bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Surgical Resection Have a Role in the Treatment of Large or Multinodular Hepatocellular Carcinoma?
Authors: Ramacciato Giovanni , Mercantini Paolo , Petrucciani Niccolò , Ravaioli Matteo , Cucchetti Alessandro , Del Gaudio Massimo , Cescon Matteo , Ziparo Vincenzo , Pinna Antonio Daniele
Published: June 2020

Several effective treatments are available for patients with small solitary hepatocellular carcinomas (HCCs). Conversely, the management of patients with large or multinodular HCCs is controversial, and the role of surgical resection is not well defined. Between 2000 and 2006, 51 patients with large or multinodular HCC underwent liver resection. Clinicopathologic and follow-up data were prospectively collected and retrospectively reviewed. The perioperative and long-term outcomes were analyzed. Univariate and multivariate analysis of prognostic factors were conducted. Although 20 patients had multinodular HCCs, 31 had large solitary tumors. Perioperative mortality occurred in eight patients and complications in 15. In patients with large solitary tumors, 5-year disease-free and overall survival were 41.3 per cent and 56.1 per cent, respectively. Those with multinodular HCCs demonstrated 5-year disease-free and overall survival rates of 0 per cent and 33.6 per cent, respectively. Liver resection can result in long-term survival in select patients with large or multinodular HCCs, even in select patients with impaired liver function. Large solitary HCCs seem to have better prognoses than multinodular tumors, with lower recurrence and higher survival rates after surgery. Randomized controlled trials comparing resection to other treatment modalities are indicated to determine optimal patient management.
Cranial Nerve Injuries are Associated with Specific Craniofacial Fractures after Blunt Trauma
Authors: Kampshoff Jesse L. , Cogbill Thomas H. , Mathiason Michelle A. , Rallies Kara J. , Martin Lynn T.
Published: June 2020

Identification of cranial nerve (CN) injuries after blunt trauma is often delayed due to concomitant life-threatening trauma, altered mental status, and associated bony or soft tissue injuries. We hypothesized that specific craniofacial fracture (FX) patterns are associated with CN injuries, permitting earlier diagnosis. The trauma registry at a single institution was queried for all CN injuries and craniofacial FXs. Associations were determined by Fisher's exact test. Ninety CN injuries were identified in 59 patients. CN injuries were diagnosed on the day of admission in 24 (41%) patients. The most frequently injured CNs were CN VII (22), CN I (16), and CN VI (14). Occipital FXs were associated with CN I injury ( P = 0.001). Sphenoid and ethmoid FXs were correlated with CN III trauma ( P = 0.019 and 0.04). Temporal bone FXs were associated with CN VII injuries ( P = 0.025). Maxillary FXs were associated with CN V injuries ( P = 0.041). Complete or partial recovery was documented after 17 per cent and 39 per cent of CN injuries, respectively. Diagnostic delay was documented in 59 per cent of patients. Specific craniofacial FXs were correlated with certain CN injuries. Partial or complete recovery of function occurred after 56 per cent of CN injuries.
Role of Early Thoracoscopy for Management of Penetrating Wounds of the Chest
Authors: Ahmed Naveed , Chung Raphael
Published: June 2020

Most nonlife-threatening penetrating wounds of the chest (PWC) are treated with a chest tube alone. This may be inadequate because missed injuries, retained hemothorax, or foreign material may be difficult to address later. Early thoracoscopy should improve outcome. We conducted a retrospective review of 88 stable patients with PWC initially treated with a chest tube and had retained a hemothorax beyond 48 hours. Twenty-seven underwent an early video-assisted thoracoscopy (VATS). Fifty-five were observed, chest tubes were manipulated, or an additional one placed. The outcome was compared with the National Trauma Data Bank and controlled for Injury Severity Score. Early VATS reduced length of stay (4.3 vs 9.4 days), days in the intensive care unit (1.3 vs 3.2), and open thoracotomy (0 vs 7). A chest tube undertreats a nonlife-threatening PWC correctable by timely VATs.
Trauma Team Activation can be Tailored by Prehospital Criteria
Authors: Claridge Jeffrey A. , Golob Joseph F. , Leukhardt William H. , Kan Justin A. , Como John J. , Malangoni Mark A. , Yowler Charles J.
Published: June 2020

A two phase prospective study was carried out at a regional Level I trauma center over 1 year. Phase I involved collecting observational data to determine which trauma criteria could potentially be used to identify patients that could be evaluated by a lower level trauma activation (category-3). A category-3 involved a smaller response team with priority access to imaging. Phase II involved implementing this third tier activation system and prospectively evaluating the outcomes related to resources and patient care. A total of 3104 patients were evaluated with 2076 patients in phase I and 1037 in phase II. Three commonly identified activation criteria out of the 36 studied were not associated with admission. These criteria were pedestrian struck by vehicle, high speed vehicular crash, and Glasgow Coma Score 12-14. These criteria were then used as triggers for a category-3 activation in phase II. Comparisons of patients with these three identified criteria between phase I and II demonstrated that significantly fewer patients were admitted, charges were reduced, emergency department times were similar, and less man-power hours were needed in phase II. The utilization of a third tiered activation system resulted in a decrease utilization of many resources without sacrificing patient care.
Article Commentary: Management of Left Pancreatic Trauma
Authors: Malgras Brice , Douard Richard , Siauve Nathalie , Wind Philippe
Published: June 2020

Left pancreatic traumas (LPTs) are rare but serious lesions occurring in 1 to 6 per cent of abdominal trauma patients and mainly resulting from blunt traumas. LPT severity is primarily dependent on the associated injuries and secondarily related to main pancreatic duct injury responsible for complications: acute pancreatitis, pseudocysts, pancreatic fistulas, or abscesses. The guidelines for blunt LPT management can be presented as follows. In case of emergency laparotomy, pancreas exploration is mandatory to detect pancreatic duct lesions. In the absence of main pancreatic duct lesions, simple drainage is advocated. In case of distal injury to the main pancreatic duct, a left pancreatectomy is mandatory. In the absence of initial laparotomy, the diagnosis is more and more based on CT and magnetic resonance cholangiopancreatography, which tend to replace endoscopic retrograde cholangiopancreatography (ERCP) as a first-intent diagnostic modality. In case of distal injury to the main pancreatic duct, spleen-preserving distal pancreatectomy is recommended. In the absence of main pancreatic duct lesions, nonoperative treatment is advocated. When LPTs are discovered at the time of complications, pancreatic fistulas and/or pseudocysts are associated with main pancreatic lesions, which can be treated by pancreatic duct stenting at ERCP and/or internal endoscopic cystogastrostomy. However, in such cases, spleen-preserving distal pancreatectomy remains the treatment of choice. Pancreatic ductal lesions resulting from LPT have to be diagnosed early to avoid late complications. Distal pancreatectomy remains the treatment of choice in case of severe pancreatic ductal lesions because the role of ERCP stenting and endoscopic techniques needs further evaluation.
Level I Verification Is Associated with a Decreased Mortality Rate after Major Torso Vascular Injuries
Authors: Norwood Scott , Cook Alan D. , Berne John D.
Published: June 2020

Major torso vascular injuries (MTVIs) are frequently fatal. Our purpose was to determine whether the American College of Surgeons’ (ACS) trauma center level of verification was associated with reduced mortality rates in a rural population-based community trauma center. Patients with blunt and penetrating MTVIs were retrospectively reviewed. Mortality rates were compared between Level II and Level I verification time periods. The primary outcome measured was death from MTVIs. Two hundred seventy-four patients (blunt, 167 [61%]; penetrating, 107 [39%]) representing 1.5 per cent of all trauma admissions were studied. Mortality decreased from 41 of 80 (51%) (Level II) to 60 of 194 (31%) (Level I) ( P = 0.002) for the entire group. Mortality reduction occurred primarily in the subgroup with blunt and penetrating thoracic injuries (Level II, 24 of 33 [73%] vs Level I, 25 of 82 [30%]; P < 0.001). A significant reduction was not observed in patients with major abdominal vascular injuries (Level II, 17 of 47 [36%] vs Level I, 35 of 112 [31%]; P = 0.581). Level I status was associated with an overall decreased mortality rate from MTVIs despite low patient numbers. The commitment of hospital resources that are required to achieve Level I ACS verification in a community hospital improves survival, particularly in patients with blunt and penetrating thoracic injuries.
Prognostic Significance of 18q LOH in Sporadic Colorectal Carcinoma
Authors: Pilozzi Emanuela , Ferri Mario , Onelli Mariadele Rapazzotti , Mercantini Paolo , Corigliano Nicola , Duranti Enrico , Dionisi Lorenza , Felicioni Francesco , Virgilio Edoardo , Ziparo Vincenzo , Ruco Luigi
Published: June 2020

Identification of molecular alterations with implication for prognosis and sensibility to chemotherapeutic agents represents a great challenge in colorectal carcinoma treatment. Controversial results have been reported on prognostic value of chromosome 18q loss. Ninety-seven unselected patients with sporadic colorectal carcinoma Stage II and III were investigated for loss of heterozygosity at 18q D18S58 and D18S61 loci. Molecular alterations were correlated with clinicopathological data and survival. 18q loss of heterozygosity (LOH) was present in 56 per cent cases of carcinoma and was not related either to the clinicopathological characteristics of the patients or to prognosis. However, patients with LOH at locus D18S61 showed a more favorable prognosis. This finding was especially true for Stage II and untreated carcinoma. Survival was not influenced by the status of D18S58 locus. In our series, LOH at chromosome 18q does not seem to predict an unfavorable outcome. It seems of special interest the benefit that D18S61 loss of heterozygosity confers to untreated patients and patients with Stage II colon carcinoma.
Modified Anterolateral Approach Provides Improved Accessibility to the Lung Hilum Vascular Region for Giant Mass Lung Cancer Pneumonectomy
Authors: Wei Bo , Jiang Fusheng , Wang Jianrui , Wang Tao
Published: June 2020

Surgical management of patients with a huge pulmonary mass remains a challenge. The surgical risk is amplified by potential hemorrhage, problematic surgical exposure, difficult handling of the tumor, and poor vascular control. We describe a technique that uses a modified anterolateral thoracotomy to accomplish pneumonectomy. An anterolateral thoracotomy was entered through the 4th or 5th intercostal space. The intercostal muscles of the involved interspace were dissected off long enough but without dividing the overlying chest wall muscles. This crucial maneuver allowed a wide rage of rib spreading. The pulmonary hila and lateral aspect of the mediastinum were thus best exposed. Seven patients with large mass pulmonary cancer were admitted for surgical resection via this approach. Intrapericardial access to pulmonary vessels was obtained for pneumonectomy in all patients, including combined carinoplasty and superior vena cava reconstruction for one case. The perioperative courses were smooth and R0-resection was achieved in all cases. The modified anterolateral approach permits very good exposure and control of the pulmonary vessels at the hilum, enabling the resection maneuver to be effective, quick, and safe.
Hemostatic Dressings Reduce Tourniquet Time While Maintaining Hemorrhage Control
Authors: Macintyre Allan D. , Quick Jacob A. , Barnes Stephen L.
Published: June 2020

Tourniquet application has become first-line treatment for extremity hemorrhage on the battlefield and has seen increased use in the civilian arena. We hypothesized that an effective windlass tourniquet could be removed after application of a hemostatic dressing in a swine model of peripheral vascular injury. A tourniquet was placed proximally in 50 forelimb-injured swine after 30 seconds of hemorrhage with cessation of hemorrhage in all cases. Hemcon®, ActCel, Quikclot®, Celox™, or standard gauze was then placed over the wound with direct pressure for three minutes. The tourniquet was then removed. Success was determined if no bleeding was identified. Standard gauze resulted in a 100 per cent failure rate with active bleeding present after each application. Celox™ was successful in maintaining hemostasis in 6 of 10 (60%) subjects. Quikclot® succeeded in 80 per cent of subjects. ActCel maintained hemostasis in nine (90%) subjects, whereas HemCon® was successful in all instances (100%). All four hemostatic dressings were superior to gauze in maintaining hemostasis after removal of an effective tourniquet. Use of hemostatic dressings in conjunction with a tourniquet may reduce tourniquet times and improve outcomes in peripheral vascular injury and warrants further study.
The Role of Laparoscopy in Small Bowel Obstruction After Previous Laparotomy for Trauma: An Initial Report
Authors: Simmons Jon D. , Rogers Emily A. , Porter John M. , Ahmed Naveed
Published: June 2020

Presently, there are no guidelines to help predict which patients are more likely to have successful laparoscopic adhesiolysis. We attempt to define which preoperative characteristics of trauma patients who later develop small bowel obstruction are most amenable to a laparoscopic operation. We did a retrospective review of all patients with small bowel obstruction after previous laparotomy for trauma. For the patients that received an operation to relieve the obstruction, the location of transition zone via CT scan and location of the previous abdominal scar were recorded. A previous upper abdominal surgical incision and a transition zone outside of the pelvis on CT scan were preoperative predictors of a successful laparoscopic adhesiolysis. The laparoscopic group had a shorter length of stay. Laparoscopic surgery as the initial operative approach in the management of SBO after previous laparotomy for trauma is safe and effective. Characteristics that make the laparoscopic approach most favorable are CT transition point above the pelvis and previous midline incision above umbilicus.
Radiation Trends in Trauma Patients
Authors: Sharma Om P. , Oswanski Michael F. , Sidhu Ramandeep , Krugh Kerry , Culler Amy Sue , Stombaugh Heather A. , Lauer Sherry K.
Published: June 2020

Today, computed tomography (CT) and other studies are used more often early in a trauma case than X-rays, exposing patients to more radiation. The long-term effects of radiation exposure (RE) in trauma patients are of great concern. Investigators randomly selected 60 patients (injury severity scores 15-25) each from the years 2000, 2003, and 2006. The cumulative effective dose (CED) was calculated from the RE of all X-rays and CTs performed during the patient's hospital stay. Total CED/patient increased from 15.97 (2000) to 16.67 (2003) to 23.27 mSv (2006); the increase from 2000 to 2006 was significant ( P < 0.05). X-rays increased over the 6-year period from 9.6/patient (pt) to 11.4/pt to 15.4/pt. CT scans increased from 2.2/pt (15.19 mSv) to 3.5/pt (21.85 mSv, P < 0.05). The CED in children increased: 12.88 versus 13.17 versus 15.32 mSv/pt ( P > 0.05). RE was 19.5 versus 22.0 versus 27.1 mSv in 16 to 45-year-olds compared with 15.5 versus 14.3 versus 27.0 mSv in older adults. Sixteen to 45-year-olds had significantly higher RE than children ( P < 0.05). RE in the first hour and first 24 hours increased but not significantly ( P > 0.05). CED increased from 2000 to 2006, due primarily from CT scans. Children had no significant CED increase during the same period and had lower RE than 16 to 45-year-old adults.
Development of a Bayesian Belief Network Model for Personalized Prognostic Risk Assessment in Colon Carcinomatosis
Authors: Stojadinovic Alexander , Nissan Aviram , Eberhardt John , Chua Terence C. , Pelz Joerg O.W. , Esquivel Jesus
Published: June 2020

Multimodality therapy in selected patients with peritoneal carcinomatosis is gaining acceptance. Treatment-directing decision support tools are needed to individualize care and select patients best suited for cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (CRS ± HIPEC). The purpose of this study is to develop a predictive model that could support surgical decisions in patients with colon carcinomatosis. Fifty-three patients were enrolled in a prospective study collecting 31 clinical-pathological, treatment-related, and outcome data. The population was characterized by disease presentation, performance status, extent of peritoneal cancer (Peritoneal Cancer Index, PCI), primary tumor histology, and nodal staging. These preoperative parameters were analyzed using step-wise machine-learned Bayesian Belief Networks (BBN) to develop a predictive model for overall survival (OS) in patients considered for CRS ± HIPEC. Area-under-the-curve from receiver-operating-characteristics curves of OS predictions was calculated to determine the model's positive and negative predictive value. Model structure defined three predictors of OS: severity of symptoms (performance status), PCI, and ability to undergo CRS ± HIPEC. Patients with PCI < 10, resectable disease, and excellent performance status who underwent CRS ± HIPEC had 89 per cent probability of survival compared with 4 per cent for those with poor performance status, PCI > 20, who were not considered surgical candidates. Cross validation of the BBN model robustly classified OS (area-under-the-curve = 0.71). The model's positive predictive value and negative predictive value are 63.3 per cent and 68.3 per cent, respectively. This exploratory study supports the utility of Bayesian classification for developing decision support tools, which assess case-specific relative risk for a given patient for oncological outcomes based on clinically relevant classifiers of survival. Further prospective studies to validate the BBN model-derived prognostic assessment tool are warranted.
Initial Experience Using a Hyaluronate-Iodine Complex for Wound Healing
Authors: Brenes Robert A. , Ajemian Michael S. , Macaron Shady H. , Panait Lucian , Dudrick Stanley J.
Published: June 2020

Hyaluronate-iodine complex is a wound healing adjuvant approved for use in the European Union. The objective of this study is to validate hyaluronate-iodine as a potential wound healing agent. Patients were recruited from the hospital, the outpatient clinic, and the wound healing center. Hyaluronate-iodine soaked gauze was applied to wounds either daily or every other day depending on the amount of wound exudate. Wounds were measured weekly, and progression was documented with digital photography. All wounds were debrided as needed using standard surgical techniques. Fourteen patients (19 wounds) were entered into this prospective study, and 10 patients completed treatment. Fourteen wounds progressed to complete healing with a mean healing time of 18.1 ± 15.1 weeks. Treatment was interrupted in four patients. One patient discontinued treatment due to pain related to application of hyaluronate-iodine, another patient for transportation issues, and the other two patients were lost to follow-up due to relocation out of state and noncompliance with scheduled appointments. Hyaluronate-iodine was helpful in the healing of all types of wounds treated in this pilot study. The antiadhesive and antimicrobial properties of hyaluronate-iodine create a desirable environment conducive to wound healing without apparent detrimental effects.
Closed Midshaft Femur Fractures: Are They Only for Trauma Centers?
Authors: Ryan Nicholas , Carroll Colin , Carter Mary B. , Roberts Craig S. , Malkani Arthur L. , Harbrecht Brian G.
Published: June 2020

Trauma centers are limited resources, particularly in rural areas, and availability of emergency care in some parts of the United States may be inadequate. The declining number of orthopedic surgeons willing to care for injured patients has limited access to fracture repair in some communities. We studied the management of closed midshaft femur fractures in both trauma centers (TCs) and nontrauma centers (NTCs) to evaluate outcome for this common orthopedic injury and determine if these issues have affected fracture care in Kentucky. All patients 16-years-old and older who suffered femur fractures in Kentucky from 2004 and 2005 were identified. There were 334 TC patients and 341 NTC patients with closed, midshaft femur fractures. The mean age of TC patients (33 ± 17 years) was significantly lower than that of NTC patients (59 ± 25 years). TC patients were more likely men (71% vs 44%), had more associated injuries (2.4 ± 2.1 vs 0.5 ± 1.2), and had longer lengths of stay (8.3 ± 9.8 vs 6.4 ± 7.1 days) (TCs vs NTCs, all P < 0.005). Although both groups ultimately underwent internal fixation (97% vs 99%, TCs vs NTCs), TC patients were more likely (2.7% vs 0.3%) to receive external fixation than the NTC patients ( P < 0.05). There was no significant difference in the percentage of patients that received only a closed reduction. There was no significant difference in hospital mortality (0.3% vs 0.9%, TCs vs NTCs, P = 0.62). Although differences in patient populations exist between TCs and NTCs, both TCs and NTCs manage substantial numbers of patients with closed, midshaft femur fractures with low mortality in this state database.
Is Gastrectomy Safe in the Elderly? A Single Institution Review
Authors: Hager Eric S. , Abdollahi Hamid , Crawford Albert G. , Moudgill Neil , Rosato Ernest L. , Chojnacki Karen A. , Yeo Charles J. , Kennedy Eugene P. , Berger Adam
Published: June 2020

The population of the United States is aging. Studies within the last several years have demonstrated that major abdominal operations in elderly patients can be done safely, but with increased rates of complications. We set out to determine the rates of morbidity and mortality in elderly patients undergoing gastric resection at a tertiary care university hospital. A retrospective analysis was performed of 157 consecutive gastric resections between January 1998 and July 2007. Group A (n = 99) consisted of patients < 75-years-old at surgery, whereas group B (n = 58) included patients who were ≥ 75 years of age at time of surgery. These two groups had their clinical and demographic data analyzed. Postoperative length of hospital stay, perioperative major morbidity, and in-hospital mortality were analyzed using analysis of variance, χ2, and multivariate analyses. The average age of patients in group A was 57 years, compared with 81 years in group B. We found no significant difference in the percentage of gastric resections for malignancy (group A, 49% vs group B, 62%) or emergency surgery (group A, 10% vs group B, 10%) between age groups. There was a significant increase in length of stay in the older patients (11.7 days vs 17.6 days; P = 0.032), as well as major complications (11.1% in group A vs 27.6% in group B; P = 0.008). The in-hospital mortality rates approached significance (group A, 4% vs group B, 12%; P = 0.057). Gastric resection in elderly patients carries with it longer hospital stays, higher risk of complications, and in-hospital mortality rates despite similarity in patient disease. This information is imperative to convey to the elderly patients in the preoperative period before gastric resection.
Stapled Hemorrhoidopexy as a Day-Surgery Procedure
Authors: Cosenza Umile M. , Masoni Luigi , Conte Stefano , Simone Mauro , Nigri Giuseppe , Mari Francesco S. , Milillo Andrea , Brescia Antonio
Published: June 2020

In the last 10 years, stapled hemorrhoidectomy has gained worldwide consensus. We studied a day-surgery stapled hemorrhoidopexy protocol to allow shorter recovery time and cost reduction. From 2003 to 2008, we performed 292 outpatient stapled hemorrhoidopexies under spinal or local anesthesia including symptomatic Grade III and IV hemorrhoid disease. We used PPH 01 to PPH 03 staplers. We assessed early and late postoperative pain with a Visual Analog Scale, whereas clinical postoperative examinations were performed at sev7en days, 6 months, and 1, 3, and 5 years after surgery. The mean surgery time was approximately 18 minutes (range, 13 to 39 minutes). Of 292 patients, 39 were not dischargeable for urine retention, severe pain, or mild bleeding. Four other patients were rehospitalized within 8 days for bleeding. Twenty-one patients reported transient fecal urgency, whereas nobody reported anal incontinence. We can conclude that stapled hemorrhoidopexy is a safe and effective procedure if performed in a day-surgery unit. The complication rate is comparable to that of inpatient procedures.
The History of Mastectomy
Authors: Loukas Marios , Tubbs R. Shane , Mirzayan Nadine , Shirak Michelle , Steinberg Ashley , Shoja Mohammadali M.
Published: June 2020

The mastectomy that is performed today is a procedure born from hundreds of years of discoveries, inventions, and amendments to existing surgical techniques. The reasons for performing this extreme surgery have changed as well, ranging from unilateral breast removal to allow greater upper limb functionality to bilateral removal of the breasts or breast tissue in individuals predisposed to breast cancer or in individuals who have already been diagnosed. The additions of surgical tools and anesthetics to the field of medicine further transformed the surgical field in general and had a large impact on the mastectomy. William Halsted's radical mastectomy served as the basis of most future breast removal techniques, and it the method recognized today as the “radical mastectomy.” Most radical surgeries are currently used for prophylaxis, whereas less invasive lumpectomies have eclipsed breast removal surgeries as of the latter half of the 20th century.
Resection and Drainage of Hilar Cholangiocarcinoma: An 11-Year Experience of a Single Center in Mainland China
Authors: Zheng-Rong Lian , Hai-Bo You , Xin Chen , Chuan-Xin Wu , Zuo-Jin Liu , Bing Tu , Jian-Ping Gong , Sheng-Wei Li
Published: June 2020

The purpose of this study is to provide appropriate approaches for resection and drainage of hilar cholangiocarcinomas. Surgical approaches and postoperative survival rates of the patients were analyzed retrospectively. The 1-, 3-, and 5-year cumulative survival rates for patients who underwent resection were 76.6, 36.2, and 10.6 per cent, which was higher than those of 60, 14.3, and 0 per cent, respectively, in palliative operation. Moreover, the 1-, 3-, and 5-year cumulative survival rates for patients who underwent R0 were 88.9, 44.4, and 13.9 per cent, which was improved compared with those of 36.4, 9.1, and 0 per cent, respectively, in nonR0 resection. In addition, the overall survival time of patients who underwent R0 resection combined with hemihepatectomy and caudate lobe resection was longer than of those who underwent R0 without this extra operation, especially within 3 years after operation. After endoscopic metal biliary endoprothesis for patients who were intolerant of resection, liver function was improved at 2 weeks postoperation and the 1-, 3-, and 5-year cumulative survival rates for these patients were 72.7, 18.2, and 0 per cent, respectively. Treatment should be personalized. Resection is the most efficacious therapy, and negative histologic margins should be achieved in radical operation and “skeletonized” surgical operation is the basic requirement of radical treatment of hilar cholangiocarcinoma. Portal vein resection is beneficial to long-term survival and R0 resection combined with caudate lobe resection and hemihepatectomy is more efficacious for patients with Bismuth-Corlette type III hilar cholangiocarcinoma. The preferred approach of drainage in palliative operation is endoscopic metal biliary endoprothesis, which is more appropriate than tumor resection for the patients who suffer from serious comorbidities.
Article Commentary: Perils, Pitfalls, and Benefits of a Surgeon as a Health System Employee: The Contracting Process
Authors: Graebner Nancy K.
Published: June 2020

One would be hard pressed today to find a general surgeon or subspecialty-trained general surgeon who has not been approached by a health system to discuss employment. The majority of physicians find these initial discussions with a hospital administrator daunting at best regardless of whether they are just finishing residency or fellowship training or have had many successful years of private practice under their belt. Just as real estate has the mantra of “location, location, location,” I would suggest that physician employment by a health system should have the mantra of “relationship, relationship, relationship.” The following tips provide guidance on how to better understand the potential perils, pitfalls, and benefits of specific content sections of a standard template employment agreement between a health system and a physician. Physicians should review, understand, and be ready to engage in dialogue with the hospital administrator before involving attorneys. My experience is that if the dialogue begins with the attorneys representing each party, the opportunity to fully develop a partnership relationship between the parties is either lost or at minimum severely delayed in its development.
Use of a Handheld, Semiconductor (Cadmium Zinc Telluride)-Based Gamma Camera in Navigation Surgery for Primary Hyperparathyroidism
Authors: Fujii Takaaki , Yamaguchi Satoru , Yajima Reina , Tsutsumi Soichi , Uchida Nobuyuki , Asao Takayuki , Oriuch Noboru , Kuwano Hiroyuki
Published: June 2020

The recent development of gamma-ray probes makes it possible to perform radioguided surgery for primary hyperparathyroidism (PHPT). There have only been a few reports, however, regarding the use of a handheld gamma camera to detect parathyroid adenoma intraoperatively. The aim of this preliminary study was to assess the efficiency of a semiconductor gamma camera (eZ-SCOPE AN) in navigation surgery for PHPT. The eZ-SCOPE is designed to be used as a handheld, regional diagnostic imaging device. Eleven consecutive patients with documented primary hyperparathyroidism underwent surgery using this compact camera. Scintigraphy images of the neck by eZ-SCOPE were acquired: 1) before skin incision; 2) after adenoma location; 3) after adenoma excision; and 4) ex vivo imaging of the specimen. In scan-positive cases by preoperative Tc-MIBI, the eZ-SCOPE revealed parathyroid adenoma in all cases (100%), whereas ultrasound and CT showed a single adenoma in 63.6 and 72.7 per cent of cases, respectively. Navigation surgery for PHPT using the eZ-SCOPE permitted intraoperative identification and removal of parathyroid adenoma in all cases. Scintigraphy images of the neck by eZ-SCOPE also revealed a single adenoma even before skin incision. Our results suggest that Tc-MIBI scintigraphy with the eZ-SCOPE is useful for navigation surgery for PHPT. The eZ-SCOPE is useful for skin marking and could be easily applied for minimally invasive radioguided parathyroidectomy in scan-positive cases.
The Contribution of Simulation Training in Enhancing Key Components of Laparoscopic Competence
Authors: Loukas Constantinos , Nikiteas Nikolaos , Kanakis Meletios , Georgiou Evangelos
Published: June 2020

This study aims to investigate how basic training contributes to the performance of complex laparoscopic tasks performed in a virtual reality (VR) environment. An assessment methodology is proposed based on quantitative error analysis of key components of laparoscopic competence. Twenty-five inexperienced surgeons were trained on four basic tasks. The effect of training was assessed on three independent scenarios (two procedural: adhesiolysis and bowel suturing, and a laparoscopic cholecystectomy [LC]). Several error parameters were post hoc analyzed to yield a quantitative performance index for two fundamental skills: proficiency and safety. Time and instrument path length were also measured and compared. Correlation analysis was performed to study how these indices correlate one another. Significant learning curves were demonstrated during training. For adhesiolysis, all four indices improved significantly ( P < 0.05). Time and path length presented plateaus for all basic tasks, whereas proficiency and safety only for two and one task(s), respectively. For bowel suturing, only time and safety errors showed a decrease ( P < 0.05). Significant performance enhancement was observed for LC in which errors and path length reduced after training ( P < 0.05). Our results revealed also an increased number of correlations after training, especially for proficiency. This study finds it possible to assess key competence skills based on the quantitative analysis of various parameters generated by a VR simulator. The improvement in basic training is transferred to more complex tasks. The proposed methodology is useful for structured evaluation of laparoscopic performance demonstrating fundamental elements of surgical competence.
Intraoperative Ultrasound Can Decrease the Re-excision Lumpectomy Rate in Patients with Palpable Breast Cancers
Authors: Davis Karole M. , Hsu Chiu-Hsieh , Bouton Marcia E. , Wilhelmson Krista L. , Komenaka Ian K.
Published: June 2020

Positive margins occur in 15 to 69 per cent of patients undergoing lumpectomy. The current study was performed to evaluate intraoperative ultrasound in patients undergoing lumpectomy for palpable breast cancer. A retrospective chart review was performed of patients with palpable cancer who underwent lumpectomy with intraoperative ultrasound from 2004 to 2009. Each patient was matched with two patients who underwent lumpectomy alone over the same time period. Matching criteria included tumor size, clinical stage, body mass index, age at diagnosis, and lymphovascular invasion or extensive intraductal component. Twenty-two consecutive patients who underwent lumpectomy with intraoperative ultrasound were matched with 44 patients who underwent lumpectomy without intraoperative ultrasound. In addition to matching criteria, the patients were similar with respect to ethnicity, insurance status, weight, predominant histology, estrogen receptor, progesterone receptor, and Her2 status. Patients who underwent lumpectomy with intraoperative ultrasound were significantly less likely to have an involved margin (41 vs 9%, P = 0.01) and less likely to require a re-excision (34 vs 9%, P = 0.04). The lumpectomy volumes in the intraoperative ultrasound group were smaller than the volumes in the lumpectomy alone group. Intraoperative ultrasound can decrease the rate of positive margins and re-excision lumpectomy in patients with palpable breast cancers.
Has the Use of Anti-Adhesion Barriers Affected the National Rate of Bowel Obstruction?
Authors: Geiger Timothy M. , Roberts Patricia L. , Read Thomas E. , Marcello Peter W. , Schoetz David J. , Ricciardi Rocco
Published: June 2020

In this study, we analyzed temporal trends in anti-adhesion barrier application and admission rates for small bowel obstruction. We used data from the Nationwide Inpatient Sample and identified patients with ICD-9 codes for “application or administration of anti-adhesion barrier substances” from October 2002 through December 2007. Next, we identified cases of bowel obstruction coded from January 1997 through December 2007. We then used Kendall correlation analyses and the Joinpoint regression program to evaluate changes in trends. From October 1, 2002 through December 31, 2007, a total of 28,014 patients had an anti-adhesion barrier substance applied. During the study period, application of anti-adhesion barriers increased from 0.7 applications per 100,000 to 2.6 applications per 100,000 population (Joinpoint and Kendall; P < 0.002). Since 1997 there has been a steady rise in hospitalizations for bowel obstruction, increasing from 18.3 cases per 100,000 to 19.8 cases per 100,000 population (Joinpoint and Kendall; P < 0.002). In conclusion, the application of anti-adhesion barriers has increased significantly since 2002, yet bowel obstructions continue to be a major health problem.
Assessing the Use of Venous Thromboembolism Risk Assessment Profiles in the Trauma Population: Is It Necessary?
Authors: Acuña David L. , Berg Gina M. , Harrison Bridget L. , Wray Trenton , Dorsch Diane , Sook Cynthia
Published: June 2020

Deep venous thrombosis (DVT) and the subsequent development of venous thromboembolism (VTE) are a significant cause of mortality, morbidity, and cost of care in trauma patients. This study aims to: 1) validate 5 as a critical threshold for high risk; 2) validate risk factors associated with DVT/VTE development; 3) evaluate exogenous estrogen and smoking as risk factors; and 4) analyze daily risk assessment profile (RAP) score changes. We performed a retrospective chart review of trauma patients admitted from January 2001 through December 2005. Univariate odds ratios were performed to assess potential risk factors for VTE. Of the 110 charts reviewed, 31 patients had confirmed DVT/VTE. Three of 26 patients with an RAP score < 5 suffered a VTE; one resulted in death. Significant risk factors included femoral venous line insertion, operation longer than 2 hours, head abbreviated injury score > 2, and Glasgow Coma Scale score < 8. RAP fluctuations were due to a changing Glasgow Coma Scale score, and whether the patient received more than four transfusions, was in surgery for more than 2 hours, or required a femoral venous catheter or major venous repair. The RAP critical value (5) was not validated. We recommend all trauma patients be treated with prophylactic anticoagulants throughout the hospital stay unless clear contraindications exist.
Geriatric Education for Surgical Residents: Identifying a Major Need
Authors: Duane TherÈSe M. , Fan Lingbo , Bohannon Arline , Han Jinfeng , Wolfe Luke , Mayglothling Julie , Whelan James , Aboutanos Michael , Malhotra Ajai , Ivatury Rao R.
Published: June 2020

This study evaluated a program designed to test and enhance residents’ knowledge of geriatrics. A 2-year prospective interventional trial was conducted. Surgical residents underwent pretesting (pre) in three areas: polypharmacy, delirium, and end of life. They then received educational materials and completed a posttest within 1 month and a patient simulation examination graded by a physician observer and the patient on his or her satisfaction. Forty-nine residents (51% interns, 55% general surgery residents) participated. Seventy per cent had no prior geriatrics education. Test scores significantly improved from pretest to posttest (12.9 ± 3.1 vs 13.78 ± 3.12, P = 0.01). The scores were consistently better on poly topics and consistently worse on end-of-life topics: pretest per cent correct: polypharmacy 60, end of life 46, P = 0.007; posttest percent correct: polypharmacy 63, end of life 49, P = 0.0014. By Pearson correlation, the pretest and posttest scores did not correlate with either the observer ( R = -0.16, P = 0.27 pre, R = -0.08, P = 0.59 post) or subscores ( R = -0.27, P = 0.11 pre, R = -0.13, P = 0.45 post), although the observer and subscore correlated with each other ( R = 0.35, P = 0.036). Performance was poor and did not correlate with better patient care by simulation. Other options for geriatric education need to be considered and evaluated.
Application of Subcutaneous Talc in Hernia Repair and Wide Subcutaneous Dissection Dramatically Reduces Seroma formation and Postoperative Wound Complications
Authors: Klima David A. , Brintzenhoff Rita A. , Tsirline Victor B. , Belyansky Igor , Lincourt Amy E. , Getz Stanley , Heniford B. Todd
Published: June 2020

Wound complications after large ventral hernia repairs when combined with wide subcutaneous dissection (OVHR/WSD) are common (33 to 66%). We evaluate a novel technique of applying talc to wound subcutaneous tissues to decrease wound complications. We accessed our prospectively collected surgical outcomes database for OVHR/WSD procedures performed. Patients were divided into those that did and did not receive subcutaneous talc (TALC vs NOTALC). Demographics intraoperative and outcomes data were collected and analyzed. The study included 180 patients (n = 74 TALC, n = 106 NOTALC). Demographics were all similar, but hernias were larger in the TALC group. TALC patients had their drains removed earlier (14.6 vs 25.6 days; P < 0.001) with dramatic reduction in postoperative seromas requiring intervention (20.8 to 2.7%; P < 0.001) and cellulitis (39.0 to 20.6%; P = 0.007). Short-term follow-up demonstrates significantly higher recurrence rates in the NOTALC group with each recurrence related to infection. The use of talc in the subcutaneous space of OVHR/WSD results in significantly earlier removal of subcutaneous drains, fewer wound complications, and a decrease in early hernia recurrence. Use of talc in the subcutaneous space at the time of wound closure is an excellent technique to decrease wound complications in large subcutaneous dissections.
Does Protected Research Time During General Surgery Training Contribute to Graduates’ Career Choice?
Authors: Bhattacharya Syamal D. , Williams Judson B. , De La Fuente Sebastian G. , Kuo Paul C. , Seigler Hilliard F.
Published: June 2020

A number of general surgery training programs offer a dedicated research experience during the training period. There is much debate over the importance of these experiences with the added constraints placed on training surgeons including length of training, Accreditation Council of Graduate Medical Education limitations, and financial barriers. We seek to quantify the impact of a protected research experience on graduates of a university-affiliated general surgery training program. We surveyed all graduates of a single university-affiliated general surgery training program who completed training from 1989 to 1999. Data was obtained for 100 per cent of the subjects. Most graduates (72/73; 98.6%) completed a dedicated research experience (range: 1-5 years). Presently, 72.6 per cent (53/73) are practicing academic surgery and 82.5 per cent (60/73) are engaged in research activities. Fifty-one of 73 graduates (69.5%) have current research funding including 32.9 per cent (24/73) with National Institutes of Health funding. Of all graduates, 42.5 per cent (31/73) have become full professors with 20.2 per cent (15/73) division/section chiefs and 14.3 per cent (10/73) department chairmen or vice chairmen. Those trainees achieving a career in academic surgery were statistically more likely to have committed 2 or more years to a protected research experience during training ( P < 0.05), fellowship training after general surgery residency ( P < 0.01), and a first job at an academic institution upon completion of training ( P < 0.001). Understanding the importance of resident research experiences while highlighting critical factors during the formative training period may help to ensure continued academic interest and productivity of future trainees.
Laparoscopic Living Kidney Donation at a Single Center: An Examination of Donor Outcomes with Increasing Experience
Authors: Cannon Robert M. , Eng Mary , Marvin Michael R. , Buell Joseph F.
Published: June 2020

This study was undertaken to examine short-term outcomes of laparoscopic donor nephrectomy performed by transplant surgeons at a medium volume institution, with the specific goal of determining the presence of a learning curve effect. With institutional review board approval, a retrospective chart review was performed examining patient demographics, operative factors, and in-hospital outcomes over a 12-year period. Specific attention was paid to differences in outcomes between patients undergoing operation in the first versus the most recent 6-year period. Continuous and categorical variables were examined using the Wilcoxon rank sum test and χ2 analysis, respectively. The study group consisted of 129 patients. Median operative time was 234 minutes with a median estimated blood loss of 100. The median preoperative creatinine was 0.9, with a postoperative median creatinine of 1.3. The overall complication rate was 12.4 per cent, with ileus being the most common. There were two cases of post op acute renal failure, both of which were self limited and did not require dialysis. No patients died. Patients in the most recent 6 years (n = 77) enjoyed a shorter length of stay (2 vs 3 days, P < 0.001) than patients in the first 6-year period (n = 52). Additionally, there was a trend towards decreased complications in the second era that did not reach significance (9.1% vs 17.3%, P = 0.17). Laparoscopic donor nephrectomy is an attractive means of donation, and can be performed with low risk to the donor and minimal learning curve effect.
Geographical Influence on Racial Disparity in Breast Cancer Presentation in the United States
Authors: Keller Deborah , Guilfoyle Cara , Sariego Jack
Published: June 2020

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It has been shown that breast cancer presentation varies between racial groups nationwide. Several studies have suggested that this is more a function of geographic rather than true racial disparity. The current study was undertaken to examine racial disparity in breast cancer presentation and to determine whether such disparity continues to be seen once geographic factors are taken into account. Breast cancer data were reviewed for all programs reporting to the American College of Surgeons Commission on Cancer National Cancer Database (NCDB) between 2000 and 2007, inclusive. These data were readily available online. Variables reviewed were: stage at the time of presentation; race; histology; and geographic location within the United States. Four broad regions of the country were chosen, corresponding to the U.S. Census Regions: Northeast, South, Midwest, and West. Patient data were classified as either “early” (stages 0, I, and II) or “late” (stages III and IV) at the time of presentation. A total of 1,388,186 patients were reported during the study period; 1,132,128 white and 256,058 nonwhite. There was a statistically significant difference in presentation between the two racial cohorts; a significantly higher percentage of whites presented with “early” disease (88.8%) when compared with nonwhites (83.8%). This statistically significant difference persisted even when the data were corrected for geographic location within the United States. There is a racial disparity with regard to breast cancer presentation throughout the United States which seems to be independent of geographic location. Nonwhites in all geographic regions present with later-stage disease than whites.