bluuebunny/crossref_metadata_2025 huggingface dataset:
Important Prognostic Factors in Adenocarcinoma of the Ampulla of Vater
Authors: Lowe Michael C. , Coban Ipek , Adsay N. Volkan , Sarmiento Juan M. , Chu Carrie K. , Staley Charles A. , Galloway John R. , Kooby David A.
Published: June 2020

Ampullary adenocarcinoma (AmpCA) carries a better overall survival (OS) rate than other periampullary cancers. We examined clinicopathologic features in AmpCA for impact on OS. Records of patients undergoing pancreaticoduodenectomy from 2000 to 2007 for AmpCA were reviewed and histological specimens were reanalyzed. Of 302 patients undergoing pancreaticoduodenectomy for malignancy, 45 (14.9%) had AmpCA. Mean age was 61.3 ± 12.2 years, mean tumor size was 2.6 ± 1.3 cm, 57 per cent were ≥ T3 tumors, 42 per cent were N1 stage, 13 (49%) had perineural invasion (PNI), and 29 (64%) had lymphovascular invasion (LVI). Thirteen were intestinal (29%), 14 were pancreaticobiliary (31%), and 18 were mixed (40%). Median OS was 42 months (range 4-80 mos). On log rank testing, ≥ T3 (24 vs 65 mos, P < 0.01), N1 (25 vs 61 mos, P < 0.01), poor differentiation (24 vs 44 mos, P = 0.01), pancreaticobiliary subtype (23 vs 44 mos, P = 0.01), and PNI (23 vs 44 mos, P < 0.01) were significant for worse survival. By multivariate analysis, N1 disease (hazard ratio [HR] 4.50,95% confidence interval [CI] 1.16-17.40) and PNI (HR 4.62, CI 1.11-19.21) maintained associations with worse survival, whereas histological subtype did not. N1 disease and presence of PNI demonstrated independent associations with worse survival. Given high percentage of mixed histology, PNI may be more informative than the subtype in predicting outcome for patients with AmpCA.
Does Specialized Surgical Training Increase Lymph Node Yield in Colon Cancer?
Authors: Nicholl Michael B. , Wright Byron E. , Conway W. Charles , Aarnes-Leong Trista , Sim Myung-Shin , Faries Mark B.
Published: June 2020

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.
Squamous Cell Carcinoma of the Breast: A Review of 177 Cases
Authors: Grabowski Julia , Saltzstein Sidney L. , Sadler Georgia , Blair Sarah
Published: June 2020

Squamous cell carcinoma (SCO of the breast is an uncommon breast neoplasm. There are limited data about its epidemiology and few studies focusing on outcomes. This study aims to identify specific characteristics of patients with breast SCC, investigate its natural history, and determine its long-term prognosis. One hundred and seventy-seven cases of SCC of the breast were identified in the California Cancer Registry from the years 1988 to 2006. At the time of diagnosis, 53 per cent of patients had localized disease, 32 per cent of patients had regional lymph node or locally advanced disease, and 8 per cent of patients had distant disease. The relative cumulative survival of patients was 68.1 per cent at 5 years and 60.2 per cent at 10 years. This is significantly worse than the relative cumulative survival of patients with all other invasive breast tumors during the same time period. Squamous cell carcinoma of the breast is a rare and aggressive disease, and it has significantly worse prognosis than other nonsquamous cell tumors of the breast. Clinicians should be aware of the aggressive nature of the tumor when counseling patients.
How Often does Computed Tomography Change the Management of Acute Appendicitis?
Authors: Santos David A. , Manunga Jesse , Hohman Donald , Avik Elisa , Taylor Edward W.
Published: June 2020

Computed tomography (CT) diagnoses appendicitis accurately, but few studies evaluate how often CT changes the management of appendicitis. Consultations for appendicitis were evaluated by surgeons and assigned to groups: high, indeterminate, and low suspicion. After assignment, CT was reviewed if completed or ordered if desired by the surgeon and changes in plans were noted. One hundred patients were evaluated for appendicitis, 70 received appendectomy. Our negative appendectomy rate was 4 of 70 (5.7%). In the high suspicion group, 63 patients had 23 CT scans performed and 2 CT scans were negative, avoiding unnecessary operation and changing management in 2 of 63 (3.2%). The intermediate suspicion group included 27 patients and 26 CT scans performed; 11 were positive resulting in nine positive appendectomies and changing management in 9 of 27 (33%). The low suspicion group had 7 CT scans performed; two were positive leading to two positive appendectomies and changing management in 2 of 10 (20%). CT promoted 10 of 100 patients to the interval appendectomy pathway with no failures in delayed operative management. CT rarely changes management in patients highly suspicious for appendicitis, but may have a role in selecting patients for interval appendectomy. CT frequently changes management if the clinical diagnosis is indeterminate.
Utility of Thoracic Computed Tomography after Blunt Trauma: When is Chest Radiograph Enough?
Authors: Barrios Cristobal , Malinoski Darren , Dolich Matthew , Lekawa Michael , Hoyt David , Cinat Marianne
Published: June 2020

The purpose of this study was to identify the utility of thoracic computed tomography (TCT) in blunt trauma patients with a normal admission chest radiograph (CXR). A retrospective study was performed of 200 consecutive blunt trauma patients who received both CXR and TCT. One hundred and forty-three patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only nine of these patients (6%): two required serial CXR for occult pneumothorax, four received additional imaging of the spine, and three were admitted to a monitored bed. Fifty-seven patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: two aortic injuries identified, 12 aortic injuries excluded, two chest tubes placed, one patient taken to the Operating Room, and four patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P < 0.001). TCT is of limited utility in patients with a normal admission CXR. A diagnostic strategy of obtaining TCT only in patients with abnormal CXR or high-risk mechanism of injury can result in significant cost savings without adversely affecting patient outcomes.
All-Terrain Vehicle Injuries at Arrowhead Regional Medical Center (Level II): Epidemiology, Risks, and Outcome
Authors: Thepyasuwan Nattapaun , Wan Xiao T. , Davis Vivian J.
Published: June 2020

The growing popularity of all-terrain vehicles (ATVs) has contributed to a rise in the number of injuries and fatalities nationwide. The Consumer Product Safety Commission reported 8,104 fatalities from 1982 to 2006 and over 146,600 emergency room-treated visits in 2006 with children 16 years of age and younger comprising roughly 29 per cent in both categories. To investigate the epidemiology and outcome of ATV-related injuries and to explore variables contributing to morbidity and mortality, we conducted a single-center, retrospective study of ATV-injured patients presenting to trauma emergency between 2003 and 2007 at a Level II trauma center. In summary, we witnessed an upward trend in the incidence of ATV injuries during this 5-year span. With 156 documented cases, adolescents aged 17 to 20 years represented the largest group (19.2%), whereas children 16 years of age and younger contributed to 12.8 per cent. Overall mortality rate was 0.64 per cent. Positive blood alcohol concentration was detected in 21 per cent. Individuals using protective gear were 1.4 and four times less likely to suffer loss of consciousness and Glasgow Coma Scale score 8 or less, respectively, compared with those without protection. Abrasions, concussions, fractures, and other life-threatening solid organ injuries were documented in virtually every organ system. With such poor outcomes, we conclude that riding an ATV is an inherently dangerous activity. To minimize the burden of injury, riders are encouraged to develop competency through training courses, compliance with safety precautions, and modification of high-risk behaviors.
Resident Work Hour Restrictions Impact Chief Resident Operative Experience
Authors: Christmas A. Britton , Brintzenhoff Rita A. , Sing Ronald F. , Schmelzer Thomas M. , Bolton Sandra D. , Miles William S. , Thomason Michael H.
Published: June 2020

Since the institution of the Accreditation Council for Graduate Medical Education resident work restrictions, much discussion has arisen regarding the potential effect on surgical resident training. We undertook this study to examine the effects on resident operative experience. We retrospectively analyzed chief residents’ Accreditation Council for Graduate Medical Education case logs before (PRE) and after (POST) the 80-hour work restriction. Overall, 22 resident logs were evaluated, six PRE and 16 POST. Four case categories were examined: total major cases, total trauma operative cases, total chief cases, and total teaching assistant cases. Significance was defined as P < 0.05. Comparing the PRE and POST groups demonstrated a trend toward fewer total major cases (1061 vs 964, P = 0.38) and fewer total trauma operative cases (55 vs 47, P = 0.37). Teaching assistant cases increased from 67 to 91 but also failed to reach significance ( P = 0.37). However, further comparison between the PRE and POST groups yielded a statistically significant decrease in the number of total chief cases (494 vs 333, P = 0.0092). The significant decrease in the number of total chief cases demonstrates that the work hour restriction most affected the chief year operative experience. Further evaluation of resident participation in nonoperative facets may reveal additional deficiencies of surgical training under work hour restrictions.
A Comparison of Two Methods of Hemostasis in Thyroidectomy
Authors: Mcnally Michael M. , Agle Steven C. , Williams R. Fredrick , Pofahl Walter E.
Published: June 2020

Safe thyroid surgery requires meticulous hemostasis. The objective of the current study is to compare the effectiveness and safety of ultrasonic dissection (UD) and electronic vessel sealing (EVS) in patients undergoing thyroidectomy. A retrospective analysis of a prospectively maintained database was performed. Between January 1, 2007 and January 25, 2008, hemostasis was achieved using EVS (LigaSure Precise, Valleylab, Boulder, CO). Since January 25, 2008, hemostasis has been achieved using UD (Harmonic Focus, Ethicon Endo-Surgery, Cincinnati, OH). Operative time, estimated blood loss, gland weight, and postoperative complications were compared. Differences were analyzed using unpaired t test and Chi square with significance assigned P < 0.05. Seventy-four patients underwent total thyroidectomy (EVS n = 59, UD n = 15). Operative time (EVS 115.0 ± 38.3 min, UD 88.0 ± 14.0 min, P = 0.012) was significantly decreased in the UD group compared with the EVS group. There were no significant differences in mean age (EVS 50.4 ± 13.9 years, UD 49.1 ± 15.6 years), gender distribution (EVS 78% female, UD 87% female), estimated blood loss (EVS 49.4 ± 44.7 mL, UD 47.0 ± 70.4 mL), and gland weight (EVS 67.4 ± 66.4 gm, UD 41.3 ± 26.6 gm). Analysis of complications, including hematoma, hypocalcemia, and recurrent laryngeal nerve palsy showed no significant difference. Based on the current analysis, ultrasonic dissection is a safe method of hemostasis for thyroid surgery. Its use decreases operative time when compared with electronic vessel sealing.
Article Commentary: Management of Bile Duct Injuries: A Practical Approach
Authors: Kapoor Vinay K.
Published: June 2020

The incidence of bile duct injury (BDI) has increased after the introduction of laparoscopic cholecystectomy. A BDI can occur in the hands of experienced surgeons also. It can result in serious complications and may even cause death of the patient; it also has financial and legal implications. Proper training, sound surgical technique, and conversion to an open operation can prevent a large number of injuries. An injury that is missed during the operation manifests in the postoperative period as a bile leak and external biliary fistula or during the follow up as a biliary stricture. Management of a BDI depends on the nature of the bile duct injured, type of injury, and expertise available; it may range from simple subhepatic drainage to Roux-en-Y hepaticojejunostomy Excellent results can be obtained when BDI is managed at a hepatobiliary center.
Volvulus of the Small Bowel in Adults
Authors: Ruiz-Tovar Jaime , Morales Vicente , Sanjuanbenito Alfonso , Lobo Eduardo , Martinez-Molina Enrique
Published: June 2020

The volvulus of the small bowel is a surgical emergency, causing small bowel obstruction. We performed a retrospective study of all the patients diagnosed and treated with small bowel volvulus between 1977 and 2007 at our institution. One hundred twenty-nine patients were analyzed. Thirty-nine patients presented primary volvulus and 90 secondary ones. The most frequent symptom was sudden abdominal pain. CT scan was the best diagnostic method with an accuracy of 83 per cent. Necrotic small bowel loops appeared in 46.5 per cent of the patients. Eighteen patients had postoperative complications (14%). Mortality rate was 9.3 per cent. A higher mortality is observed among patients with previous abdominal surgeries and cardiopathies. Necrotic loops are associated with higher mortality and incidence of surgical complications; patients with diabetes are associated with a higher incidence of necrotic loops. Cardiopathies are associated with more frequent medical and surgical complications. Recurrence rate was 3.9 per cent associated with simple devolvulation. Primary volvulus are more frequent among males and patients with diabetes. Jejunal location is associated with primary volvulus and these correlate with a higher incidence of necrotic loops. Primary volvulus presents a higher incidence of surgical complications. A bowel obstruction with sudden abdominal pain must be suspicious of small bowel volvulus. The main aim is to achieve an early diagnosis to prevent a necrotic small bowel. CT scan is the imaging test with the best diagnostic accuracy. Primary volvulus, the presence of necrotic loops, and patients with cardiopathies, diabetes mellitus, and with previous abdominal surgery are associated with a worse outcome.
Open-Book Pelvic Fractures with Perineal Open Wounds: A Significant Morbid Combination
Authors: Duchesne Juan C. , Bharmal Husain M. , Dini Arash A. , Islam Tareq , Schmieg Robert E. , Simmons Jon D. , Wahl Georgia M. , Davis John A. , Krause Peter , Mcswain Norman E.
Published: June 2020

Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group ( P < 0.001), with cost of $120,647.30 and $62,952.72 respectively ( P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.
Trauma Attending Physician Continuity: Does it Make a Difference?
Authors: Jacobs David G. , Sarafin Jennifer L. , Head Karen E. , Christmas A Britt , Huynh Toan , Miles William S. , Sing Ronald F.
Published: June 2020

Continuity of care is important in achieving optimal outcomes in trauma patients, but the optimal length of the trauma attending (TA) rotation is unknown. We hypothesize that longer TA rotations provide greater continuity, and therefore improve outcomes. We did a retrospective comparison of trauma patient outcomes from two consecutive 6-month periods during which we transitioned from a 1-month TA rotation to a 1-week TA rotation. The Wilcoxon rank sum test, and the χ2 were used for statistical analysis. Over the 12-month study period 1924 patients were admitted to the Trauma Service. The two groups were similar with regard to age, gender, injury mechanism, Injury Severity Score and Glasgow Coma Scale scores, and Abbreviated Injury Scores for the chest, abdomen, and extremities. Although mortality, patient charges, and violations of the standard of care were similar between the two groups, overall morbidity was lower (18.6% vs 23.2%), and hospital length of stay higher (9.07 days vs 8.41 days) in the 1-week TA group compared with the 1-month TA group. A one-week TA rotation was associated with a longer hospital length of stay, but improved morbidity. Longer TA rotations do not necessarily provide improved continuity or improved outcomes.
Article Commentary: Chronic Venous Insufficiency: Current Management of Varicose Vein Disease
Authors: Deatrick Kristopher B. , Wakefield Thomas W. , Henke Peter K.
Published: June 2020

This review encompasses the basic pathophysiology, diagnosis, and current therapies for superficial venous insufficiency.
Disorders of Sexual Differentiation: Surgical Challenges of Vaginal Reconstruction in Complete Androgen Insensitivity Syndrome (CAIS)
Authors: Munoz Jose A. , Swan Kenneth G.
Published: June 2020

Disorders of sexual differentiation have proven difficult to treat not only because of physicians’ lack of understanding regarding the determinants of sexual orientation, but also because of the psychological impact associated with sexual dysfunction. Patients with complete androgen insensitivity syndrome not only must undergo gonadectomy after puberty, requiring post-gonadectomy hormonal replacement, but also can suffer from underdeveloped, blind vaginal pouches. As a result, sexual intercourse is compromised. Many attempts have been made throughout medical history to correct the vaginal defect, including surgical and nonsurgical approaches, each with its own technical difficulties and complications. Presently, consensus regarding the optimal time for intervention is when the patient is ready to begin sexual life. However, the optimal surgical approach has not been established. In general, nonsurgical vaginal dilatation, like the Frank and Ingram methods, should be followed by surgical interventions, such as described by McIndoe, Vecchietti, and intestinal transplantation, in case of failure of the more conservative procedures.
Concomitant Rib Fractures and Minor Liver or Spleen Injuries in Blunt Trauma: What is the Potential for Missed Diaphragmatic Injuries?
Authors: Plurad David S. , Nielsen Jamison S. , Hancock James , Navaran Prashanth , Green Donald J. , Lam Lydia , Inaba Kenji , Demetriades Demetrios
Published: June 2020

Nonoperative management (NOM) of blunt liver or spleen injuries (LSI) is widely accepted, but diaphragmatic injuries (DI) can be elusive. We hypothesize that rib fractures and minor LSI (RF+ minor LSI) are associated with DI. Patients with blunt injury undergoing exploratory laparotomy between January 1, 2000, and December 31, 2007, were identified from our registry. The association between injury variables and DI was examined with logistic regression. Organ Injury Scores of the liver and spleen of Grade I/II were defined as “minor.” A potentially nonoperative (PNO) patient had a rib fracture and minor LSI but no bowel injury or hypotension (systolic blood pressure less than 90 mmHg). The incidence of DI was 7.5 per cent (53 of 705) overall but 20 per cent (seven of 35) in patients with RF + minor LSI. Nineteen PNO patients had four (21.1%) DIs. RF + LSI (3.26 [1.74-6.12], P < 0.001) and motor vehicle collisions (4.93 [2.36-10.32], P < 0.001) were independently associated with DI. The incidence of laparotomy in all critically ill blunt injury patients (n = 2177) decreased significantly ( P = 0.003). RF + minor LSI are associated with DI even when there are no other operative injuries. Because NOM is increasingly accepted, the potential for missed DI exists. When high-quality imaging is not available or is equivocal, further studies should be considered.
Risk Factors and Consequences of Incidental Parathyroidectomy during Thyroidectomy
Authors: Spiliotis John , Vaxevanidou Archondia , Sergouniotis Fotios , Tsiveriotis Konstantinos , Datsis Anastasios , Rogdakis Athanasios , Kekelos Spiridon
Published: June 2020

The objectives of this retrospective study were to investigate the incidence, risk factors, and clinical significance of incidental parathyroidectomy during thyroidectomy. In this study, there were 315 patients who underwent thyroidectomy between 1996 and 2006. All the operations were performed by a single experienced surgeon (J.S.). Pathology reports on all specimens were reviewed and information regarding patient demographics, diagnosis, operative details, and postoperative complications were collected. A total of 315 thyroidectomies were performed: 101 total thyroidectomies (32.1%) and 214 subtotal thyroidectomies (67.9%). Two hundred and eighty patients were operated on for benign disease (88.9%) and 35 for malignant disease (11.1%). Incidental parathyroidectomy was identified in 32 cases (10.2%). Preoperative diagnosis of malignant disease ( P = 0.009) and duration of the disease ( P = 0.001) were significant predictors of incidental parathyroidectomy. Incidental parathyroidectomy was significantly correlated with postoperative hypoparathyroidism ( P = 0.03). Transient postoperative hypoparathyroidism occurred in 18 cases (6%) and permanent in three cases (1%). The duration of the disease was the sole significant predictor of postoperative hypoparathyroidism ( P < 0.001). Incidental parathyroidectomy seems to be the result of the use of extensive surgical procedures. The preoperative diagnosis of malignant disease and the delay of the operation, which leads to a more advanced thyroid disease, make the use of extensive surgical procedures necessary.
Perineal Hernia: Surgical Anatomy, Embryology, and Technique of Repair
Authors: Stamatiou Dimitrios , Skandalakis John E. , Skandalakis Lee J. , Mirilas Petros
Published: June 2020

Perineal hernia is the protrusion into the perineum of intraperitoneal or extraperitoneal contents through a congenital or acquired defect of the pelvic diaphragm. The first case was reported by de Garangeot in 1743. Perineal hernias may occur anteriorly or posteriorly to the superficial transverse perineal muscles. Congenital perineal hernia is a rare entity. Failure of regression of the peritoneal cul de sac of the embryo is considered a predisposing factor for hernia formation. Acquired perineal hernias are primary or secondary. Primarily acquired perineal hernias are caused by factors associated with increased intra-abdominal pressure. They are more common in females as a result of the broader female pelvis and the attenuation of the pelvic floor during pregnancy and childbirth. Secondarily acquired perineal hernias are incisional hernias associated with extensive pelvic operations such as abdominoperineal resection of the anorectum and pelvic exenteration. Pain in the perineal area, intestinal obstruction, topical skin erosion, and difficulty with urination necessitate the surgical repair of a perineal hernia. This can be accomplished through transabdominal, perineal, or combined abdominoperineal approaches. The defect in the muscles of the pelvic diaphragm may be closed either with direct suturing or by using autogenous tissues or synthetic mesh.
Laparoscopic Primary Closure of Common Bile Duct Combined with Percutaneous Cholangiographic Drainage for Treating Choledocholithiasis
Authors: Huang Shing-Moo , Yao Chung-Chin , Cheng Ya-Wen , Chen Ling-Yun , Pan Huichin , Hsiao Kuang-Ming , Yang Mei-Due , Wu Chew-Wun , Lui Wing-Yiu , Lai Te-Jen
Published: June 2020

The aim of this study was to compare the efficacy and safety of laparoscopic primary closure of the common bile duct (CBD) combined with percutaneous transhepatic cholangiographic drainage (PTCD) and laparoscopic choledocholithotomy with T-tube placement for the treatment of CBD stones. Between January 1991 and July 2002, 50 patients with choledocholithiasis and a CBD diameter larger than or equal to 1 cm underwent laparoscopic CBD explorations. The study group consisted of 10 patients undergoing laparoscopic primary closure of the CBD combined with PTCD. The control group consisted of 40 patients undergoing laparoscopic choledocholithotomy with T-tube placement. Parameters were compared statistically. The study group showed higher female/male ratio (6/4 vs 8/32, P = 0.02), less stone numbers (1.90 ± 0.88 vs 3.40 ± 1.65, P = 0.0078), shorter operation time (138 ± 37 minutes vs 191 ± 75 minutes, P = 0.014), and shorter postoperative stays (7 ± 3 days vs 10 ± 3 days, P = 0.0013). It seems that laparoscopic primary closure of the CBD combined with PTCD can shorten the operation time and postoperative stays as compared with laparoscopic choledocholithotomy with T-tube placement for the treatment of CBD stones.
Design, Development, and Validation of a Take-Home Simulator for Fundamental Laparoscopic Skills: Using Nintendo Wii® for Surgical Training
Authors: Bokhari Ravia , Bollman-Mcgregor Jyoti , Kahol Kanav , Smith Marshall , Feinstein Ara , Ferrara John
Published: June 2020

Assuring quality surgical trainees within the confines of reduced work hours mandates reassessment of educational paradigms. Surgical simulators have been shown to be effective in teaching surgical residents, but their use is limited by cost and time constraints. The Nintendo Wii® gaming console is inexpensive and allows natural hand movements similar to those performed in laparoscopy to guide game play. We hypothesize that surgical skills can be improved through take-home simulators adapted from affordable off-the-shelf gaming consoles. A total of 21 surgical residents participated in a prospective, controlled study. An experimental group of 14 surgical residents was assigned to play Marble Mania® on the Nintendo Wii® using a unique physical controller that interfaces with the WiiMote® controller followed by a simulated electrocautery task. Seven residents assigned to the control group performed the electrocautery task without playing the game first. When compared with the control group, the experimental group performed the task with fewer errors and superior movement proficiency ( P < 0.05). The experimental group demonstrated increased ambidexterity with improvement in proficiency of the nondominant hand over time. In conclusion, the Nintendo Wii® gaming device along with Marble Mania® serves as an effective take-home surgical simulator.
Flexion-Extension Cervical Spine Plain Films Compared with MRI in the Diagnosis of Ligamentous Injury
Authors: Duane Therèse M. , Cross Justin , Scarcella Nicholas , Wolfe Luke G. , Mayglothling Julie , Aboutanos Michel B. , Whelan James F. , Malhotra Ajai K. , Ivatury Rao R.
Published: June 2020

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 ± 10.2, Glasgow Coma Scale was 13.8 ± 3.5, lactate 2.2 ± 1.7 mmol/L, and hospital stay of 8 ± 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.
Role of Growth Factors in Improved Skin Flap Viability Caused by Phosphodiesterase-5 Inhibitor
Authors: Bandera Bradley C. , Pham Thach , Hill-Pryor Crystal , Bah-Sow Mariama , Franco Nelson , Prasad Balakrishna M. , Pizarro Jose
Published: June 2020

Flap necrosis is one of the major complications of reconstructive surgery and sildenafil citrate has been shown to decrease flap necrosis in preclinical animal models. However, the mechanisms underlying sildenafil's therapeutic efficacy are not known. As with other phosphodiesterase 5 selective inhibitors, sildenafil causes vasodilation and enhanced blood flow. In addition, sildenafil can also alter gene expression. This study is designed to test the hypothesis that increased expression of angiogenic growth factors may be responsible for therapeutic efficacy of sildenafil. A modified McFarlane flap measuring 3 X 10 cm was created on the dorsal skin of male Sprague-Dawley rats. For growth factor expression experiment, rats were administered either vehicle or sildenafil 10 mg/Kg intraperitoneal (IP). Ribonucleic acid (RNA) extracted from skin flap was analyzed to assess the messenger ribonucleic acid (mRNA) levels of different angiogenic growth factors. For skin flap viability experiment, fibrin film impregnated with vehicle, fibroblast growth factor (FGF) (5.0 μg) or vascular endothelial growth factor (VEGF) (2.0 μg) was applied to the wound. The skin flap was then returned to its native position and stapled in place. Total affected area (area of necrosis and blood flow stasis) of each rat on postoperative day 14 was analyzed with orthogonal polarization spectral imaging. Daily systemic treatment with sildenafil significantly ( P < 0.05) increased the expression of FGF1 and FGF Receptor 3 on postoperative day 3 by 5.08- and 4.78-fold, respectively. In addition, sildenafil increased the expression of VEGF-A, VEGF-B, and VEGF-C by 2.66-, 2.02-, and 2.00-fold, respectively. Subcutaneous treatment with FGF but not VEGF-A tended to decrease total affected area in rats. These data demonstrate that sildenafil altered the expression of FGF and VEGF. Altered expression of growth factors may be, at least partly, responsible for the beneficial effects of sildenafil citrate on skin viability.
Vena Cava Filter Insertion and the General Surgery Armamentarium: A 13-Year Experience
Authors: Sing Ronald F. , Nguyen Phuong H. , Christmas A. Britton , Jacobs David G. , Heniford B. Todd
Published: June 2020

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n = 16), vena cava thrombosis (n = 9), post-VCF pulmonary embolism (n = 2), and a ventricle perforation requiring operative repair (n = 1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe “landing zone” for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.
Review of Re-Excision for Narrow or Positive Margins of Invasive and Intraductal Carcinoma
Authors: Gupta Aditya , Subhas Gokulakkrishna , Dubay Linda , Silapaswan Sumet , Kolachalam Ramachandra , Kestenberg William , Ferguson Lorenzo , Jacobs Michael J. , Goriel Yousif , Mittal Vijay K.
Published: June 2020

The trend in breast surgery has shifted towards breast conservation. Re-excision rates for narrow or positive margins have been variable in published reports. A retrospective analysis of 3246 patients who underwent either a lumpectomy for a palpable mass or a needle localization biopsy between January 2003 and December 2007 was done. Five hundred and eighty-five patients underwent re-excision surgery for margins. The mean patient age was 59-years-old (range 25-93). Needle localization was used to guide initial excision in 372 of 585 patients (64%). Invasive carcinoma was seen in 402 (69%) patients, ductal carcinoma in situ (DCIS) alone in 183 (31%) patients, and 308 (53%) patients had both invasive carcinoma and DCIS. Well-differentiated carcinomas accounted for only 24 per cent of the re-excisions. Four hundred and sixteen patients underwent re-excision of margins, whereas 169 underwent mastectomy as the second surgery. Residual carcinoma was seen in 38 per cent of cases with involved margins, as compared with 24 per cent with <1 mm margins and only 12 per cent cases with >1 mm margins. Residual DCIS was seen in 65 per cent with involved margins, 50 per cent with <2 mm margins, and 35 per cent of cases with 2 to 5 mm margins ( P <0.001, χ2 association). Lesser re-excision was noted in well-differentiated invasive carcinomas. Only 12 per cent of patients with margins greater than 1 mm had residual tumor on re excision, which raises the possibility of nonoperative management in such cases.
Outcomes of Low Anterior Resection Anastomotic Leak after Preoperative Chemoradiation Therapy for Rectal Cancer
Authors: Harris Lisa J. , Phillips Benjamin R. , Maxwell Pinckney J. , Isenberg Gerald A. , Goldstein Scott D.
Published: June 2020

Anastomotic leak remains a major cause of morbidity and mortality after colorectal surgery, especially with low anastomoses. The aim of this study was to assess outcomes of patients who developed an anastomotic leak after low anterior resection of the rectum for rectal cancer. An Institutional Review Board-approved retrospective review of 89 consecutive patients undergoing open low anterior resection with primary anastomosis for cancer of the mid/lower rectum at a single institution between January 2001 and December 2008 was performed. All patients received neoadjuvant chemotherapy and radiation therapy. Proximal diversion was performed in all patients. Perioperative data were collected and analyzed with attention to management and outcomes after development of anastomotic leak. Nine patients (10.1%) developed anastomotic leak. Mean age was 62 years. Mean tumor level was 4.8 cm above the anal verge. Symptomatic anastomotic leak developed in seven (78%) patients. Percutaneous drainage was performed in five (55.6%) patients with an average of 4.4 procedures required for management of anastomotic leak. Five (55.6%) patients required reoperation. Only two procedures (25%) involved laparotomy. No operative procedures were performed emergently. There were no mortalities. Excluding one patient who received completion proctectomy for local recurrence, restoration of intestinal continuity was achieved in five (63%) of eight patients. Mean time to stoma closure was 289 days. The potentially lethal complication of anastomotic leak after low anterior resection for rectal cancer can be managed expectantly and electively in patients who are proximally diverted with the expectation of stoma reversal in the long term.
Gastrointestinal Carcinoids: An Increasing Incidence of Rectal Distribution
Authors: Avenel Paul , McKendrick Alasdair , Silapaswan Sumet , Kolachalam Ramachandra , Kestenberg William , Ferguson Lorenzo , Jacobs Michael J. , Goriel Yousif , Mittal Vijay
Published: June 2020

Carcinoid tumors are slow-growing and usually become symptomatic late in the course of the disease. We evaluated our 10-year experience in the management of GI carcinoid tumors. The records of 133 patients with GI carcinoids were reviewed. The rectum was the most common site for carcinoid tumors with an incidence of 30 per cent followed by jejunoileal at 29.3 per cent. Other sites of carcinoid tumors were the appendix (8.3%), colon (8.3%), and duodenum (3.8%). Endoscopy was the most helpful modality in diagnosing GI carcinoids. CT was not helpful in preoperative diagnosis of carcinoid tumor. Fifteen patients died in follow-up with eight deaths related to carcinoid tumors, in the small bowel (6), rectum (1), and colon (1). Overall survival was 68.7 per cent and mortality rate was 19.5 per cent from carcinoid tumors. Most of the deaths occurred in patients with carcinoid syndrome, synchronous malignancy, and malignant carcinoid tumors. The mean disease-free survival was 51 months (range, 15 to 138 months). Screening colonoscopy, in addition to decreasing colorectal adenocarcinoma mortality, is useful in diagnosing carcinoid tumors at an earlier stage and in decreasing mortality from malignant colorectal carcinoid tumors.
The Incidence of Benign and Malignant Neoplasia Presenting as Acute Appendicitis
Authors: Sieren Leah M. , Collins Jay N. , Weireter Leonard J. , Britt Rebecca C. , Reed Scott F. , Novosel Timothy J. , Britt L.D.
Published: June 2020

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.
Laparoscopic Sleeve Gastrectomy: Outcomes at a Military Training Center
Authors: Rice Robert D. , Simon Todd E. , Seery Jason M. , Frizzi James D. , Husain Farah A. , Choi Yong U.
Published: June 2020

Laparoscopic sleeve gastrectomy (LSG) has gained support as a single-staged and stand-alone bariatric procedure. Reports of excess weight loss of 35 to 83 per cent, reduction in comorbidities, and decreased operative morbidity have garnered support for LSG. This study represents an initial outcome analysis of LSG performed solely at a military treatment center. This study is a retrospective analysis of all patients receiving LSG at Dwight D. Eisenhower Army Medical Center from September 2007 to December 2009. The patients were planned for a stand-alone procedure. One hundred and fifteen patients received LSG over this time period with a mean body mass index of 45.5 ± 6.2 (range 35.1-58.3). The average age was 47.4 ± 12.5 years. Diabetes mellitus was seen in 47 per cent and 68 per cent of patients had hypertension. The mean and median length of operation was 124 ± 48 and 115.5 minutes. The mean percentage of excess weight loss was 16.6 ± 6.40 per cent at 1 month, 31.5 ± 7.6 per cent at 3 months, 41.2 ± 13.9 per cent at 6 months, and 53.7 ± 12.5 per cent at 1 year from surgery. One or more of patient's preoperative diabetic or hypertensive medications were improved postoperatively in 18.7 per cent and 16.3 per cent, respectively. Incidence of major complications occurred in 4.35 per cent of patients in this study to include four leaks (3.4%), one death (0.87%), and 10 readmissions. Midterm analysis of outcomes related to LSG as a single-stage bariatric procedure is promising as long-term outcome data is collected; the efficacy of this procedure as a sole bariatric procedure will continue to be borne out.
Aggressive Operative Treatment for Emetogenic Rupture Yields Superior Results
Authors: Neel Dustin , Davis Eric G. , Farmer Russell , Richardson J. David
Published: June 2020

The treatment of emetogenic rupture remained controversial and was particularly so when the patient arrived for definitive care greater than 24 hours postrupture. We treated patients with continued extravasation of contrast from the esophagus by early operation regardless of the timing of their presentation. All primary repairs received a reinforced closure and many delayed repairs had an onlay flap for closure of the leak. We treated 31 patients with emetogenic rupture; 24 of 25 patients with extravasation had operative repair, whereas six with small, contained ruptures were treated medically. Twelve were operated on within 24 hours, whereas 24 presented from 36 to 796 hours postrupture. We were able to achieve closure of the defect by primary suture repair or with a tissue flap in all patients. There were no postoperative leaks. One patient each died in the operated group and observed group. There were minimal complications and a relatively short hospital stay. Our results support the use of aggressive operative treatment for emetogenic rupture regardless of the timing of patient presentation. Such treatment preserved esophageal function and was accomplished with relatively low morbidity and mortality.
Gender Differences in Glucose Variability after Severe Trauma
Authors: Mohr Alicia M. , Lavery Robert F. , Sifri Ziad C. , Anjaria Devashish J. , Koernig Robert , Deitch Edwin A. , Livingston David H.
Published: June 2020

Gender differences in the physiological response to trauma can affect outcome. Both hyperglycemia and blood glucose (BG) variability predict a poor outcome after trauma. This study examined the hypothesis that both BG levels and the degree of BG variability after trauma are gender-specific and correlate with mortality and morbidity. A retrospective observational cohort study of 1915 trauma patients requiring critical care was performed. Admission BG as well as all BG values obtained during the first week while in the intensive care unit were analyzed. In each patient, the mean BG and the degree of BG variability were calculated. A total of 1560 males and 355 females were studied with an overall mortality rate of 12 per cent. Seventy-six per cent of deaths had a BG greater than 125 mg/dL on admission and as BG variability worsened, the mortality rate also increased. There was a significant difference in male BG variability when comparing survivors with nonsurvivors. Female BG variability did not predict mortality. Failed glucose homeostasis is an important marker of endocrine dysfunction after severe injury. Increased BG variability in males is associated with a higher mortality rate. In females, mortality cannot be predicted based on BG levels or BG variability. These data have significant implications for gender-related differences in postinjury management.
Video-Assisted Thoracoscopic Surgery as a Primary Intervention in Pediatric Parapneumonic Effusion and Empyema
Authors: Schneider Christopher R. , Gauderer Michael W.L. , Blackhurst Dawn , Chandler John C. , Abrams Randel S.
Published: June 2020

The use and effectiveness of video-assisted thoracoscopic surgery (VATS) for the treatment of empyema and complex parapneumonic collections in pediatric patients is well documented. Timing of this intervention still remains controversial. We reviewed our experience with VATS to determine if it should be used as the initial procedure in children with pleural collections. We reviewed all pediatric (age younger than 17 years) patients with a diagnosis of pneumonia admitted between July 1998 and June 2008. Demographics, comorbidities, laboratory data, and hospital length of stay (LOS) were evaluated. Patients were divided into groups: those who only had thoracentesis or thoracostomy (Group A), those who underwent a procedure and then required VATS (Group B), and those who went directly to VATS (Group C). We identified 382 patients admitted with pneumonia. Of these, 79 (21%) required a thoracic drainage procedure. Overall, 49 (67%) of patients with a thoracic fluid collection underwent VATS at some point. With regard to type of intervention, there was no statistical difference noted in clinical variables. Thirty (38%) patients were in Group A, 18 (22%) in Group B, and 31 (39%) in Group C. LOS for Group C (10.5 days) was significantly ( P < 0.05) shorter than for both Group A (14.8 days) and Group B (15 days). Only two (6%) patients required conversion to open thoracotomy. A high percentage of children initially treated by tube thoracostomy eventually require additional interventions, leading to increased LOS. As a result of its simplicity, safety, and efficacy, VATS pleural evacuation can be recommended as the initial intervention in pediatric parapneumonic effusions and empyema in patients who do not require emergent drainage.