bluuebunny/crossref_metadata_2025 huggingface dataset:
FAST Enough? A Validation Study for Focused Assessment with Sonography for Trauma Ultrasounds in a Level II Trauma Center
Authors: Holmes Galen , Romero Javier , Waxman Kenneth , Diaz Graal
Published: June 2020

The Focused Assessment with Sonography for Trauma (FAST) is widely used as the initial screening tool for abdominal trauma. Several recent studies have questioned its use. Using the Trauma Registry, 1 year of data at a Level II trauma center were reviewed. All trauma patients with dictated FAST examinations were identified. Disconcordant findings were reviewed. Predictive values for determining intraperitoneal injuries were calculated. Nine hundred seventy-four designated trauma patients were entered into the Trauma Registry. Of these, 633 had dictated FAST examinations. There were 533 true-negatives, 11 true-positives, 77 false-negatives, and six false-positives. Of the 77 false-negatives, 33 had retroperitoneal injuries and 25 had intra-peritoneal injuries. No adverse outcomes were identified from diagnostic delay. For predicting intraperitoneal injury, FAST had a negative predictive value of 96 per cent, positive predictive value of 63 per cent, sensitivity of 29 per cent, specificity of 99 per cent, and accuracy of 95 per cent. Our data demonstrate that FAST was useful for the initial assessment of intraperitoneal injuries. FAST was 95 per cent accurate and allowed for rapid triage to operative management when indicated. The data also confirm that a negative FAST does not exclude abdominal injury.
Magnetic Resonance Imaging-Guided Breast Biopsy in Lesions Not Visualized by Mammogram or Ultrasound
Authors: Oxner Christopher R. , Vora Lalit , Yim John , Kruper Laura , Ellenhorn Joshua D.I.
Published: June 2020

The use of magnetic resonance imaging (MRI) for the diagnosis and evaluation of breast lesions is still in evolution. The aim of this study was to evaluate the outcome of MR-guided biopsy for suspicious lesions seen on MRI but not visualized by mammography or ultrasound. A retrospective review was conducted on all patients undergoing MRI-guided core needle biopsy at a National Cancer Institute-designated comprehensive cancer center. Biopsies were performed using a 1.5-Tesla MR with a seven-channel breast coil taking six cores in a clock face configuration with a 10-gauge vacuum-assisted VACORA biopsy device. One hundred twenty-seven patients underwent 187 biopsies without major complication. The lesion size ranged from 4 to 12 mm. Pathology on MRI-guided core biopsy material revealed 126 (68%) benign lesions. Of these, 12 were intraductal papillomas and two were fibroadenomas. Sixty-one (32%) were deemed clinically significant and included the following pathology: invasive cancer 19 patients (10%), ductal carcinoma in situ (DCIS) in 25 patients (13%), atypical ductal hyperplasia (ADH) 15 patients (8%), and lobular carcinoma in situ in one patient (1%). There were two specimens upgraded from ADH to DCIS and one specimen that was biopsied was called ADH but there was no residual atypia on final pathology. With a median follow-up of 24 months, there were no patients with benign pathology returning with a clinically significant lesion later. MRI-guided biopsy provides an accurate and safe method for sampling suspicious lesions when no other reasonable means of biopsy is available. MRI-guided biopsy yielded clinically significant findings in approximately one-third of the sampled specimens. This technique can provide a good representative sample of clinically significant pathology. MRI-guided biopsy is a relatively new modality, which can provide a nonsurgical diagnostic specimen in the absence of mammographic or ultrasound findings.
Multifocal Micropapillary Thyroid Cancer: A New Indication for Total Thyroidectomy?
Authors: Ricci Joel A. , Alfonso Antonio E.
Published: June 2020

American Thyroid Association guidelines recommend total thyroidectomy (TT) for thyroid cancers 1 cm or greater. Liberal use of neck sonography has resulted in an increased incidence of papillary cancers detected at earlier stages with approximately half at the micropapillary level and occasionally multifocal. Concerns regarding the safety of routine TT, especially in young patients with favorable cancers, and the clinical significance of detected multifocal micropapillary cancers have been raised. Records of 516 consecutively treated patients with thyroid cancer were reviewed. A subset of 269 cases with well-differentiated papillary thyroid cancer (WDPTC) confined within the capsule of the involved lobe undergoing TT was analyzed. Patients were stratified according to age, tumor size, evidence of ipsilateral multifocality, and presence or absence of contralateral nonpalpable malignancy. Overall contralateral histologic malignancy was demonstrated in 46.4 per cent (125 of 269). The incidence was 34 per cent (30 of 88) of subcentimeter (less than 1 cm) tumors and significantly increased to 52 per cent (95 of 181) in tumors 1 cm or greater ( P = 0.006). This incidence significantly approached 76 per cent (13 of 17) in subcentimeter but multifocal tumors when 45 years or older ( P = 0002). One patient developed permanent hypocalcemia (0.4%). There were no recurrent nerve injuries. The incidence of bilateral cancer was significant in 1-cm or greater WDPTC. Patients with subcentimeter multifocal tumors, when older than 45 years, were even at higher risk for bilateral cancer. Because TT is advocated for patients with WDPTC 1 cm or greater, it should also be considered in those older than 45 years with ipsilateral multifocal micropapillary cancers, because it can be performed safely.
The Use of Bioabsorbable Staple-Line Reinforcement Performing Stapled Hemorrhoidopexy to Decrease the Risk of Postoperative Bleeding
Authors: Mari Francesco Saverio , Masoni Luigi , Cosenza Umile Michele , Favi Francesco , Berardi Giammauro , Dall'Oglio Anna , Pindozzi Fioralba , Brescia Antonio
Published: June 2020

Postoperative staple-line bleeding after stapled hemorrhoidopexy represents a major issue of this procedure, especially in the day surgery setting. In this study we assess the possible benefit of using circular bioabsorbable staple-line reinforcement to reduce the risk of hemorrhage when performing stapled hemorrhoidopexy in a day surgery setting. Patients with symptomatic II to III grade hemorrhoidal disease were randomly assigned into two groups. In Group A we performed a stapled hemorrhoidopexy using PPH33-03® with Seamguard®, a bioabsorbable staple-line reinforcement; in Group B, we used only a PPH33-03® stapler. We evaluated the intraoperative and postoperative staple-line bleeding and, secondarily, the duration of surgery, need for additional hemostatic stitches, and presence of postoperative complications. One hundred patients were enrolled in the study. Group A patients showed a statistically significant decrease of intraoperative bleeding (4 vs 42% in Group B) and hemostatic stitch placement (5.7 vs 42%) with the consequent reduction in mean operative time, postoperative pain, and tenesmus. There were no differences between the two groups in hemorrhoidal disease control or postoperative late complications. The use of bioabsorbable staple-line reinforcement while performing stapled hemorrhoidopexy may allow improvement of the safety of this procedure, especially in a day surgery setting.
Surgical Outcomes for Cancer at the Gastroesophageal Junction
Authors: Matsumoto Sohei , Takayama Tomoyoshi , Wakatsuki Kohei , Enomoto Koji , Tanaka Tetsuya , Migita Kazuhiro , Ito Masahiro , Nakajima Yoshiyuki
Published: June 2020

The aim of this study was to evaluate the clinicopathological characteristics and prognostic factors of cancer at the gastroesophageal junction (GEJ) whose center is situated at a site within 2 cm above and below the junction. This retrospective study included 90 patients with cancer at the GEJ, including 58 with adenocarcinoma (ADC) and 32 with squamous cell carcinoma (SCC). ADC tumors were larger in size than SCC tumors. ADC and SCC at the GEJ showed a similar distribution of the pattern of lymphatic spread. The rate of lower mediastinal lymph node metastasis was approximately 20 per cent, which is similar to the nodes along the celiac artery and the nodes along the common hepatic artery. The overall survival rates were similar between the groups. The presence of five or more lymph node metastases was an independent prognostic factor according to a multivariate analysis. When two or more lymph nodes larger than 10 mm were detected preoperatively, five or more lymph node metastases were proven by histology in most cases. The most frequent sites of recurrence of ADC and SCC were the peritoneum and lymph nodes, respectively. Aggressive additional treatment may be needed if two or more lymph nodes are seen on preoperative imaging.
Evaluation of the New Classification and Surgical Strategy for Myasthenia Gravis
Authors: Cui Xin-Zheng , Ji Xin-Ying , Gao Feng , Yang Kun-Peng , Bai Hui-Ling , Hong-Bing Ma , Li Tao , Zhang Qing-Yong
Published: June 2020

The aim of this study was to discuss the new methods of clinical classification and staging of patients with myasthenia gravis (MG) proposed by our group and to summarize the experiences of surgical treatment of MG with a novel incision by cutting the sternum cross-sectionally at the second intercostal level. A retrospective analysis was made for the clinical data from the patients with MG who underwent thymectomy from July 1988 to May 2009. The surgical procedures were designed into three groups, a group with Osserman classification and median incision of the sternum (Group 1), a group with MGFA typing (Myasthenia Gravis Foundation of America) and a small transverse sternal incision at the second intercostal level (Group 2), and a group with new typing and a smaller transverse sternal incision at the second intercostal level (Group 3). Observation of the clinical typing and staging was made in the patients with myasthenia crisis. The parameters such as procedure duration in Group 2 and 3 was significantly lower than those in Group 1 ( P < 0.05). The incidence of myasthenia crisis in Group 3 was significantly lower than that in Groups 2 and 3 ( P < 0.05). The procedure with a smaller transverse sternal incision at the second intercostal level (Group 3) is a safer method for patients with MG. The combination of this procedure with the new typing and staging methods proposed by our group could facilitate the selection of operation indications and opportunity, resulting in the lower incidence of myasthenia crisis and mortality. Our new procedure is well deserved to be a preferential selection by other hospitals.
Mortality Factors in Geriatric Blunt Trauma Patients: Creation of a Highly Predictive Statistical Model for Mortality Using 50,765 Consecutive Elderly Trauma Admissions from the National Sample Project
Authors: Hranjec Tjasa , Sawyer Robert G. , Young Jeffrey S. , Swenson Brian R. , Calland James F.
Published: June 2020

Elderly patients are at high risk for mortality after injury. We hypothesized that trauma benchmarking efforts would benefit from development of a geriatric-specific model for risk-adjusted analyses of trauma center outcomes. A total of 57,973 records of elderly patients (age older than 65 years), which met our selection criteria, were submitted to the National Trauma Database and included within the National Sample Project between 2003 and 2006. These cases were used to construct a multivariable logistic regression model, which was compared with the American College of Surgeons Committee on Trauma's Trauma Quality Improvement Project's (TQIP) existing model. Additional spline regression analyses were performed to further objectively quantify the physiologic differences between geriatric patients and their younger counterparts. The geriatric-specific and TQIP mortality models shared several covariates: age, Injury Severity Score, motor component of the Glasgow Coma Scale, and systolic blood pressure. Our model additionally used temperature and the presence of mechanical ventilation. Our geriatric-specific regression mode generated a superior c-statistic as compared with the TQIP approximation (0.85 vs 0.77; P = 0.048). Spline analyses demonstrated that elderly patients appear to be less likely to tolerate relative hypotension with higher observed mortality at initial systolic blood pressures of 90 to 130 mmHg. Although the TQIP model includes a single age component, these data suggest that each variable needs to be adjusted for age to more accurately predict mortality in the elderly. Clearly, a separate geriatric model for predicting outcomes is not only warranted, but necessary.
Clinicopathological Features of Benign Biliary Strictures Masquerading as Biliary Malignancy
Authors: Wakai Toshifumi , Shirai Yoshio , Sakata Jun , Maruyama Tomohiro , Ohashi Taku , Korira Pavel V. , Ajioka Yoichi , Hatakeyama Katsuyoshi
Published: June 2020

Discrimination between benign and malignant biliary strictures is difficult, with 5.2 to 24.5 per cent of biliary strictures proving to be benign after histological examination of the resected specimen. This study aimed to evaluate the clinicopathological features of benign biliary strictures in patients undergoing resection for presumed biliary malignancy. From January 1990 to August 2010, 5 of 153 (3.3%) patients who had undergone resection after a preoperative diagnosis of biliary malignancy had a final histological diagnosis of benign biliary stricture. The infiltration of immunoglobulin G4-positive plasma cells was evaluated by immunohistochemistry. None of the five patients had a history of trauma or earlier hepatobiliary surgery and all five underwent hemihepatectomy (combined with extrahepatic bile duct resection in three patients). Postoperative morbidity was recorded in two patients (transient cholangitis and biliary fistula), but there was no postoperative mortality. Histological re-examination identified immunoglobulin G4-related sclerosing cholangitis (n = 2) and nonspecific fibrosis/inflammation (n = 3). No preoperative clinical or radiographic features were identified that could reliably distinguish patients with benign biliary strictures from those with biliary malignancies. Although benign biliary strictures are rare, differentiating benign strictures from malignancy remains problematic. Thus, the treatment approach for biliary strictures should remain surgical resection for presumed biliary malignancy.
Article Commentary: The Continued Challenge of Staphylococcus aureus in the Surgical Patient
Authors: Fry Donald E.
Published: June 2020

Staphylococcus aureus continues to be a common pathogen from community-acquired infections and for infections after surgical procedures. A review of the history of this pathogen indicates that it will likely continue to develop new virulence characteristics and that it will continue to develop new patterns of resistance. This presentation addresses the three major areas for surgeons in the future. First, vancomycin is losing its effectiveness against methicillin-resistant S. aureus (MRSA). The future antibiotic choices for treating this pathogen are discussed. Second, vancomycin is losing its effectiveness for prevention of MRSA infections at the surgical site, and another antibiotic choice needs to be developed for prevention of both methicillin-sensitive and methicillin-resistant staphylococci. Third, decolonization of staphylococci from the nasopharynx is discussed commonly in the literature, but valid evidence for this practice is limited. Controlled clinical trials to prevent surgical site infection by decolonization with mupirocin or other agents are needed. In summary, S. aureus will continue to challenge surgeons as an adaptable pathogen that can defy all of our treatment efforts.
A Survival Comparison of Mucin-Producing Adenocarcinoma of the Esophagus to Conventional Adenocarcinoma after Esophagectomy
Authors: Zheng Dennis J. , Cooke David T.
Published: June 2020

The objective of this study was to test the hypothesis that mucin-producing adenocarcinoma (MA) exhibits a more advanced clinical presentation and worse prognosis than conventional adeno-carcinoma (CA) in patients undergoing esophagectomy. Patient demographic and clinical variables and cancer-specific survival were collected from the U.S. Surveillance Epidemiology and End Results database between 1988 and 2006. Esophagectomy was performed for 105 patients with MA and 5473 patients with CA. The MA cohort exhibited a similar age at presentation, gender, and anatomic location (lower third of the esophagus/abdominal) as the CA cohort. We found trends toward advanced pathologic stage of disease of MA compared with CA (Stage IIB to IV 56 vs 46%), higher grade tumors (Grade III/IV, 44 vs 34%), positive lymph nodes (51 vs 40%), and poorer mean survival. For both groups, after multivariate analysis, age at diagnosis, tumor stage, and grade were negative predictors of survival (hazard ratios 1.02, 1.39, and 1.32, respectively; P < 0.001). Although this study suggests that patients with resected MA of the esophagus have a trend toward worse clinical presentation and survival than patients with resected CA, the observations are not significant and do not support our hypothesis or results from single-institution studies.
Death or Dialysis? the Risk of Dialysis-Dependent Chronic Renal Failure after Trauma Nephrectomy
Authors: Dozier Kristopher C. , Yeung Louise Y. , Miranda Marvin A. , Miraflor Emily J. , Strumwasser Aaron M. , Victorino Gregory P.
Published: June 2020

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.
Localization and Definitive Control of Lower Gastrointestinal Bleeding with Angiography and Embolization
Authors: Yi William S. , Garg Gaurav , Sava Jack A.
Published: June 2020

Angiography has long been a mainstay of lower gastrointestinal bleeding localization. More recently, angioembolism has been used therapeutically for bleeding control, but there are limited data on its efficacy. This study was designed to evaluate the efficacy of angiography and embolization for localizing and treating lower gastrointestinal bleeding as well evaluate the occurrence of bowel ischemia after embolization. This study is a retrospective descriptive review of all patients undergoing mesenteric angiography at a tertiary hospital over an eight-year period. Clinical data were recorded including patient demographics, causes of bleeding, procedures, and outcomes. Patients were excluded if the cause of bleeding was upper gastrointestinal bleeding or the medical record was missing data. Localization and definitive control of bleeding was the primary end point. One hundred fifty-nine angiograms were performed on 152 patients. Mean age was 72 years. Angiographic localization was successful in 23.7 per cent of patients. Although embolization after angiographic localization achieved definitive control of bleeding in 50 per cent of patients, the success rate was only 8.6 per cent of all patients who had angiography. One patient developed postembolization ischemia requiring laparotomy. Angiographic localization of lower gastrointestinal bleeding is successful in only 23.7 per cent of patients. Definitive hemostasis through embolization was successful in only 8.6 per cent of patients who underwent angiography for lower gastrointestinal bleeding.
Laparoscopic Hepatectomy is a Safe and Effective Approach for Resecting Large Colorectal Liver Metastases
Authors: Doughtie C. Anne , Egger Michael E. , Cannon Robert M. , Martin Robert C. G. , McMasters Kelly M. , Scoggins Charles R.
Published: June 2020

Hepatectomy is an accepted treatment modality for large (greater than 5 cm) colorectal liver metastases (CLM). Recently, laparoscopic hepatectomy has emerged as a viable option; however, its use for patients with large CLM is undefined. A retrospective analysis of a single institution's prospective database was performed for patients with large CLM resected between 1995 and 2010. Patients were stratified by operative approach. Patient characteristics, tumor burden, operative factors, hospital course, and long-term outcomes were compared using nonparametric, Fisher's exact, and Kaplan-Meier testing. Eighty-four patients were identified. Eight patients (9.5%) underwent laparoscopic resection. Age (59.5 vs 60 years), body mass index (26.8 vs 27.5 kg/m2), size of largest tumor (6.8 vs 7.5 cm), R0 resection (100 vs 89.5%), hepatic recurrence (25 vs 43.4%), and transfusion rate (14.3 vs 30.9%) of laparoscopic compared with open resection were similar. However, complication rate (12.5 vs 60.5%; P = 0.0192), blood loss (225 vs 400 mL; P = 0.0427), and length of stay (3.5 vs 7.0 days; P = 0.0005) were significantly higher in the open resection cohort. Median disease-free survival was 14.4 and 13.2 months for laparoscopic and open patients, respectively. Laparoscopic resection appears to be a safe approach for resecting large CLM. Tumor size does not preclude laparoscopic hepatectomy.
Surgical Intensive Care Unit Admission Variables Predict Subsequent Readmission
Authors: Lissauer Matthew E. , Diaz Jose J. , Narayan Mayur , Shah Paulesh K. , Hanna Nader N.
Published: June 2020

Intensive care unit (ICU) readmissions are associated with increased resource use. Defining predictors may improve resource use. Surgical ICU patients requiring readmission will have different characteristics than those who do not. We conducted a retrospective cohort study of a prospectively maintained database. The Acute Physiology and Chronic Health Evaluation (APACHE) IV quality database identified patients admitted January 1 through December 31, 2011. Patients were divided into groups: NREA = patients admitted to the ICU, discharged, and not readmitted versus REA = patients admitted to the ICU, discharged, and readmitted. Comparisons were made at index admission, not readmission. Categorical variables were compared by Fisher's exact testing and continuous variables by t test. Multivariate logistic regression identified independent predictors of readmission. There were 765 admissions. Seventy-seven patients required readmission 94 times (12.8% rate). Sixty-two patients died on initial ICU admission. Admission severity of illness was significantly higher (APACHE III score: 69.54 ± 21.11 vs 54.88 ± 23.48) in the REA group. Discharge acute physiology scores were equal between groups (47.0 ± 39.2 vs 44.2 ± 34.0, P = nonsignificant). In multivariate analysis, REA patients were more likely admitted to emergency surgery (odds ratio, 1.9; 95% confidence interval, 1.01 ± 3.5) more likely to have a history of immunosuppression (2.7, 1.4 ± 5.3) or higher Acute Physiology Score (1.02; 1.0 ± 1.03) than NREA. Patients who require ICU readmission have a different admission profile than those who do not “bounce back.” Understanding these differences may allow for quality improvement projects such as instituting different discharge criteria for different patient populations.
Water as a Contrast Medium: A Re-evaluation Using the Multidetector-row Computed Tomography
Authors: Makarawo Tafadzwa P. , Negussie Edsa , Malde Sachit , Tilak Jacqueline , Gayagoy Jennifer , Watson Jenna , Francis Faiz , Lincoln Denis , Jacobs Michael J.
Published: June 2020

Water as an intraluminal negative contrast medium produces improved image quality with reduced artefact. However, rapid absorption of oral water in the bowel relative to speed and timing of image capturing has limited its clinical application. These findings predate advances in multidetector-row computed tomography (CT). To re-evaluate differences in image quality, we studied image clarity and luminal distention between the same group of patients who received both a pancreas protocol CT (PPCT) that uses oral water and a conventional positive oral contrast scan. We reviewed 66 patients who had previously undergone both a PPCT and an oral contrast abdominal CT. CT images were independently reviewed by two board-certified radiologists who scored degree of hollow viscus distention and visualization of mural detail using a Likert 5-point scale. Results were evaluated by using the Wilcoxon-signed rank test. Student's t test was applied to evaluate the differences in radiation dosage and Spearman's correlational test was used to evaluate interrater correlation between the radiologists. In comparing the mean radiation dosage, there was no statistical difference between the two protocols, and there was good interrater association with ratios of 0.595 and 0.51 achieved for the PPCT and conventional oral scan, respectively. The Wilcoxon signed-rank test showed statistical differences in the stomach ( P < 0.001) for both clarity ( P < 0.001) and distention ( P < 0.001), the duodenum for both clarity ( P < 0.001) and distention ( P = 0.02), and the ileum for distention ( P = 0.02) with the PPCT having a better median score for organ clarity in the stomach and duodenum and better luminal distention in the stomach, equal distention in the duodenum, and slightly worse distention in the ileum. For the remainder of the bowel and organs evaluated, there was no statistically significant difference in the ratings between the two protocols. Using present CT scan technology, water can be an effective contrast medium causing better or equal distention in the bowel and better or equal clarity than routine barium contrast. This calls for a need to reconsider the use of water as a contrast medium in clinical practice.
Hirschsprung's Disease in the Preterm Infant: Implications for Diagnosis and Outcome
Authors: Baxter Katherine J. , Bhatia Amina M.
Published: June 2020

Hirschsprung's disease (HD), congenital absence of ganglion cells, is considered uncommon in preterm infants. The aim was to describe the frequency, presentation, and surgical outcomes of preterm infants with HD. A retrospective cohort study was conducted of all patients diagnosed with HD from 2002 to 2012 at a single children's hospital. Clinical presentation and surgical outcomes were obtained for term (37 weeks of gestation or greater) and preterm infants. One hundred twenty-nine subjects with HD were identified, 24 (19%) preterm and 105 (81%) term. Preterm infants were more likely to be diagnosed after 30 days of life (66.7 vs 37.1%, P < 0.01; median age 2.9 vs 0.3 months, P < 0.05) and to have associated major congenital anomalies (45.8 vs 20.0%, P < 0.01). Fewer preterm infants had primary pull-through operations (45.8 vs 76.2%, P < 0.005). Preterm infants were more likely to have an episode of Hirschsprung's-associated enterocolitis (45.8 vs 24.0%, P < 0.05) but were not more likely to die from any cause (8.3 vs 5.8%, P = 0.64). HD may be more common in preterm infants than previously recognized, and increased comorbidities in these patients may lead to delayed diagnosis and increased morbidity. HD should be considered in the preterm infant presenting with a bowel obstruction, especially when accompanied by associated anomalies.
Current Outcome of Esophagectomy in the Very Elderly: Experience of a German High-volume Center
Authors: Schweigert Michael , Solymosi Norbert , Dubecz Attila , Stadlhuber Rudolf J. , Ofner Dietmar , Stein Hubert J.
Published: June 2020

Operative management of esophageal carcinoma in the very elderly is still controversially discussed. It is not yet decided whether the risk warrants the procedure. The aim of this study is to analyze the outcome of esophagectomy for esophageal cancer in the very elderly. Factors influencing the clinical course and determining the outcome are identified. A retrospective study 292 consecutive cases of esophagectomy for nonmetastatic esophageal cancer at a German tertiary referral hospital between 2004 and 2011 were reviewed. Two age groups (75 years or older and younger than 75 years) were formed. The mean age was 63 years. Altogether 45 patients were 75 years or older. There were no significant differences in American Society of Anesthesiologists score, operative procedure, or in the frequency of anastomotic leakage between the age groups. However, very elderly patients with anastomotic leak had an eight times higher risk for fatal outcome than the very elderly without leak (odds ratio [OR], 8.54; 95% confidence interval [CI], 1.0 to 112.18; P = 0.025). Moreover, the odds for postoperative death were five times higher in very elderly patients with leak than in younger patients sustaining anastomotic leakage (OR, 5.67; 95% CI, 0.67 to 73.83; P = 0.046). In general, the very elderly had a three times higher risk for a fatal outcome (OR, 3.30; 95% CI, 1.37 to 7.86; P = 0.008). In-hospital mortality of the very elderly was 11 out of 45 compared with 8 per cent (20 of 247) in the younger group. Fatal outcome was more often caused by medical (seven) than by surgical complications (four cases). The remaining 34 patients recovered well. Very elderly patients undergoing esophagectomy have no elevated risk for occurrence of surgical complications, whereas the mortality of these complications is much higher. Improved outcome is achievable by timely management of postoperative surgical as well as medical complications. Notwithstanding the increased mortality, esophagectomy should be considered in thoroughly selected very elderly patients with curable esophageal carcinoma.
Safety, Efficacy, and Cost Savings of Single Parathyroid Hormone Measurement for Risk Stratification after Total Thyroidectomy
Authors: McCullough Meghan , Weber Collin , Leong Chris , Sharma Jyotirmay
Published: June 2020

The management of hypocalcemia (HC) after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of parathyroid hormone (PTH) level after TTx may allow for prediction of postoperative HC and lead to shorter hospital stays. A prospective database was queried between January 2010 and June 2012 with 95 patients who had undergone TTx identified. Patient demographics; preoperative diagnosis; laboratory values and cost; complications; intravenous calcium supplementation; and length of stay (LOS) were analyzed. A PTH-based algorithm was retrospectively applied and theoretical cost savings were analyzed in terms of laboratory cost, LOS, and total cost. Ninety-five patients underwent TTx: 37 patients (38.9%) had cancer, whereas 27 (28.4%) had Graves’ disease and the remaining 31 (32.6%) had a benign multinodular goiter. Postoperative PTH was recorded in 72 patients (74.4%); 46 (63.8%) had PTH greater than 10 pg/mL and 26 (36.9%) had PTH less than 10 pg/mL. Transient HC occurred in 10 patients (38.4%) with PTH less than 10 pg/mL (relative risk, 17.69; P = 0.0001). Patients with PTH less than 10 pg/mL incurred a 14.9 per cent higher hospital cost compared with those with PTH greater than 10 pg/mL. With retrospective implementation of the algorithm, there is a potential 46.4 per cent cost savings for the PTH less than 10 pg/mL group, 67.3 per cent savings for the PTH greater than 10 pg/mL group, and 46.7 per cent savings when taken altogether. Algorithmic risk stratification based on postoperative PTH less than 10 pg/mL serves as both a sensitive (100%) and specific (76.7%) predictor of postoperative HC. Such risk stratification may allow for same-day discharge in a number of patients, and even in patients requiring an overnight stay, result in cost savings as a result of a reduction in laboratory expenditures.
Use of a Sestamibi-only Approach to Routine Minimally Invasive Parathyroidectomy
Authors: Opoku-Boateng Adwoa , Bolton John S. , Corsetti Ralph , Brown R. E. , Oxner Chris , Fuhrman George M.
Published: June 2020

We performed this study to compare a sestamibi-only radio-guided approach (MIBI) versus using intraoperative parathyroid hormone monitoring (IOPTH) in the performance of minimally invasive parathyroidectomy (MIP) in patients with a clearly positive preoperative sestamibi scan from January 2000 to June 2010. Five of 81 patients in the MIBI group required additional surgery, three at the time of MIP when the intraoperative findings were in conflict with the preoperative sestamibi scan and two required a second operation as a result of an undiscovered second adenoma. In the IOPTH group, five patients had an unnecessary bilateral neck exploration as a result of an inadequate drop in PTH levels, whereas six had their disease cured because the PTH levels predicted additional pathology. One patient in the IOPTH group remains hypercalcemic and represents the only surgical failure in this study. The MIBI group had a shortened operating room time and less cost ( P < 0.001). No deaths or complications, including recurrent laryngeal nerve injuries, occurred in this study. Although both strategies are effective in managing hyperparathyroidism, a MIBI-only approach is less expensive and has shorter operative times with an occasional need for reoperation, whereas the IOPTH group results in more extensive surgery that will occasionally be unnecessary.
Laparoscopic Appendectomy for Acute Appendicitis: A Safe Same-day Surgery Procedure?
Authors: Cross Wirt , Kowdley Gopal Chandru
Published: June 2020

Over 250,000 cases of appendicitis occur annually in the United States. The mainstay of treatment is surgical removal with admission. Recently, antibiotic therapy as an alternative has been introduced and the state of Maryland has incentivized 23-hour procedures. We studied patients with appendicitis discharged from the recovery room and those with length of stay (LOS) less than 24 hours. We retrospectively reviewed all appendectomies performed from June 2010 to October 2012 by three general surgeons. We excluded cases that were converted to open, appendectomies performed in the setting of another disease process, and incidental appendectomies. A total of 84 laparoscopic appendectomies were included. Of these, 55 patients had LOS less than 24 hours. Pathology, comorbidities, and readmission were recorded. χ2 analysis was used for determining statistical significance. Average LOS for all patients was 25 hours with a minimum stay of 2 hours and a maximum stay of 96 hours. For patients discharged in less than 24 hours, there was one readmission and 52 (95%) of these patients had simple appendicitis on pathology. A total of 19 patients (22%) were discharged in less than 7 hours (from the recovery room). Among these patients, there were no readmissions, and 18 (95%) were cases of simple appendicitis ( P = 0.4431). There was no significant difference in complications or readmission between patients discharged in less than 24 hours and those who stayed longer. Our subgroup analysis indicated that discharge from the postanesthesia care unit after uncomplicated laparoscopic appendectomy should be further evaluated.
Dilemma of Blunt Bowel Injury: What are the Factors Affecting Early Diagnosis and Outcomes
Authors: Al-Hassani Ammar , Tuma Mazin , Mahmood Ismail , Afifi Ibrahim , Almadani Ammar , El-Menyar Ayman , Zarour Ahmad , Mollazehi Monira , Latifi Rifat , Al-Thani Hassan
Published: June 2020

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presentation. We aimed to study the predictors for early diagnosis and outcomes in patients with BBMI. Data were collected retrospectively from the database registry between January 2008 and December 2011 in the only Level I trauma unit in Qatar. Patients with BBMI were divided into Group A (surgically treated within 8 hours) and Group B (treated after 8 hours). Data were analyzed and χ2, Student's t test, and multivariate regression analysis were performed appropriately. Among 984 patients admitted with blunt abdominal trauma (BAT), 11 per cent had BBMI with mean age of 35 ± 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, respectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B (18 ± 11 vs 13 ± 8; P = 0.02). Presence of pain and seatbelt sign ( P = 0.02) were evident in Group B. Hypotension ( P = 0.004) and hypothermia ( P = 0.01) were prominent in Group A. The rate of positive Focused Assessment Sonography for Trauma was greater in Group A ( P = 0.001). Among operative findings, bowel perforation was more frequent in Group B ( P = 0.04), whereas mesenteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more frequent finding in Group A ( P = 0.005). The overall mortality rate was 15.6 per cent. In patients with BAT, the presence of abdominal pain, hypotension, ISS greater than 16, hypothermia, pelvic fracture, and mesenteric hematoma might help in early diagnosis of BBMI. Moreover, base deficit and mean ISS were independent predictors of mortality. Delayed operative interventions greater than 8 hours increased morbidity rate but had no significant impact on mortality.
Predictors of Early Postoperative Outcomes in 375 Consecutive Hepatectomies: A Single-institution Experience
Authors: Abbass Mohammad Ali , Slezak Jeffery M , Difronzo L. Andrew
Published: June 2020

Although the safety of hepatic resection has improved, it is still a highly morbid procedure. A retrospective cohort of 375 patients undergoing hepatectomy (2004 to 2012) was done. All procedures were performed by a single surgeon at a tertiary center. To help identify trends over time, two subgroups were identified: Group 1 (n = 195 from October 2004 to December 2010) and Group 2 (n = 180 from January 2011 to November 2012). The two study groups had similar patient characteristics except there were more patients with cirrhosis in Group 2 (10 vs 17%, P = 0.04). A similar number of major hepatectomies was noted. Median estimated blood loss was 400 mL versus 300 mL ( P = 0.04) in Group 2. Overall complications were more common in Group 1 (54 vs 45%). Fewer Grade 3 or greater Clavien complications (22 vs 13%, P = 0.04) and fewer hospital readmissions were noted in Group 2 (20 vs 8%, P = 0.002). Morbidity was associated with worse Eastern Cooperative Oncology Group (ECOG) performance status, age older than 60 years, and open surgery. Grade 3 or greater Clavien complications were also associated with age older than 60 years, higher American Society of Anesthesiologists class, and worse ECOG status and median estimated blood less greater than 400 mL. Higher Model for End-stage Liver Disease score and advanced ECOG status were correlated with mortality. Outcomes of hepatic resection improved time despite more complex patient characteristics and an equal number of major hepatectomies being performed. However, worse ECOG performance status was a major predictor of postoperative complications and increased mortality.
The Association between High-risk Behavior and Central Nervous System Injuries: Analysis of Traffic-related Fatalities in a Large Coroner's Series
Authors: Pakula Andrea , Shaker Adel , Martin Maureen , Skinner Ruby
Published: June 2020

High-risk behaviors leading to traffic fatalities are often a result of severe traumatic brain and spine injuries. The objective of the study was to analyze patterns of behavior in drivers and motorcyclists that are associated with central nervous system (CNS)-related prehospital deaths that may serve as a basis for future prevention initiatives. Our study group comprised 514 fatalities with severe CNS injuries documented at autopsy. The majority (n = 491) was the result of motor vehicle collisions (MVCs). In this group, male drivers predominated and the majority, 80 per cent, wore seatbelts. Toxicology analysis revealed 53 per cent of drivers with a mean concentration of ethanol above the legal limit. Texting while driving comprised 45 per cent of the study group. Less than 5 per cent of the fatalities were the result of road or weather conditions. In the motorcycle group (n = 23), 100 per cent of the victims were unhelmeted. We report a large autopsy series of CNS-related deaths with analysis of behavioral factors associated with the fatalities. Substance abuse and distracted driving are dominant patterns of high-risk behavior in MVCs and not wearing a motorcycle helmet is deadly for victims of motorcycle crashes.
What Do Patients Think of Medical Students during Their Hospitalization? One Institution's Experience
Authors: Mora-Pinzon Maria , Lal Ankita , Edquist Sarah , Francescatti Amanda , Hughes Tasha , Hayden Dana , Brand Marc , Saclarides Theodore
Published: June 2020

Multiple studies have shown patients have a positive attitude toward medical students in outpatient facilities, but it is unknown whether these results can be extrapolated to inpatients. The purpose of this study is to describe the patients’ attitude toward medical students in the inpatient facility and factors that may affect it. A 43-item questionnaire was provided to patients of the general surgery department; it gathered demographics, clinical condition, and patients’ opinions regarding the medical students’ involvement in their care. Eighty-four patients completed the questionnaire. Forty-three per cent were males and the average age was 56 years old (range, 26 to 86 years). Sixty-one patients (72.6%) felt that having medical students enhanced the care provided. Patients’ attitudes toward students were as follows: seven patients (8.3%) refused medical students, 40 (47.6%) accepted a limited involvement, and 37 (44%) offered no objections. Patients who refused medical students or preferred a limited involvement were more likely to 1) consider their health as good or excellent; 2) feel that the rounds were too early; and 3) feel that the residents did not spend enough time with them. More patients prefer that medical students have a limited involvement, especially when referring to minor procedures (e.g., nasogastric tube, intravenous line). Better more thorough communication with patients positively affects their attitudes toward students. More studies are required to confirm these results and to analyze other factors that may improve the patients’ attitudes toward medical students.
Contemporary Experience with Cholecystectomy: Establishing ‘Benchmarks’ Two Decades after the Introduction of Laparoscopic Cholecystectomy
Authors: Udekwu Pascal O. , Sullivan William G.
Published: June 2020

With quality and public reporting of increasing importance, benchmarks are anticipated to grow in relevance. We studied cholecystectomy in a practice in an urban tertiary care hospital. A total of 1083 cholecystectomies were performed in 2008 and 2009. Laparoscopic cholecystectomy was performed in 97.8 per cent of patients with a 2.2 per cent conversion rate. A planned open procedure was performed in only 2.2 per cent of patients. Approximately half of procedures were urgent and performed during an acute hospitalization. Most patients (74%) were female and most patients were overweight or obese (64.8%). Ages into the tenth decade of life were represented. Comorbidities included hypertension, 28.7 per cent; coronary disease, 15.6 per cent; diabetes mellitus, 13.4 per cent; gastroesophageal reflux disease, 10.7 per cent; and asthma, 5.5 per cent. Of female patients, 98 (12.2%) were postpartum and five (0.6%) were pregnant. Of 137 patients without gallstones, 59.1 per cent had biliary dyskinesia and 27 per cent had acalculous cholecystitis. Preoperative magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in most patients with suspected choledocholithiasis. Intraoperative cholangiograms were performed in 6.9 per cent of patients, 3.3 per cent for abnormal liver function studies. Postoperative ERCP was used in most patients with positive intraoperative cholangiograms. All-cause mortality was 0.8 per cent and attributable mortality was 0.2 per cent. Complications occurred in 7.5 per cent of patients, including retained common bile duct stones in 1.1 per cent, bile duct leak in 0.3 per cent, and common bile duct injury in 0.1 per cent.
Validation of the Sentinel Lymph Node Biopsy Technique in Head and Neck Cancers of the Oral Cavity
Authors: Radkani Pejman , Mesko Thomas W. , Paramo Juan C.
Published: June 2020

The purpose of this study was to present our experience and validate the use of sentinel lymph node (SLN) mapping in patients with head and neck cancers. A retrospective review of a pro-spectively collected database of patients with a diagnosis of squamous cell carcinomas of the head and neck from 2008 to 2011 was done. The group consisted of a total of 20 patients. The first node(s) highlighted with blue, or identified as radioactive by Tc99-sulfur radioactive colloid, was (were) identified as the SLNs. In the first seven patients, formal modified neck dissection was performed. In the remaining 13 patients, only a SLN biopsy procedure was done. At least one SLN was identified in all 20 patients (100%). Only one patient (5%) had positive nodes. In this case, the SLN was also positive. In the remaining 19 cases, all lymph nodes were negative. After an average of 24 months of follow-up, there have been three local recurrences (15%) but no evidence of distant metastatic disease. SLN mapping in head and neck cancers is a feasible technique with a high identification rate and a low false-negative rate. Although the detection rate of regional metastatic disease compares favorably with published data as well as the disease-free and overall survival, further studies are warranted before considering this technique to be the “gold standard” in patients with oral squamous cell carcinoma and a negative neck by clinical examination and imaging studies.