bluuebunny/crossref_metadata_2025 huggingface dataset:
Reflections on Dissection: Leave No Student Behind
Authors: Skandalakis John E.
Published: June 2020

Dissection is being reduced–and even removed–from the medical curriculum in Australia, New Zealand, the United Kingdom, Ireland, and the United States. Dissection's contribution to the curriculum is too important to be diminished. To understand the human body, students must dissect. To avoid anatomical complications, future surgeons need the knowledge they can gain from dissection. Cadavers reveal the uniqueness of each body and the body's strength and fragility, which cannot be learned from books or computers. Cadavers offer surgical skill-building opportunities and confrontation with death. For all its strengths, however, dissection alone does not teach everything the student needs to know. Other educational tools (books, CT and MRI, animation of developmental processes) successfully fill in gaps of knowledge. Surgeons and educators must recognize the threat that decreased dissection poses to our students and patients. They must take steps to support dissection in the medical curriculum or, if it has disappeared, to bring it back.
Current Management of Sinusoidal Portal Hypertension
Authors: Ravindra Kadiyala V. , Eng Mary , Marvin Michael
Published: June 2020

Portal hypertension resulting from cirrhosis was one of the biggest challenges faced by general surgeons up until the past two decades. The management of portal hypertensive variceal hemorrhage has undergone dramatic changes during this period. Endoscopic variceal ligation and transjugular intrahepatic portosystemic shunts are currently used with great success. The degree of liver dysfunction remains the most important determinant of outcome in these patients. Patients with cirrhosis who have good liver function and recurrent variceal bleed remain candidates for shunt surgery. However, the need for surgical intervention has become a rarity. The success of liver transplantation has ensured that portal hypertension is cured permanently and one does not often see the critically ill and decompensated patient with cirrhosis on the surgical service. A review of the current treatment options in this very ill patient population is the primary focus of this article.
Periappendiceal Dermoid: A Rare Cause of Right Lower Quadrant Pain
Authors: Ghersi Marcelo M. , Carrillo Sergio A. , Danielpour Payman , Willis Irvin
Published: June 2020

Dermoids are mature teratomas lined with a stratified squamous epithelium. They are known to present anywhere in the body, mostly with minimal or no associated symptoms. The authors present the case of a 44-year-old man who presented with an acute abdomen suggestive of appendiceal disease. On surgical exploration, the patient was found to have an inflamed cystic lesion in the mesoappendix that was resected and diagnosed as a dermoid cyst on pathological examination. This is the seventh case in the literature of a periappendiceal dermoid, but the first that presents in such a manner. This report is presented because of its important clinical applications for the general surgeon.
Cutaneous Metastases in Patients with Rectal Cancer: A Report of Six Cases
Authors: Gazoni Leo M. , Hedrick Traci L. , Smith Philip W. , Friel Charles M. , Swenson Brian R. , Adams Joshua D. , Lisle Turner C. , Foley Eugene F. , Ledesma Elihu J.
Published: June 2020

Cutaneous metastases from rectal cancer are rare manifestations of disseminated disease and uniformly represent dismal survival. A retrospective review of six patients with rectal cancer metastatic to the dermis was performed. The diagnosis of rectal cancer was made concurrently with the diagnosis of the dermal metastases in all six patients. A 100 per cent histopathologic concordance existed between the tissue of the dermal metastases and primary rectal tumor. The progression of systemic metastatic disease was the cause of death in 83.3 per cent of patients (5/6). No patient survived more than 7 months from the time of diagnosis. Recognition of suspicious skin lesions as possible harbingers of undiagnosed visceral malignancy is important in managing patients both with and without a history of previous cancer.
Lobular Neoplasia: Is Surgical Excision Warranted?
Authors: Sohn Vance Y. , Arthurs Zachary M. , Kim Flora S. , Brown Tommy A.
Published: June 2020

The treatment of breast cancer associated with lobular neoplasia detected on core needle biopsy (CNB) remains controversial. The purpose of this study was to review the prevalence of lobular neoplasia in CNB specimens and to correlate CNB pathology to final surgical pathology. Patients with lobular neoplasia were included for analysis in this retrospective review. Patients with concomitant malignant or atypical lesions were excluded. Method of initial diagnosis, clinical history, pathology results, and follow-up data were then analyzed. From January 1994 to December 2005, 5257 CNBs were performed at our tertiary level medical facility. Of patients with lobular neoplasia, 42 of 50 (84%) patients had atypical lobular hyperplasia, whereas 8 (16%) patients were diagnosed with lobular carcinoma in situ on CNB specimens. There were no associated malignancies in 21 patients who underwent immediate surgical excision. Of those patients who were serially followed, four developed malignancies at an average of 73 months after the sentinel diagnosis. Three of the four (75%) malignancies occurred in the ipsilateral breast. Patients with a diagnosis of lobular neoplasia by CNB should not routinely undergo an open surgical biopsy. Lobular neoplasia should only be considered a risk marker for future invasive breast cancer.
Optimal Treatment of Hepatic Abscess
Authors: Hope William W. , Vrochides Dennis V. , Newcomb William L. , Mayo-Smith William W. , Iannitti David A.
Published: June 2020

Many treatment strategies have been proposed for pyogenic liver abscesses; however, the indications for liver resection for treatment have not been studied in a systematic manner. The purpose of our study was to evaluate the role of surgical treatment in pyogenic abscesses and to determine an optimal treatment algorithm. We retrospectively reviewed the medical records of all patients who had a pyogenic liver abscess at Rhode Island Hospital between 1995 and 2002. Abscesses and treatment strategies were classified into three groups each. The abscess groups included Abscess Type I (small <3 cm), Abscess Type II (large >3 cm, unilocular), and Abscess Type III (large >3 cm, complex multilocular). The treatment strategy groups included Treatment Group A (antibiotics alone), Treatment Group B (percutaneous drainage plus antibiotics), and Treatment Group C (primary surgical therapy). Descriptive statistics were calculated and χ2 used for comparison with a P < 0.05 considered significant. Our study consisted of 107 patients with pyogenic liver abscess. The success rate for small abscesses treated with antibiotics was 100 per cent. The success rate with antibiotics and percutaneous drainage for large, unilocular abscesses was 83 per cent and for large, multiloculated abscesses was 33 per cent. None of the 27 patients who had surgical therapy for large, multiloculated abscesses had recurrences. Surgical treatment for large (>3 cm), multiloculated abscesses had a significantly higher success rate than percutaneous drainage plus antibiotic therapy (33% versus 100%, P ≤ 0.01). The mortality rate for the percutaneous drainage plus antibiotic group was not significantly different from the primary surgical group (4.2% versus 7.4%, P = 0.40). We propose a treatment algorithm with small abscesses being treated with antibiotics alone; large, uniloculated abscess with percutaneous drainage plus antibiotics; and large, multiloculated abscessed treated with surgical therapy.
Recurrence after Laparoscopic Ventral Hernia Repair: A Prospective Pilot Study of Suture versus Tack Fixation
Authors: Greenstein Alexander J. , Nguyen Scott Q. , Buch Kerri E. , Chin Edward H. , Weber Kaare J. , Divino Celia M.
Published: June 2020

Mesh fixation in laparoscopic ventral hernia repair requires the use of tacks and/or permanent transabdominal sutures. Sutures pass through all fascial and muscle layers of the anterior abdominal wall, whereas tacks secure the mesh simply to peritoneum. Controversy exists regarding the optimal fixation method. In this pilot study, we compared recurrence rates between these two techniques. Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively and nonrandomly enrolled in the study and underwent either suture-fixation or tack-fixation. Office charts, computed tomography, and telephone interviews were used to determine recurrence events. χ2 and Student's t tests were performed to compare group characteristics and multivariate Cox regression analysis was used to assess for recurrence predictors after adjusting for potential confounders. From 2004 to 2005, 27 patients had suture repairs and 21 had tack repairs. The two groups had similar demographic, history, and operative variables. At a mean follow-up of 18 months, the recurrence rate was 14 per cent. In multivariate analyses, fixation method did not significantly affect recurrence. In this pilot study, patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experienced similar recurrence rates. Future studies will be needed to validate these findings.
Synchronous Mucosa-Associated Lymphoid Tissue Lymphoma and Gastrointestinal Stromal Tumor of the Stomach Presenting with Gastric Bleeding
Authors: Yamaguchi Tetsuya , Takahashi Hiroshi , Kagawa Ryuzaburo , Takeda Ryoji , Sakata Shingo , Yamamoto Michihiro , Nishizaki Daisuke , Yasui Hiroshi
Published: June 2020

We report an extraordinarily rare case of synchronous mucosa-associated lymphoid tissue lymphoma and gastrointestinal stromal tumor of the stomach. An 80-year-old man presented with gastric bleeding. Gastroscopy showed an ulcerative lesion and a submucosal tumor at the upper corpus of the stomach. The ulcerative lesion was proven by biopsy to be mucosa-associated lymphoid tissue lymphoma, but the submucosal tumor could not be diagnosed. Due to the repeating episodes of massive gastric bleeding, a total gastrectomy with lymphadenectomy was performed. After the operation, the submucosal tumor was pathologically proven to be a gastrointestinal stromal tumor. In this case, synchronous occurrence of mucosa-associated lymphoid tissue lymphoma and gastrointestinal stromal tumor seems to be coincidental rather than related with the same pathogenic triggering. Surgical resection of the stomach provided an accurate diagnosis and an effective treatment.
Sigmoid Colon Duplication Cysts
Authors: Paulson E. Carter , Mahmoud Najjia N.
Published: June 2020

Enteric duplication cysts are uncommon congenital anomalies that can occur anywhere along the length of the alimentary tract or nearby organs. Overall, the colon is the least common site of congenital alimentary duplications. Colonic duplication cysts can present with symptoms of diverticulitis and can be confused with acquired giant sigmoid diverticula. We present a case of a sigmoid colon duplication cyst presenting as persistent diverticulitis in an adult male. We review the literature and attempt to differentiate congenital colonic duplication cysts from the more common, acquired giant colonic diverticula.
Resuscitation of Hypotensive Head-Injured Patients: Is Hypertonic Saline the Answer?
Authors: Pascual Jose L. , Maloney-Wilensky Eileen , Reilly Patrick M. , Sicoutris Corinna , Keutmann Michael K. , Stein Sherman C. , Leroux Peter D. , Gracias Vicente H.
Published: June 2020

Hypertonic saline (HTS) may decrease intracranial pressure (ICP) in severe traumatic brain injury (STBI) and effectively resuscitates hypotensive patients. No data exist on institutional standardization of HTS for hypotensive patients with STBI. It remains unclear how HTS affects brain tissue oxygenation (PbtO2) in STBI. We hypothesized HTS could be safely standardized in patients with STBI and would lower ICP while improving cerebral perfusion pressure (CPP) and PbtO2. Under institutional guidelines in a Level I trauma center, 12 hypotensive STBI intensive care unit subjects received HTS. Inclusion criteria included mean arterial pressure (MAP) ≤ 90 mmHg, Glasgow Coma Scale (GCS) ≤ 8, ICP ≥ 20 mmHg, and serum [Na+] < 155 mEq/L. All patients underwent ICP monitoring. Hemodynamics, CPP, ICP, and PbtO2 data were collected before and hourly for 6 hours after HTS infusion. Guideline criteria compliance was greater than 95 per cent. No major complications occurred. Mean ICP levels dropped by 45 per cent (P < 0.01) and this drop persisted for 6 hours. CPP levels increased by 20 per cent (P < 0.05). PbtO2 remained persistently elevated for all time points after HTS infusion. Institutional use of HTS in STBI can be safely implemented in a center caring for neurotrauma patients. HTS infusion in hypotensive STBI reduces ICP and raises CPP. Brain tissue oxygenation tends to improve after HTS infusion.
Are Adrenal Injuries Predictive of Adrenal Insufficiency in Patients Sustaining Blunt Trauma?
Authors: Castaldo Eric T. , Guillamondegui Oscar D. , Greco Joseph A. , Feurer Irene D. , Miller Richard S. , Morris John A.
Published: June 2020

Adrenal insufficiency (AI) is an uncommon life-threatening development in trauma patients. The aim of this study was to determine if adrenal injury sustained during blunt trauma is associated with an increased risk of AI. A single-institution retrospective cohort review was performed over a 3-year period on all patients with blunt trauma requiring intensive care admission and mechanical ventilation for longer than 24 hours. Adrenal injuries were identified on admission CT scan. All patients with AI were identified as noted by practice management guidelines. Patients were stratified by Injury Severity Score (ISS) as less than 16, 16 to 25, and greater than 25 and relative risks were calculated. Multiple logistic regression was performed using age, race, sex, Glasgow Coma Scale, ISS, length of hospitalization, and adrenal injury as covariates with AI as the outcome of interest. A secondary analysis was then performed with adrenal injury classified as bilateral versus unilateral or no adrenal injury and relative risks were calculated for ISS strata. A total of 2072 patients were identified with 71 developing AI. Adrenal injuries were noted in 113 patients with eight subsequently developing AI. Multiple logistic regression model (P < 0.01) showed that age (P < 0.01) and increasing ISS (P = 0.02) were predictive of AI. Adrenal injury was not an independent predictor of AI (P = 0.12). After controlling for age and ISS, adrenal injury was not an independent predictor of the development of AI. Adrenal insufficiency should be considered with increasing injury severity and age in the intensive care setting after blunt trauma.
Article Commentary: Current Status of Heroic Limb Salvage for Critical Limb Ischemia
Authors: Taylor Spence M.
Published: June 2020

The treatment of chronic lower extremity peripheral arterial disease is in a state of flux. During the past decade, vascular surgeons have assumed the responsibility for the endovascular care of patients needing vascular intervention. Once surgeons began performing these procedures, a change in attitude toward angioplasty resulted in an “endovascular explosion” and an overall reassessment of the traditional approaches to critical limb ischemia. Our current method of assessing outcomes is also in a state of flux. The original measure of procedural success, reconstruction patency, has been found to be a poor predictor of both patient palliation and functional success. A shift toward determining more accurate, patient-oriented outcome measures is ongoing. Until then, evidence would suggest that there are patients with such severe medical comorbidities, which include impaired ambulatory ability at presentation, that the benefits of revascularization seem to be insignificant. As our patient population ages and our healthcare system continues to fail financially, economic rationing motivated by lack of evidence-based data to the contrary may dictate that these patients are best served by primary limb amputation.
Article Commentary: Pain after Mastectomy and Breast Reconstruction
Authors: Vadivelu Nalini , Schreck Maggie , Lopez Javier , Kodumudi Gopal , Narayan Deepak
Published: June 2020

Breast cancer is a potentially deadly disease affecting one in eight women. With the trend toward minimally invasive therapies for breast cancer, such as breast conserving therapies, sentinel node biopsies, and early treatments of radiation and chemotherapy, life expectancy after breast cancer has increased. However, pain after breast cancer surgery is a major problem and women undergoing mastectomy and breast reconstruction experience postoperative pain syndromes in approximately one-half of all cases. Patients post mastectomy and breast reconstruction can suffer from acute nociceptive pain and chronic neuropathic pain syndromes. Several preventative measures to control acute post operative pain and chronic pain states such as post mastectomy pain and phantom pain have been tried. This review focuses on the recent research done to control acute and chronic pain in patients receiving minimally invasive therapies for breast cancer, such as breast conserving therapies of mastectomies and breast reconstruction, sentinel node biopsies, and early treatments of radiation and chemotherapy.
Combined Endorectal Advancement Flap with Alloderm® Graft Repair of Radiation and Cryoablation-Induced Rectourethral Fistula
Authors: Lesser Timothy , Aboseif Sherif , Abbas Maher A.
Published: June 2020

Rectourethral fistula is a potentially devastating disease for the patient and difficult management problem for the physician. We report a case of radiation and salvage cryoablation-induced rectourethral fistula for treatment of prostate cancer successfully repaired with a combined endorectal advancement flap with Alloderm® graft. The surgical technique is described in detail. The patient is now one year post-repair with no evidence of recurrence.
Lack of Complications in Minor Skin Lesion Excisions in Patients Taking Aspirin or Warfarin Products
Authors: Shalom Avshalom , Klein Doron , Friedman Tal , Westreich Melvyn
Published: June 2020

Many patients undergoing surgical procedures take medications that influence the coagulation system. It is common practice to discontinue the use of aspirin and warfarin products 7 to 10 days before any major surgical procedure. However, there is some controversy as to whether these medications should be discontinued for minor dermatological procedures. Our aim was to study the incidence of complications in patients receiving aspirin or warfarin and undergoing minor dermatological procedures. Two thousand three hundred twenty-six patients, operated on by a single surgeon, were studied for complications. Warfarin was used by 28 patients, 228 took aspirin, and the remainder took neither. There was no difference in the complication rate among the three groups as long as the surgeon diligently obtained hemostasis. It appears that patients taking aspirin or warfarin do not need to discontinue these medications before minor dermatological procedures.
Prognostic Indicators of Quality of Life after Cholecystectomy for Biliary Dyskinesia
Authors: Geiger Timothy M. , Awad Ziad T. , Burgard Michael , Singh Amolak , Davis Wade , Thaler Klaus , Miedema Brent W.
Published: June 2020

Approximately 30 per cent of patients who undergo cholecystectomy for biliary dyskinesia will continue to have symptoms after surgery. Quality of life has not been evaluated but may be decreased in these patients. The purpose of this study was to measure quality of life after laparoscopic cholecystectomy in these patients to better define optimal treatment of biliary dyskinesia. All patients with biliary dyskinesia (defined as the absence of gallstones, and a gallbladder ejection fraction of <35%) who underwent cholecystectomy at our institution from January 31, 2000 to January 31, 2005 were identified. Preoperative data including ultrasound, biochemical data, and pathology were retrieved by chart review. Postoperative assessment included the Gastrointestinal Quality of Life Index and a symptom survey. The postoperative quality of life was compared with historic standards. The quality of life was also compared with preoperative variables to determine if any variables predicted outcome. A total of 66 patients were identified as fitting the inclusion criteria. Forty-three patients were reached by phone and 30 agreed to participate. Patients were noted to have good recall as to preoperative symptoms when the retrospective survey of symptoms was compared with the medical record. The mean ± SD postoperative quality of life in the study population was 113 ± 20. This is higher than in historic patients with gallbladder disease before (84 ± 19) and after (102 ± 13) cholecystectomy. Quality of life in the study group was lower than the healthy control (125 ± 13). Patients having both postprandial nausea and vomiting before surgery had a lower quality of life ( P < 0.029) after surgery as compared with those without these preoperative symptoms. When adjusted for nausea and vomiting, the quality of life in study patients (119 ± 14) was similar to normal controls. No other symptom, laboratory, pathologic, or sonographic data were predictive of a lower quality of life. Cholecystectomy is beneficial for most patients with biliary dyskinesia. Nausea and vomiting were negative predictors of quality of life after cholecystectomy. These patients with nausea and vomiting may have a global gastrointestinal motility disorder and are less likely to benefit from cholecystectomy.
Postprocedural Necrotizing Fasciitis: A 10-Year Retrospective Review
Authors: Miller Aaron T. , Saadai Payam , Greenstein Alexander , Divino Celia M.
Published: June 2020

Necrotizing fasciitis (NF) is a severe soft tissue infection, which has a reported 25 per cent to 60 per cent mortality rate. In addition, NF has been reported to occur after invasive procedures. We present a 10-year retrospective study on postprocedural NF and its differences with community-acquired NF. A retrospective study was conducted from 1996 to 2006. Charts were searched using International Classification of Diseases, 9th Revision codes for NF and gas gangrene. Patients who developed NF in the area of their previous procedure without any other inciting cause of the NF were deemed eligible for the study. Eleven patients met eligibility criteria. Seven patients’ initial procedures were elective, whereas four were semiemergent. The median age was 48 years (range, 24–81 years). The time between the initial procedure and operation for NF varied from 3 days to over 3 months. No single laboratory value helped in diagnosing NF. Sixteen different bacteria were isolated from the 11 patients. Ten of 11 patients required multiple débridements. There were four mortalities, three of whom had comorbidities known to predispose to infection. NF is a rare but serious complication after invasive procedures. As a result of important differences that exist between postprocedural and community-acquired NF, we propose that postprocedural NF should be classified in its own subcategory.
Progressive Splenomegaly following Splenic Artery Embolization
Authors: Runyan Bratcher L. , Smith R. Stephen , Osland Jacqueline S.
Published: June 2020

Nonoperative management of splenic injury is standard in hemodynamically stable patients. Splenic artery embolization is a useful adjunct to nonoperative management for patients with ongoing hemorrhage. However, the complications of embolization are not well defined. We report a case of progressive splenomegaly requiring delayed splenectomy after embolization. A 57-year-old hemodynamically stable, blunt trauma patient had a Grade III splenic injury with associated subcapsular hematoma. Nonoperative management was initiated, but his hemoglobin levels progressively declined prompting proximal splenic artery embolization. His hemoglobin levels remained stable postembolization and he was discharged on postinjury day 5. The patient was readmitted 10 days later with increasing abdominal pain and shortness of breath. Repeat CT revealed an enlarged subcapsular fluid collection, but his hemoglobin level remained stable and he was discharged 5 days later. He returned again 2 days later with similar complaints, and CT demonstrated that his subcapsular fluid collection was further enlarged. Repeat hemoglobin level was again stable. The patient requested operative intervention due to intractable pain, and splenectomy was performed without complications. Operative findings included a sterile, contained subcapsular hematoma. Splenic embolization has emerged as an adjunct to nonoperative management of splenic injury; however, the indications for splenic embolization are yet to be defined, and the spectrum and frequency of potential complications are poorly documented. This case report highlights a potentially serious complication that can occur after splenic embolization.
Laparoscopic and Hand-Assisted Distal Pancreatectomy
Authors: Laxa Bernadette U. , Carbonell Alfredo M. , Cobb William S. , Rosen Michael J. , Hardacre Jeffrey M. , Mekeel Kristin L. , Harold Kristi L.
Published: June 2020

With the increased use of CT, discovering incidental pancreatic lesions has become commonplace. Lesions in the distal pancreas lend themselves well to laparoscopic resection. We reviewed our experience with laparoscopic distal pancreatectomy. During the study period, 32 distal pancreatectomies were performed. There were 20 females. Mean patient age was 58.0 years (range, 23–83 years) and mean body mass index was 29.9 kg/m2 (range, 19.9–44.7 kg/m2). Technique was laparoscopic (25) or hand-assisted (seven) with one conversion in each group. The spleen was preserved in six patients (18.8%). Mean operative time overall was 238 minutes (range, 140–515 minutes); hand-assisted was 222 minutes and laparoscopic was 254 minutes. Estimated blood loss averaged 221 mL (range, 50–1800 mL). Mean tumor size was 2.7 cm (range, 0.6–7 cm). Tumor pathology was serous cystadenoma (10), neuroendocrine tumor (six), mucinous cystic neoplasm (four), intrapapillary mucinous neoplasm (four), adenocarcinoma (three), other (four), and solid pseudopapillary neoplasm (one). Mean length of stay was 5 days (range, 3–11 days). Complications were pancreatic fistula (six), wound infection (two), pulmonary embolism (one), pancreatitis (one), myocardial infarction (one), postoperative bleed from combined laparoscopic bilateral oophorectomy (one), and pancreatic stump staple line bleed requiring reoperation (one). There were no perioperative deaths. All pancreatic fistulas resolved with conservative management.
Nonfocused Enhanced CT Evaluation of Acute Appendicitis Increases Length of Stay in the Emergency Department but Does Not Increase Perforation Rate
Authors: Riesenman Paul J. , Riesenman Kathryn P. , Stone Taylor J. , Beidler Stephanie K. , Douillet Christelle D. , Rich Preston B.
Published: June 2020

Nonfocused enhanced CT (NFECT) using intravenous and oral contrast is highly sensitive and specific for the diagnosis of acute appendicitis but requires additional time for transit of oral contrast and imaging interpretation. The aim of this study was to review our use of NFECT for the evaluation of acute appendicitis. Over a 2-year period, 295 adult patients presented to our emergency department and were diagnosed with acute appendicitis. Of these patients, 240 (81%) had undergone some form of cross-sectional imaging of the abdomen, and the majority (n = 193 [65%]) had NFECT scans performed during their evaluation. Fifty-five (19%) patients did not undergo cross-sectional radiographic evaluation (nonimaging group). Compared with the nonimaging group, patients who underwent NFECT were older (37 vs 32 years; P = 0.015) and more likely to be female (49% vs 20%; P < 0.001). Length of stay in the emergency department was significantly greater for patients who underwent NFECT (606 vs 321 minutes; P < 0.001), but there was no significant difference in the rate of acute appendiceal perforation (15% vs 9%; P = 0.297). In conclusion, use of NFECT for the diagnosis of acute appendicitis nearly doubles the patient's time in the emergency department with no significant increase in the acute perforation rate.
Pancreatic Resection with Islet Cell Autotransplant for the Treatment of Severe Chronic Pancreatitis
Authors: Argo Joshua L. , Contreras Juan L. , Wesley Mary M. , Christein John D.
Published: June 2020

Pancreatic resection can alleviate pain in properly selected patients with severe chronic pancreatitis (CP), although the apancreatic state causes “brittle” diabetes. Islet auto-transplantation (IAT) after resection can decrease diabetes-related morbidity. Twenty-six consecutive patients with CP who underwent 27 pancreatic resections with IAT from April 2005 to December 2007 were evaluated in this retrospective case control study. Data were collected by chart and operative note reviews and query of hospital databases. Subgroup analysis was performed on 21 cases of total pancreatectomy and six cases of pancreaticoduodenectomy (PD). Mean age was 43.8 years and 46.2 per cent of patients were female. The most common etiology of CP was alcoholism (34.6%), followed by idiopathic causes (30.8%) and pancreatic divisum (23.1%). There was no mortality and the complication rate was 56 per cent. Islet equivalents infused and islet equivalents/gram of pancreas were 82,094 and 2,739 respectively. Mean discharge insulin dose was 10.7 units/day. Mean follow-up was 6.5 months. At 6 months, 80 per cent of patients reporting had decreased or eliminated their use of narcotic medication and all total pancreatectomy patients required insulin (mean 23 units/day). In appropriately selected patients, pancreatic resection with IAT is safe and effective for the treatment of intractable pain associated with CP.
Acetabular and Isolated Pelvic Ring Fractures: A Comparison of Initial Assessment and Outcome
Authors: Tibbs Brian M. , Kopar Piroska , Dente Christopher J. , Rozycki Grace S. , Feliciano David V.
Published: June 2020

The purpose of this study was to describe the comparative outcomes of patients with pelvic ring fractures, acetabular fractures, and combinations of the same. Patients with pelvic or acetabular fractures were identified in the Hospital Trauma Registry, and all appropriate data were collected by reviewing the patients’ medical records, the hospital operative logs, transfusion records, and the records of surgical morbidity conferences. Patient management was consistent over the time period of the study. Univariate analysis of continuous variables was done using Student's t test; and categorical variables were analyzed with χ2 analysis. All statistical analysis was performed using JMP software (SAS International Inc., Cary, NC) with significance set at P < 0.05. One thousand, three hundred and thirty-four patients with 320 acetabular, 826 pelvic ring, and 188 combination fractures over 10 years were analyzed. Age, race, and gender were typical of trauma patients and similar amongst groups. Injury Severity Score was significantly higher (21.3 vs 12.9, P < 0.05) and Glasgow Coma Scale was significantly lower (12.5 vs 13.6, P < 0.05) in patients with pelvic ring fractures as compared with acetabular fractures. Hypotension was more common in patients with pelvic ring fractures (13.9% vs 5.3%, P < 0.05). Patients with pelvic ring fractures required more blood transfusions (3.83 vs 1.36, P < 0.05) and base deficit was lower (-6.7 vs -5.5, P = 0.03). Mortality was significantly higher among patients with pelvic ring fractures (16.5% vs 5.6%, P < 0.01). Among survivors, hospital length of stay (LOS) (18.7 vs 14.8 days, P = 0.08) and intensive care unit LOS (7.8 vs 4.7 days, P = 0.008) were significantly longer with pelvic ring fractures. Functional Independence Measurement scores trended to a higher functional outcome in patients with acetabular fractures (10.3 vs 10.0, P = 0.08). Patients with pelvic ring fractures have a worse admission base deficit, higher transfusion requirements, and increased hypotension on admission. This is reflected in their significantly higher mortality and longer hospital and intensive care unit LOS in survivors. Such clinical information is helpful when caring for patients with acetabular vs pelvic ring fractures.
Three-Year Results of Mandated Work Hour Restrictions: Attending and Resident Perspectives and Effects in a Community Hospital
Authors: Vaughn Danny M. , Stout Christopher L. , Mccampbell Beth L. , Groves Joshua R. , Richardson Albert I. , Thompson William K. , Dalton Martin L. , Nakayama Don K.
Published: June 2020

In response to the Accreditation Council of Graduate Medical Education mandated resident work hour restrictions, our residency program used a night float system in 2003. We undertook a survey of attending staff and residents to assess its effects on patient care and resident education. An anonymous survey was administered to attending staff and residents 1 year and 3 years after work hour restrictions took effect. The areas of disagreement include: beneficial effect on education (residents vs faculty: in 2004, 87% vs 22%, respectively, P = 0.02; in 2006, 71% vs 22%, P = 0.03); beneficial effect on patient care (in 2004, 53% vs 10%, P = 0.03); and compromised continuity of care (in 2004, 27% vs 70%, P = 0.04; in 2006, 7% vs 89%, P = 0.0002). One area of agreement was that residents’ quality of life had improved. Both disagreed that more errors were being made and that work hour restrictions should be mandated on practicing surgeons. Attending staff and residents have deeply held opinions regarding the effects of work hour restrictions. This reflects a continuing dissatisfaction with providing patient care and educating residents under a set of requirements that solely addresses resident sleepiness and fatigue.
Laparoscopic Cholecystectomy for Biliary Dyskinesia in Children: Report of 100 Cases from a Single Institution
Authors: Constantinou Constantinos , Sucandy Iswanto , Ramenofsky Max
Published: June 2020

Laparoscopic cholecystectomy (LC) is increasingly performed in the pediatric population. Biliary dyskinesia (BD) is largely responsible for this increase and is presently the most common indication for LC in this age group. In our institution the diagnosis of BD is made in patients with biliary symptoms, absence of biliary stones, and an ejection fraction <35 per cent on hydroxy iminoadiacetic acid (HIDA) scan. We reviewed our experience of 100 children with BD that underwent LC. Data that was prospectively collected and entered into electronic medical records by gastroenterologists, primary care physicians, and pediatric surgeons was reviewed and analyzed. Patients were symptomatic for an average of 15 months before undergoing surgery. Seventy-seven per cent reported resolution of symptoms from 6 months to 5 years following LC, whereas the rest complained of persistent symptomatology. When the two groups were compared, patients with persistent symptoms were more likely to be female and to have longer symptom duration. An ejection fraction <35 per cent reliably predicts successful outcome of LC in patients with BD. The diagnosis of BD should be entertained early in the differential of functional abdominal pain in children and referred to Pediatric Surgery when its presence is confirmed.
Radiofrequency Ablation for Unresectable Tumors of the Liver
Authors: Howard J. Harrison , Tzeng Ching-Wei D. , Smith J. Kevin , Eckhoff Devon E. , Bynon J. Steve , Wang Thomas , Arnoletti J. Pablo , Heslin Martin J.
Published: June 2020

Surgical resection of primary or metastatic tumors of the liver offers patients the best long-term survival. Liver resections may not be appropriate in patients with bilobar metastases, liver dysfunction, or severe comorbidities. Radiofrequency ablation (RFA) is a technique used to destroy unresectable hepatic tumors through thermocoagulation. We retrospectively reviewed a consecutive series of patients undergoing RFA with unresectable hepatic tumors for local recurrence and overall survival. Under an Institutional Review Board-approved protocol, all patients treated with RFA at the University of Alabama at Birmingham from September 1, 1998, to June 15, 2005, were identified. During this time period, 189 lesions in 107 patients were treated with RFA. Patients’ charts were retrospectively reviewed. Data is presented as mean ± SEM. Significance is defined as P < 0.05. Patient demographics revealed 62 per cent males and 38 per cent females with a mean age of 59 (±1) years. Hepatocellular carcinoma (HCC) represented 54 per cent of the tumors treated. Metastatic colorectal cancer represented 22 per cent and the remaining 24 per cent were other metastatic tumors. Overall recurrence rates for all tumors after RFA was 53 per cent. Local recurrence rates for HCC, colorectal cancer, and other metastatic lesions were 27.6 per cent, 29.1 per cent, and 52 per cent, respectively. The morbidity rate for the procedure was 11 per cent. There was one mortality (0.9%) related to RFA. Laparoscopic RFA for HCC in Childs-Pugh Class C cirrhotics (n = 6) resulted in 50 per cent of patients being transplanted with no evidence of disease at a mean follow-up period of 14 months. RFA is a safe and effective way for treating HCC and other unresectable tumors in the liver that are not eligible for hepatic resection. More effective control of systemic recurrence will dictate survival in the majority of patients with metastatic cancers. Local ablation for HCC in cirrhotic patients may be an effective bridge to transplantation. Liver transplantation may still be the most effective long-term treatment for localized HCC.
Does Cholecystectomy Prior to the Diagnosis of Pancreatic Cancer Affect Outcome?
Authors: Gray Stephen H. , Hawn Mary T. , Kilgore Meredith L. , Yun Huifeng , Christein John D.
Published: June 2020

Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7%; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58–0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.
Emergent and Elective Colon Surgery in the Extreme Elderly: Do the Results Warrant the Operation?
Authors: Morse Bryan C. , Cobb William S. , Valentine John D. , Cass Anna L. , Roettger Richard H.
Published: June 2020

With the elderly population rising continuously, surgeons are increasingly confronted by the dilemma of operative management in these patients, which frequently encompasses end-of-life issues. Increasing age and emergent surgery are known risk factors for poor outcomes in colon surgery. The purpose of this study is to delineate differences in outcomes between emergent and elective colon surgery and identify risk factors that can guide the surgeon in caring for the extreme elderly (age 80 years or older). From 2001 to 2006, a retrospective review of the resident database at Greenville Hospital System identified 104 extreme elderly patients who underwent colon surgery (65 elective, 39 emergent). Comparing elective and emergent operations, results showed substantial differences in morbidity (20% vs 51.2%, P < 0.001), 30-day mortality rate (7.7% vs 30.7%, P < 0.005), and length of stay (13.6 days vs 21.6 days, P < 0.004). Percentage of patients discharged to home was significantly less in the emergent group (13% vs 59%, P < 0.001). Evaluation of the emergent surgery group revealed male gender, history of smoking, and ischemic changes on pathologic examination were statistically significant risk factors for failure of surgery. As a result of the high-risk nature of emergent colon operations in the extreme elderly, it is important that surgeons carefully assess the benefits in relation to the risks and functional outcomes of surgery when planning patient care and providing informed consent.
The Reverse J Arteriovenous Graft Configuration for Hemodialysis Access: Rationale, Technique, and Outcomes
Authors: Cull David L. , Carsten Christopher G. , Kalbaugh Corey A. , York John W. , Campbell Ted R. , Cass Anna L. , Taylor Spence M.
Published: June 2020

The long-term survival of patients on hemodialysis is often limited by the exhaustion of vascular access sites. A fundamental principle of vascular access surgery is that the arteriovenous (AV) access be placed as far distally in the arm as possible. This principle enhances the secondary patency of the AV grafts by preserving the proximal veins for AV graft revision and provides venous outflow for a new AV access to be placed more proximally in the extremity. The standard straight and looped AV graft configurations violate this principle by bypassing long segments of vein in the extremity that could be used for AV graft revision or new AV graft placement. We have developed a novel AV graft configuration that preserves venous outflow and enhances the longevity of each AV access site. The purpose of this review is to describe the reverse J AV graft technique and to report our outcomes with the procedure. Between February 2004 and April 2007, 26 AV grafts were placed using the reverse J configuration. Eighteen (69%) AV grafts were placed in the upper arm, 7 (27%) were placed in the forearm, and 1 (4%) was placed in the thigh. Median follow-up was 320 days. The secondary AV graft patency was 90 per cent at 6 months, 84 per cent at 12 months, and 84 per cent at 18 months. Five AV grafts were subsequently revised to a loop configuration. Overall patient survival was 85 per cent at 6 months, 68 per cent at 12 months, and 62 per cent at 18 months. Compared with the standard straight and looped AV graft configurations, the reverse J AV graft configuration preserves the length of venous outflow in the extremity for AV graft revision or new AV graft placement. Therefore, the reverse J configuration enhances the secondary patency of AV graft patency and AV access site longevity.
Presentation of a Medullary Endocrine Neoplasia 2A Kindred with Cushing's Syndrome
Authors: Zaydfudim Victor , Stover Daniel G. , Caro Susan W. , Phay John E.
Published: June 2020

Although medullary thyroid cancer (MTC) can produce adrenocorticotropic hormone (ACTH) in up to 40 per cent of cases as determined by immunohistochemistry, clinical hypercortisolism is rarely seen. We report a medullary endocrine neoplasia 2A (MEN 2A) kindred whose proband case presented with Cushing's syndrome (CS). This 51-year-old woman presented with debilitating weakness, exertional dyspnea, 50 pound weight gain, moon facies, worsening hypertension, striae, and hirsutism. A comprehensive evaluation diagnosed ectopic ACTH production from unresectable metastatic MTC to the liver. Genetic testing revealed a germline RET proto-oncogene mutation at codon 609. Further genetic testing identified six family members with the same mutation. The patient underwent palliative bilateral laparoscopic adrenalectomies with significant improvement in major comorbidities. Overall CS resulting from ectopic ACTH overproduction by MTC is rare, occurring in 0.6 per cent of all patients with medullary thyroid carcinoma. About 50 cases have been previously reported in the literature, but only three in families with MEN 2A. We describe the first case of a MEN 2A kindred presenting with CS from ectopic ACTH production by metastatic medullary thyroid carcinoma. We advocate consideration of early bilateral laparoscopic adrenalectomies in patients with symptomatic hypercortisolism from unresectable metastatic medullary thyroid carcinoma.
Blood Glucose Variability is Associated with Mortality in the Surgical Intensive Care Unit
Authors: Dossett Lesly A. , Cao Hanqing , Mowery Nathan T. , Dortch Marcus J. , Morris John M. , May Addison K.
Published: June 2020

Intensive insulin therapy has widely and rapidly been adopted as the standard of care for the treatment of hyperglycemia in the intensive care unit (ICU). Variability in blood glucose is increasingly recognized as an important factor in outcomes in the chronic diabetic in addition to hemoglobin A1C. We tested the hypothesis that measures of blood glucose variability would be associated with mortality in the surgical ICU. A retrospective analysis of a cohort of ventilated, critically ill surgical and trauma ICU patients placed on an automated insulin protocol was performed. Blood glucose (BG) variability was measured by comparing standard deviation, percentile values, successive changes in blood glucose, and by calculating the triangular index for various glucose-related indices. Eight hundred and fifty-eight patients had 46,474 blood glucose and insulin dose data points. One hundred and twenty-one patients died for an overall mortality rate of 14 per cent. Several measures of blood glucose variability (maximum successive change in BG and the triangular index) were different between the groups despite similar mean BG between survivors (117 mg/dL) and nonsurvivors (118 mg/dL). Increased blood glucose variability is associated with mortality in the surgical ICU. Further studies should focus on the demographic, clinical, and genetic factors responsible for this observation and identify strategies to minimize BG variability.
Endoscopic Retrograde Cholangiopancreatography after Laparoscopic Roux-en-Y Gastric Bypass: A Case Series and Review of the Literature
Authors: Patel Jitesh A. , Patel Nilesh A. , Shinde Trupti , Uchal Miroslav , Dhawan Manish K. , Kulkarni Abhijit , Colella Joseph J.
Published: June 2020

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important tool in the diagnosis and treatment of pancreaticobiliary pathology. ERCP in patients that have undergone Roux-en-Y gastric bypass (RYGB) is particularly challenging because traditional transoral endoscopy may be limited. We present our experience with ERCP after RYGB and review the literature. In 2007 eight patients underwent ERCP after RYGB using open or laparoscopic transgastric access. After introduction of pneumoperitoneum, a total of four ports were placed. A purse-string was placed around a gastrotomy 4 to 6cm proximal to the pylorus. The endoscope was introduced through a 15 mm left-upper-quadrant port and the gastrotomy. Endoscopy was then performed. Laparoscopic gastrotomy was used in all patients that underwent a previous laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 6) and open gastrotomy was used for patients with a previous open RYGB (n = 2). Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. There were no postoperative complications. Laparoscopic transgastric ERCP after LRYGB is feasible, highly successful, may be performed expeditiously, and does not seem to add significant morbidity to the procedure. The ability to perform ERCP in this patient population is critical due to their tendency to have preexisting biliary disease and to develop gallstones and the associated complications.