagnosis with a sensibility of 95 per cent. Further studies are necessary to detect predictive factors of malignant tumor development of severe clinical conditions.
Risk Factors and Clinicopathological Study of Prognostic Factors in the Peritoneal Mesothelioma
Authors: Tudor Edward C.G. , Chua Terence C. , Liauw Winston , Morris David L.
Published: June 2020

This study evaluates the clinical and treatment related prognostic indicators for survival of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma. We did an observational study of the risk factors and clinicopathological factors of 20 patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma at the St George Hospital, Sydney. Survival analysis was performed using the Kaplan-Meier method and prognostic factors were correlated with survival using the Log Rank test. There were six females. The mean age was 55 years. The overall median survival was 30 (0.5-87) months with 1- and 3-year survival of 78 per cent and 46 per cent, respectively. The overall median disease-free survival was 8 months. Factors influencing a longer disease-free survival included age ≥ 55 ( P = 0.006), not smoking ( P = 0.04), female ( P = 0.03), and epithelioid tumors ( P = 0.002). Overall survival was influenced by not consuming alcohol ( P = 0.003), complete cytoreduction ( P = 0.02), and epithelioid tumors ( P = 0.01). Risk factors identified to be prognostic for survival include the female gender, not smoking, not consuming alcohol, and an epithelioid tumor type. Treatment factor associated with an improved survival was a complete cytoreduction.
Surgical Treatment of Intrahepatic Cholangiocarcinoma—A Single Center Experience
Authors: Lanthaler Monika , Biebl Matthias , Strasser Stefan , Weissenbacher Annemarie , Falkeis Christine , Margreiter Raimund , Nehoda Hermann
Published: June 2020

This study aimed to evaluate outcome after liver resection for intrahepatic cholangiocarcinoma (ICC). In a 72-month period a total of 25 patients operated on for ICC were followed-up with postoperatively. Eleven right hemihepatectomies (8 extended), seven left hemihepatectomies (3 extended), one segmental resection, two bisegmentectomies (II + III), and four nonanatomical resections were performed. Median observation period was 2.7 (range: 0.2-6.9) years. Analysis focused on age, gender, tumor-size, operating time, histologic resection margin, Tumor-Node-Metastasis-stage, reoperations, postoperative complications, tumor recurrence, survival rate and a putative relation between p53 accumulation, ki67 index, MUC1 positivity, and prognosis. Mean tumor size was 6.49 ± 3.93 cm. Eighteen patients (72%) underwent lymph node dissection. Major postoperative complications occurred in 10 patients. Seventeen patients (68%) showed tumor recurrence. Mean time to tumor recurrence was 6.7 (5.7-15.4) months. We found no correlation between p53 accumulation/ki67 index counts/Mucin 1 cell surface associated antibody (MUC1) positivity and ICC prognosis. A total of 13 patients died (52%) including one early and 12 late deaths. Mean time from surgery to death was 14.6 (7.4-30.9) months. Survival rate at 1 year was 84 per cent, at 3 years 57 per cent, and at 5 years 45 per cent. In our review only a small number of these 25 patients are indeed cured.
The Effect of Pelvic Septic Complications on Function and Quality of Life after Ileal Pouch-Anal Anastomosis: A Single Center Experience
Authors: Selvaggi Francesco , Sciaudone Guido , Limongelli Paolo , Di Stazio Crescenzo , Guadagni Ilaria , Pellino Gianluca , De Rosa Michele , Riegler Gabriele
Published: June 2020

Ileal pouch-anal anastomosis (IPAA) has become the procedure of choice for surgical treatment of intractable ulcerative colitis (UC). Surgical complications occurring in the short-term, like pelvic sepsis, are responsible for pouch dysfunction. We prospectively evaluated 118 patients with IPAA for UC operated on between 1987 and 2002. Follow-up intervals were at 3, 6, and 12 months in the first year, then every year for at least 5 years. Patients answered a questionnaire 1 and 5 years after ileostomy closure. One hundred and seventeen patients completed the early follow-up. Nine patients developed early pelvic sepsis (7.69%); six required pouch salvage procedure. In about 33.3 per cent of cases more than one procedure was necessary. Eighty-eight patients were available for 5-year functional evaluation. Patients developing early sepsis (n = 9) showed worse long-term functional results compared with the remaining study population (n = 79): stool frequency; night evacuation; perfect day/night continence; discrimination; antidiarrhoeals need; pad usage; and sexual restriction were significantly different ( P < 0.05). Quality of life and satisfaction after surgery were good in all patients. This observation did not correlate with function. Eighty-eight and 97 per cent would undergo IPAA again and would recommend it to others respectively, in septic group and controls. Functional outcome after IPAA may be influenced by early septic complications. Overall quality of life and satisfaction with surgery are comparable with those of controls.
Impact of Elevated per Cent Carbohydrate-deficient Transferrin at Hospital Admission on Outcomes in Trauma Patients
Authors: Mckinzie Brian P. , Worrall Cathy L. , Simpson Kit N. , Couillard Deborah J. , Leon Stuart M.
Published: June 2020

Chronic alcohol consumption has been linked to increased morbidity and mortality in the intensive care unit setting. The purpose of our study was to assess outcomes in trauma patients admitted to our institutional university-affiliated, Level I emergency trauma unit (ETU) with and without per cent carbohydrate-deficient transferrin (%CDT) elevations over a 12-week timeframe. Markers for alcohol consumption including %CDT, gamma glutamyl transferase, and serum osmolality were measured along with the standard trauma laboratory panel on arrival to the ETU. Intensive care unit length of stay (LOS), length of time requiring ventilator support, hospital LOS, total hospital charges as well as incidences of postoperative complications were collected on all patients with a LOS greater than or equal to 48 hours. Demographics between the groups were similar. Drinking histories were more significant in the elevated %CDT group ( P = 0.0006). Patients with elevated %CDT had significantly longer ICU and hospital LOS (5.1 vs 3.9, P = 0.01; 8.7 vs 7.1 days, P = 0.0052) and ventilator days (2 vs 1.5 days, P = 0.0286). Complications and hospital charges were similar between groups. Trauma patients presenting to the ETU with %CDT elevations appear to be at risk for longer ICU and hospital LOS.
Single-Incision Transumbilical Laparoscopic Splenic Cyst Unroofing: First Reported Case
Authors: Saber Alan A. , El-Ghazaly Tarek H.
Published: June 2020

Single-incision laparoscopic surgery is an emerging minimally invasive approach. When using the single-incision laparoscopic surgery approach, the surgeon operates almost exclusively through a single point of entry, usually the patient's umbilicus. This approach is steadily gaining popularity among minimally invasive surgeons, as it combines the cosmetic advantage of Natural Orifice Translumenal Surgery with the technical familiarity of conventional laparoscopic surgery. In this report, we describe our implementation of the single-incision laparoscopic approach to perform an unroofing of a posttraumatic splenic cyst; in this case, the entire procedure is performed through a 2-cm intraumbilical incision.
Roux-en-Y Reconstruction with Stapled Distal Jejunal Pouch after Total Gastrectomy
Authors: Ishigami Sumiya , Aridome Kuniaki , Nakajo Akihiro , Matsumoto Masataka , Uchikado Yasuto , Setoyama Tetsuro , Arigami Takaaki , Arima Hideo , Ueno Shinichi , Kijima Yuko , Aikou Takashi , Natsugoe Shoji
Published: June 2020

Roux-en-Y reconstruction after total gastrectomy is a simple and safe procedure; however, it eliminates the gastric reservoir function and markedly changes the postoperative digestive physiology. The patients therefore suffer from insufficient food intake and malabsorption. It has been reported that jejunal pouch reconstruction increases food intake and improves the nutritional status. We established a novel Roux-en-Y reconstruction with stapled distal jejunal pouch after total gastrectomy. A jejunal pouch, 8 cm in size, was attached at the jejunojejunostomy. We performed this novel reconstruction for 20 gastric cancer patients after total gastrectomy with lymph node dissection as a feasible study. One year after operation, the average percentage weight was maintained in more than 90 per cent and 17 (85%) of these patients were in the normal range of the body mass index. This procedure may improve postoperative malnutrition after total gastrectomy according to our feasible study. A multicenter randomized trial of this approach comparing with Roux-en-Y reconstruction without a pouch is ongoing.
Trends in the Utilization of High-Volume Hospitals by Minority and Underinsured Surgical Patients
Authors: Scarborough John E. , Bennett Kyla M. , Pietrobon Ricardo , Kuo Paul C. , Pappas Theodore N.
Published: June 2020

Race- and insurance-based disparities exist in the utilization of high-volume hospitals for complex surgery. Retrospective analysis of the Nationwide Inpatient Sample from 1988 through 2005 was performed to examine hospital volume trends for eight procedures. Ordered logistic regression analyses were performed to determine temporal trends in the utilization of high-volume hospitals by minority and Medicaid-insured patients compared with white patients and those with private insurance or Medicare. Black patients are increasing their utilization of higher-volume hospitals, but not at a rate sufficient to overcome existing disparities relative to the utilization of such hospitals by white patients. Meanwhile, disparities in the utilization of higher-volume hospitals are increasing for Hispanics and patients who are primarily insured through Medicaid. Existing racial and insurance-based disparities in the utilization of high-volume surgical care will persist or become even more pronounced without active intervention from health care policymakers.
Laparoscopic Common Duct Exploration in 90-Bed Rural Hospital
Authors: Shively Eugene H. , Richardson Malcolm , Romines Robert , Englund Graham , Watkins James
Published: June 2020

Laparoscopic common bile duct exploration (LCBDE) is an effective procedure when endoscopic retrograde cholangiopancreatography is not available. From January 2004 until December 2009, 1254 patients presented with biliary tract disease. Laparoscopic cholecystectomy was attempted in 1240 (98%) cases and completed in 1232 (98%) cases. Laparoscopic cholangiograms were performed in 627 (50%) cases. LCBDE was carried out in 33 (2.6%) cases. Of the 33 LCBDEs, 29 (2.3%) were via the cystic duct, four (0.32%) through a choledochotomy; eight (0.64%) of the total laparoscopic cholecystectomies were converted to open cholecystectomies. LCBDE can be done safely in small hospitals and is very useful when endoscopic retrograde cholangiopancreatography is not available.
Surgical Treatment for Women with Breast Cancer: Do Randomized Clinical Trials Represent Current Medical Practices?
Authors: Frederick Wayne A.I. , Ames Sarah , Downing Stephanie R. , Oyetunji Tolulope A. , Chang David C. , Leffall Lasalle D.
Published: June 2020

Randomized clinical trials have not shown survival differences between breast cancer patients who undergo breast-conserving surgery and those who undergo modified radical mastectomy (MRM). Recent studies however, have suggested that these randomized clinical trials findings may not be representative of the entire population or the nature of current patient care. A retrospective analysis of female invasive breast cancer patients who underwent surgery in the Surveillance, Epidemiology, and End Results database (1990-2003) was performed. Survival was compared amongst women who underwent partial mastectomy, partial mastectomy plus radiation (PMR), or MRM. Cox proportional hazards regressions were used to investigate the impact of method of treatment upon survival, after adjusting for patient and tumor characteristics. A total of 218,043 patients, mean age 62 years, were identified. MRM accounted for 51.5 per cent of the study population whereas PMR accounted for 34.9 per cent. On multivariate analyses, significant improvement was observed in patient survival associated with PMR when compared with MRM patients (hazard ratio = 0.71, 95% confidence interval = 0.67-0.74, P < 0.001). This population-based study suggests that there is a survival benefit for women undergoing PMR in the treatment of breast cancer.
Free and Local Continuing Medical Education Does Not Guarantee Surgeon Participation in Maintenance of Certification Learning Activities
Authors: Stafford Renae E. , Dreesen Elizabeth B. , Charles Anthony , Marshall Harry , Rudisill Michele , Estes Eithiel
Published: June 2020

The American Board of Surgery has adopted the Maintenance of Certification requirement for surgeons. It requires continuous professional development (CPD) using active and passive learning modalities in contrast to traditional continuing medical education (CME). The Rural Trauma Team Development Course developed by the American College of Surgeons Committee on Trauma is a CPD learning activity. We provided 22 free courses between May 2007 and June 2009 to trauma care providers at 11 affiliated community and critical access hospitals. The course was taught on-site by an interdisciplinary group and at least one trauma surgeon was faculty. Free Category I CME credits and continuing education units were provided. Two hundred thirty-four providers attended and the majority were RNs (60%) and emergency medical technicians (21.8%). Only 18 were physicians (7.7%) and none were surgeons. The majority felt that they would change their practice as a result of the course but cited the lack of attendance at the course by emergency physicians and surgeons as a deficit. It may be that surgeons have barriers such as time away from a practice to attending these newer types of educational opportunities. Those who develop and offer these courses may need to develop different strategies to reach this target audience.
The Effect of Diabetes Mellitus on Surgical Site Infections after Colorectal and Noncolorectal General Surgical Operations
Authors: Ata Ashar , Valerian Brian T. , Lee Edward C. , Bestle Sharon L. , Elmendorf Sarah L. , Stain Steven C.
Published: June 2020

Patients undergoing colorectal surgery (CRS) are known to be at increased risk of surgical site infection (SSI). We assessed the effect of diabetes and other risk factors on SSI in patients undergoing CRS and patients undergoing general surgery (GS). American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File from 2005 to 2006 was used. χ2 tests, t tests, and logistic regression were used to assess the risk factors. Of the 129,909 study patients 10.1 per cent were patients undergoing CRS. The incidence of SSI in patients undergoing CRS was 3.8 times higher (95% CI, 3.6–4.1) than in patients undergoing GS. The incidence of SSI was higher in diabetics than nondiabetics in patients undergoing CRS (15.4 vs 11.0%, P < 0.001) and patients undergoing GS (5.3 vs 3.1%, P < 0.001). The significant univariate predictors of SSI for patients undergoing GS and patients undergoing CRS were: males, American Society of Anesthesiologists (ASA) class, diabetes emergency surgery, operation time, and greater than 2 units of intraoperative red blood cell transfusion. For patients undergoing GS, increasing age was also significant. After multivariate adjustment, significant predictors of SSI for patients undergoing GS and patients undergoing CRS were: male gender, diabetes, ASA class, emergency surgery, and operation time. For patients undergoing GS, age also remained significant. Among patients undergoing CRS, insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) were 1.32 ( P < 0.05) times more likely than nondiabetics to develop SSI. Among patients undergoing GS, only IDDM (OR, 1.39; P < 0.001) were at increased risk. In this large hospital-based study, patients undergoing CRS were three times more likely to get SSI than patients undergoing GS. Diabetic patients with CRS (IDDM and NIDDM) and patients undergoing GS (IDDM) were at increased risk of SSI compared with nondiabetics. More intense glycemic control may reduce SSI in patients undergoing CRS with diabetes.
Initial Experience with Single-Incision Laparoscopic Cholecystectomy
Authors: Carr Aaron , Bhavaraju Avinash , Goza John , Wilson Russell
Published: June 2020

Single-incision laparoscopic surgical procedures are being developed with the goal of improving cosmesis, reducing postoperative pain, and increasing patient satisfaction. We performed this study to evaluate our initial experience with single-incision laparoscopic cholecystectomy. We used an infraumbilical incision with two upper low-profile 5-mm ports and one lower standard 5-mm port and either a standard 30° Storz laparoscope or an Olympus deflectable tip laparoscope. All patients were followed postoperatively to evaluate the feasibility and outcomes of the procedure. A total of 60 gallbladders were successfully removed by this method (95.2% success rate). Three cases were converted to standard laparoscopic cholecystectomy (4.8% conversion rate) with no conversion to open cholecystectomy. There were no major complications (bile duct injury, liver injury, bowel injury, biliary leak). Median operative time was 51 ± 21 minutes. Diagnoses included cholelithiasis (55%), biliary dyskinesia (32%), biliary colic (13%), and one case of gangrenous cholecystitis. Median patient age was 47 years with a strong female predominance (87%). Our initial experience demonstrates that single-incision laparoscopic cholecystectomy is effective and safe. We are confident that single-incision laparoscopic cholecystectomy is a viable alternative to standard laparoscopic cholecystectomy.
Rectosigmoid Intussusception through the Anus Mimicking Rectal Prolapse
Authors: Torres Marla L. , McCafferty Michael H.
Published: June 2020

Intussusception of the colon usually occurs in infants and children. Although rectal prolapse is not uncommon, presentation of more proximal segments of large bowel through the anus is extremely rare. We report two cases of rectosigmoid intussusception in which sigmoid colon intussusception was diagnosed as rectal prolapse preoperatively.
Pulmonary Contusion in the Pediatric Population
Authors: Hamrick Miller Carlton , Duhn Ryan Donsworth , Carney David Edward , Boswell William Carson , Ochsner Mims Gage
Published: June 2020

Pulmonary contusion in the adult population is an independent risk factor for respiratory failure, ventilator associated pneumonia, and acute respiratory distress syndrome. Pilot studies in adults note an increased risk when volume of pulmonary contusion exceeds 20 per cent of total lung volume. The purpose of this study was to determine if children with pulmonary contusion suffer the same morbidity as adults. From January 2005 to May 2007, all trauma patients ages 3 to 18-years-old were assessed for CT evidence of pulmonary contusion. Children were excluded if injury included confounding variables, which could result in respiratory failure independent of contusion status. CT images were reviewed and pulmonary contusion was calculated as a percentage of total lung volume. Outcomes including need for invasive ventilation, pneumonia, and development of oxygenation problems were recorded. Data collected included patient age, Injury Severity Score, arterial blood gas findings, and number of rib fractures. Twenty-six patients met criteria for the study with a mean age of 13.35 years and mean Injury Severity Score of 24. The mean percentage of pulmonary contusion was 19.81 per cent. No patients required intubation. Pediatric pulmonary contusion does not carry the same morbidity as noted in the adult population. Invasive airway management is rarely required.
Initial Institutional Experience with Thoracoscopic Assisted Esophagectomy
Authors: Lata Adrian L. , Oaks Timothy , Levine Edward A.
Published: June 2020

We report our initial experience with thoracoscopic assisted esophagectomy (TAE) in patients with esophageal carcinoma. Clinical outcome measures are reported for 14 consecutive patients who underwent thoracoscopically assisted esophagectomy at our institution between January 2007 and June 2009. These outcomes were compared with 18 patients who underwent open esophagectomy (OE) during this time. All 14 patients were male, with a median age of 63. All had distal esophageal adenocarcinoma: stage I (7), II A (2), II B (3), and III (2). Surgical approaches included laparotomy combined with thoracoscopy and cervical (n = 12), or intrathoracic anastomosis (n = 2). Compared with an open approach, the thoracoscopic assisted esophagectomies were longer (median time 460 vs 386 minutes), and they were associated with less blood loss (250 mL vs 500 mL) and less respiratory complications (14.3% vs 27.8%). In our TAE group more lymph nodes were removed (median number 12 in TAE vs 10 in OE). The overall morbidity was similar in both groups (42.8% in TAE vs 50% in OE group), but the in-hospital mortality was reduced with TAE (7.1% with TAE vs 16.7% with OE). TAE is feasible with a low conversion rate, acceptable morbidity, and low mortality.
Surgical Intensive Care Unit Mobility is Increased after Institution of a Computerized Mobility Order Set and Intensive Care Unit Mobility Protocol: A Prospective Cohort Analysis
Authors: Hildreth Amy N. , Enniss Toby , Martin Robert S. , Miller Preston R. , Mitten-Long Donna , Gasaway Janice , Ebert Fran , Butcher Wendy , Browder Kevin , Chang Michael C. , Hoth Jason J. , Mowery Nathan T. , Meredith J.W.
Published: June 2020

In some populations, intensive care unit (ICU) mobility has been shown to be safe and beneficial. We gathered data on 50 nonintubated surgical patients in a 10-bed surgical ICU (SICU) who met physiologic inclusion criteria beginning in May 2008 (A group). In January 2009, we began mandatory entry of computerized mobility orders as part of a standardized ICU order set. We also created a mobility protocol for nurses in this ICU. We then collected data on 50 patients in this postintervention cohort (B group). Both groups had similar baseline characteristics. A group patients had some form of mobility orders entered in 29 patients (58%) versus 47 patients (82%) in the B group, P < 0.05. In the A group, 11 patients (22%) were mobilized; in the B group, 40 patients (80%) were mobilized, P < 0.05. In our SICU patient population, mandatory entry of computerized mobility orders as part of a standard SICU order set and establishment of an ICU mobility nursing protocol was associated with an increase in number of mobility orders entered as well as an increase in SICU patient activity. Further studies should focus on measurement of the effect of mobility interventions on patient outcomes.
Mixed Flora: Indication for Therapy or Early Warning Sign?
Authors: Qureshi Irfan , Kerwin Andrew J. , McCarter Yvette S. , Tepas Joseph T.
Published: June 2020

“Mixed flora” is a commonly returned result yielding not in either indication for therapy or identification of potential causative organisms. We sought to determine whether mixed flora (MF) was in fact a harbinger of impending pneumonia or a benign result that could be therapeutically ignored. Bronchoalveolar lavage (BAL) results of injured adults undergoing mechanical ventilation in a trauma intensive care unit were stratified by identified organisms and by colony counts. The incidence of mixed flora as a component of the specimen report was compared for diagnostic (greater than 105 colony forming units/mL) versus nondiagnostic results using χ2 accepting P < 0.05 as significant. Nondiagnostic specimens were then stratified as MF only or MF and other identified pathogenic organisms. This group was further evaluated to determine the use of antibiotic therapy and development of pneumonia. Finally, patients with nondiagnostic reports and subsequent BAL were analyzed to determine specific species if subsequent BAL were required or if later pneumonia occurred. During 2007, 159 BALs were performed on injured patients of which 93 were diagnostic for pneumonia, whereas 66 were nondiagnostic. Of the diagnostic specimens, 15 (16%) included mixed flora. Of the 66 nondiagnostic specimens, 39 (59%) contained mixed flora. Nine (60%) of the 15 with diagnostic mixed flora were started on antibiotic therapy for an average of 6.2 days. The remaining 39 (82%) patients with mixed flora received no antibiotic therapy and never developed pneumonia. These data demonstrate that in the absence of diagnostic threshold of an identifiable pathogenic organism, therapy for pneumonia should not be instituted or continued.
Combined Analysis of Allograft Inflammatory Factor-1, Interleukin-18, and Toll-Like Receptor Expression and Association with Allograft Rejection and Coronary Vasculopathy
Authors: Barker Andrea K. , McDaniel D. Olga , Zhou Xinchun , He Zelda , Aru Giorgio , Thomas Tammy , Moore Charles K.
Published: June 2020

In cardiac transplantation settings, the initial myocardial ischemia and reperfusion may cause myocyte tissue injury and the release of allograft inflammatory factor-1 (AIF-1). This in part may trigger the innate immune response through the modulation of Toll-like receptor-2 (TLR-2) and AIF-1 expression and function, causing the release of proinflammatory cytokines. The goal was to demonstrate these markers in the peripheral blood and biopsy specimen from recipients with cardiac allograft rejection and coronary vasculopathy (CV). Peripheral blood and endomyocardial specimens were tested by reverse transcriptase-polymerase chain reaction and immunohistochemistry stains for identification of TLR-2, -4, interleukin-18, and AIF-1 markers and analyzed against clinical rejection grades for rejection. The differences for mRNA transcript levels were determined by one-way analysis of variance. The mRNA expression levels were significantly varied for TLR-2 in monocytes with different rejection grades ( P < 0.0001). The mean ± SEM level of mRNA expression for 3A grade rejection was 64.21 ± 3.8; grade 1A, 38.4 ± 3.5; and for Grade 0 was 38.46 ± 2.8. The TLR-4 mRNA expression was increased but the specificity was not statistically significant. The TLR-2 immunoreactivity was strongly detected in infiltrating mononuclear cells and cardiac myocytes in Grade 3A rejection. AIF-1 expression was increased significantly in the group with 3A rejection and Grade III CV as compared with Grade 0 or 1A. Interleukin-18 receptors were strongly detected in Grade 3A rejection and CV. The expression profiles of AIF-1, TLR-2, and interleukin-18 were correlated with biopsy-proven allograft rejection in both peripheral blood and local tissue, suggesting a potential for diagnostic biomarkers for early detection of allograft rejection.
Rib Fracture Patterns Predict Thoracic Chest Wall and Abdominal Solid Organ Injury
Authors: Al-Hassani Ammar , Abdulrahman Husham , Afifi Ibrahim , Almadani Ammar , Al-Den Ahmed , Al-Kuwari Abdulaziz , Recicar John , Nabir Syed , Maull Kimball I.
Published: June 2020

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.
Improving Dialysis Access: Regional Anesthesia Improves Arteriovenous Fistula Prevalence
Authors: Schenk Worthington G.
Published: June 2020

An autologous arteriovenous (AV) fistula is the preferred form of angioaccess for chronic hemodialysis. A prospective study was carried out to evaluate the potential of regional anesthesia to improve AV fistula prevalence. One hundred ninety-three patients underwent preoperative duplex ultrasound evaluation over a 14-month period. The qualification of each patient to receive either an autologous AV fistula or a prosthetic graft was based on specific sonographic criteria. Patients scheduled for placement of a graft received an ultrasound-directed supraclavicular brachial plexus block, which produces dense sympathetic blockade. After the regional block, those patients who met criteria for primary fistula construction on repeat ultrasound received a fistula instead of a graft. Of 62 patients scheduled to receive an AV graft, 23 or 37 per cent were recruited to receive a fistula instead. The outcome of the recruited fistulas was compared with the 121 planned fistulas. There was no statistically significant difference in primary failure rate (4.3 vs 5.8%). The recruited fistulas had a shorter average maturation time, 83 ± 48 versus 132 ± 82 days ( P = 0.023). Within the study population, functioning fistula prevalence was increased from 61.7 to 79.8 per cent. Regional anesthesia and immediate preoperative ultrasound is a useful strategy for increasing fistula prevalence.
Clinical Integration of Picture Archiving and Communication Systems with Pathology and Hospital Information System in Oncology
Authors: Duncan Lisa D. , Gray Keith , Lewis James M. , Bell John L. , Bigge Jeremy , McKinney J. Mark
Published: June 2020

The complexity of our current healthcare delivery system has become an impediment to communication among caregivers resulting in fragmentation of patient care. To address these issues, many hospitals are implementing processes to facilitate clinical integration in an effort to improve patient care and safety. Clinical informatics, including image storage in a Picture Archiving and Communication System (PACS), represents a tool whereby clinical integration can be accomplished. In this study, we obtained intraoperative photographs of 19 cases to document clinical stage, extent of disease, disease recurrence, reconstruction/grafting, intraoperative findings not identified by preoperative imaging, and site verification as part of the Universal Protocol. Photographs from all cases were stored and viewed in PACS. Images from many of the cases were presented at our interdepartmental cancer conferences. The stored images improved communication among caregivers and preserved pertinent intraoperative findings in the patients’ electronic medical record. In the future, pathology, gastroenterology, pulmonology, dermatology, and cardiology are just a few other subspecialties which could accomplish image storage in PACS. Multidisciplinary image storage in a PACS epitomizes the concept of clinical integration and its goal of improving patient care.
Transplant Renoportal Vein Conduit for Complete Mesenteric Thrombosis: A Case Report
Authors: Baker Talia B. , Jay Colleen L. , Fryer Jonathan P. , Abecassis Michael M.
Published: June 2020

Portal vein thrombosis, which is present in up to one quarter of patients with end-stage liver disease, presents a technical challenge at the time of liver transplantation. Thromboendovenectomy when feasible has been advocated in these patients. However, in patients with complete mesenteric thrombosis where this technique is typically not successful, a number of alternative techniques have been attempted including caval transposition, portal arterialization, and multi-visceral transplantation often with discouraging results. We present herein a single case where transplant renal vein outflow was used to provide portal vein inflow in a patient with complete mesenteric thrombosis undergoing simultaneous liver-kidney transplant.
The Use of Pelvic Radiation in Stage II Rectal Cancer: A Population-Based Analysis
Authors: Kuo Isabella , Wong Jan H. , Roy-Chowdhury Sharmila , Lum Sharon S. , Morgan John W. , Kazanjian Kevork
Published: June 2020

National Institutes of Health (NIH) guidelines recommend the use of pelvic radiation in T3N0 rectal cancer. We sought to determine the rate of compliance with NIH radiation guidelines for patients with T3N0 rectal cancer. We performed a retrospective cohort study of T3N0 rectal cancer diagnosed between January 1, 1994, and December 31, 2003, in Region 5 of the California Cancer Registry (R5 CCR). Three hundred twenty-nine patients with T3N0 rectal cancer were identified. The mean age of the study population was 68 years (range, 28 to 93 years). Only 54.1 per cent of patients with T3N0 cancer received pelvic radiation. There was no difference in gender ( P = 0.13) or the number of nodes examined ( P = 0.19) between patients who had treatment with pelvic radiation and those who did not. However, patients receiving radiation were significantly younger (mean 64 years with radiation therapy [XRT] vs 72 years without XRT, P < 0.001) and significantly more likely to be treated with systemic chemotherapy (75% with XRT vs 8.6% without XRT, P < 0.001). Significant numbers of patients with T3N0 rectal cancer are not receiving pelvic radiation in R5 CRR. NIH guidelines are not being translated into clinical practice. The reasons for this warrant continued investigation.
A Prospective Clinical Evaluation of the Effects of Intraoperative Systemic Anticoagulation in Patients Undergoing Arteriovenous Fistula Surgery
Authors: Wang Bonnie R. , Rowe Vincent L. , Ham Sung Wan , Han Sukgu , Patel Kaushal , Weaver Fred A. , Woo Karen
Published: June 2020

No standard presently exists for the use of systemic heparin during angioaccess surgery to decrease the incidence of postoperative thrombotic complications. Our objective was to study the effects of intraoperatively administered heparin on 30-day patency and postoperative bleeding complications in patients undergoing autogenous arteriovenous (AV) fistula surgery. A prospective, double-blinded, randomized controlled study was performed on 48 patients undergoing AV fistula creation from April 2007 through November 2009. Of the 48 patients, 22 were randomized to the control group and received no heparin. Twenty-six were randomized to receive heparin (75 units/kg intravenously) before clamping of the artery. There was no significant difference in 30-day patency between the heparin and control groups (92% vs 86%, P = 0.65), respectively. Three patients (12%) developed hematomas in the heparin group compared with one (5%) in the control group; however the difference was not statistically significant ( P = 0.61). The results suggest that intraoperative administration of heparin has no statistically significant effect on 30-day patency rates or postoperative bleeding complications. Larger trials with longer term follow-up and assessment of maturation rates are needed to determine the effect of intraoperative anticoagulation on these outcomes of arteriovenous fistula surgery.
Time from Diagnosis to Surgical Treatment of Breast Cancer: Factors Influencing Delays in Initiating Treatment
Authors: Wright G. Paul , Wong Jan H. , Morgan John W. , Roy-Chowdhury Sharmila , Kazanjian Kevork , Lum Sharon S.
Published: June 2020

No clear guidelines exist defining the appropriate time frame from diagnosis to definitive surgical treatment of breast cancer. Studies have suggested that treatment delays greater than 90 days may be associated with stage migration. We sought to evaluate demographic factors that influence 30-day and 90-day benchmarks for time from diagnosis to definitive surgical treatment of breast cancer. Between 2004 and 2007, 19,896 women with stage I to III invasive breast cancer were treated with primary surgical therapy and did not receive preoperative systemic therapy in the California Cancer Registry. Overall, 75.7 per cent of patients were treated within 30 days of diagnosis, and 95.5 per cent of patients were treated within 90 days of diagnosis. Multivariate analyses revealed that treatment delays were associated with smaller tumor size, use of total mastectomy, lower socioeconomic status, and Hispanic and nonHispanic black race/ethnicity. Furthermore, disparities in those that did not meet 30-day benchmark timeframes were exaggerated with 90-day treatment delays. These benchmarks can be used to measure disparities in health care delivery.
A Preliminary Report on the Clinical Experience with AlloDerm in Breast Reconstruction and its Radiologic Appearance
Authors: Cao Hop S. Tran , Tokin Christopher , Konop Jason , Ojeda-Fournier Haydee , Chao James , Blair Sarah L.
Published: June 2020

Human acellular tissue matrix (AlloDerm) use in breast reconstruction has become popular. Traditionally used for prosthesis coverage, it is also used in our practice as a filler for lumpectomy defects and a contouring device. However, no report presently exists that describes its appearance on oncologic surveillance studies. We performed a retrospective review of all charts of patients having undergone cancer-related breast reconstruction using AlloDerm as a filler at a single institution between 2005 and 2009. Postoperative mammograms and dynamic contrast enhanced breast magnetic resonance imaging were reviewed with a dedicated breast imager. Sixteen women underwent surgery involving placement of an AlloDerm roll in the breast. Postoperative films were unavailable for two of them. Of the remaining 14 patients, nine had postoperative mammograms only, three had postoperative dynamic contrast enhanced breast magnetic resonance imaging only, and two patients had both. In all cases, evaluation of the postoperative images was not affected by the presence of AlloDerm. In our short-term, retrospective experience, we find that a thorough radiographic evaluation of the breast tissue remains possible when AlloDerm rolls are used in reconstruction.
A Tale of Two (Anal Fistula) Plugs: Is there a Difference in Short-Term Outcomes?
Authors: Buchberg Brian , Masoomi Hossein , Choi John , Bergman Herlinda , Mills Steven , Stamos Michael J.
Published: June 2020

Treatment of complex anal fistulas presents an ongoing challenge to colorectal surgeons. The anal fistula plug is an attractive definitive option due to its minimal risk of incontinence, simple design, and easy application. Our objective was to compare the Cook Surgisis® AFP™ plug and the newer Gore Bio-A® plug in the management of complex anal fistulas. A retrospective chart review of patients treated with Cook and Gore fistula plugs between August 2007 and December 2009 was performed. Success was defined as closure of all external openings and absence of drainage and abscess formation. Twelve Cook patients underwent 16 plug insertions and 10 Gore patients underwent 11 plug insertions. The overall procedural success rate in the Gore group was 54.5 per cent (6 of 11) versus 12.5 per cent (2 of 16) in the Cook group. The reasons for failure were unknown in the majority of patients and plug dislodgement in two patients. Our short-term results with the Gore fistula plug suggest a higher procedural success rate in comparison to the Cook plug. Patients should be cautioned regarding potentially high failure rates; however, longer follow-up and a larger patient population are needed to confirm significant differences in fistula plug efficacy.
Article Commentary: Laparoscopy Associated Mesenteric Vascular Complications
Authors: Richmond Bryan K. , Thalheimer Liza
Published: June 2020

Since the first reported case in 1994, a small but significant number of patients have developed major mesenteric arterial and venous thromboses after laparoscopy, usually with catastrophic outcomes. The basic science data in both animal and human models suggest that these events were due in part to specific predisposing patient factors, combined with the physiologic changes in splanchnic hemodynamics that occur during induction and maintenance of pneumoperitoneum. The following manuscript examines the science of this phenomenon in detail and the features of the reported cases to date, with the goal being to increase awareness of this serious and likely underreported phenomenon.
Splenic Injury Due to Colonoscopy: Analysis of the World Literature, a New Case Report, and Recommendations for Management
Authors: Michetti Christopher P. , Smeltzer Emily , Fakhry Samir M.
Published: June 2020

Splenic injury is a rare complication of colonoscopy. Most literature on the topic is case-report based. Our objective was to perform a comprehensive analysis of characteristics of splenic injury due to colonoscopy from available published reports in the world literature, to compare and contrast this entity with that of traumatic splenic injury, and provide recommendations for management based on the analysis. We reviewed the PubMed database without restrictions using the terms splenic trauma after colonoscopy, splenic rupture from colonoscopy, splenic injury following colonoscopy, and splenic complications of colonoscopy, and also reviewed the references from the resulting publications. Retrieved manuscripts (case reports, reviews, and abstracts) were reviewed by two authors, and data extracted for 15 specific characteristics of each patient reported using a standardized data collection tool. Data were analyzed using descriptive statistics. Splenic injury due to colonoscopy is extremely rare as reported in published literature. The majority of patients that seek medical attention have delayed symptoms, and most require splenectomy. Subcapsular hematoma is the most common injury pattern seen. Selection criteria for operative management may be extrapolated from management guidelines for traumatic splenic injury, although nonoperative failure rates are higher for splenic injury due to colonoscopy than for trauma.
Comparison of Serum Tumor Markers for Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma
Authors: Tao Lian-Yuan , Cai Lei , He Xiao-Dong , Liu Wei , Qu Qiang
Published: June 2020

Serum tumor markers such as alpha-fetoprotein (AFP), carcinoembryonic antigen, carbohydrate antigen (CA) 19-9, CA242, and CA50 were analyzed to evaluate their diagnostic values in single and combined tests for distinguishing intrahepatic cholangiocarcinoma (ICC) from hepatocellular carcinoma (HCC). Preoperative serum levels of AFP, carcinoembryonic antigen, CA19-9, CA242, and CA50 were measured in 45 ICC and 76 HCC patients. The serum levels and the positive rate of AFP, CA19-9, and CA242 were significantly different between the ICC patients and HCC patients. Although AFP (—) was the most sensitive assay for distinguishing ICC from HCC (91.1%), its specificity was significantly lower than that of CA242 (+) and CA19-9 (+). The combination of AFP (-) and CA242 (+) afforded a high specificity of 94.3 per cent and showed highest accuracy (78.5%). Evaluation of patients without liver cirrhosis also showed similar results. The diagnostic value of CA242 (+) is better than that of CA19-9 (+) and AFP (-) in distinguishing ICC from HCC. Combined detection of AFP (—) and CA242 (+) can improve the specificity and accuracy of diagnosing ICC.