bluuebunny/crossref_metadata_2025 huggingface dataset:
Flat Inferior Vena Cava: Indicator of Poor Prognosis in Trauma and Acute Care Surgery Patients
Authors: Ferrada Paula , Vanguri Poornima , Anand Rahul J. , Whelan James , Duane Therese , Wolfe Luke , Ivatury Rao
Published: June 2020

Flat inferior vena cava (IVC) on ultrasound examination has been shown to correlate with hypovolemic status. We hypothesize that a flat IVC on limited echocardiogram (LTTE) performed in the emergency room (ER) correlates with poor prognosis in acutely ill surgical patients. We conducted a retrospective review of all patients undergoing LTTE in the ER from September 2010 until June 2011. IVC diameter was estimated by subxiphoid window. Flat IVC was defined as diameter less than 2 cm. Fat IVC was defined as diameter greater than 2 cm. Need for intensive care unit admission, blood transfusion requirement, mortality, and need for emergent operation between patients with flat versus Fat IVC were compared. One hundred one hypotensive patients had LTTE performed in the ER. Average age was 38 years. Admission diagnosis was blunt trauma (n = 80), penetrating trauma (n = 13), acute care surgery pathology (n = 7), and burn (n = 1). Seventy-four patients had flat IVC on initial LTTE. Compared with those with fat IVC, flat patients were found have higher rates of intensive care unit admission (51.3 vs 14.8%; P = 0.001), blood transfusion requirement (12.2 vs 3.7%), and mortality (13.5 vs 3.7%). This population also underwent emergent surgery on hospital Day 1 more often (16.2 vs 0%; P = 0.033). Initial flat IVC on LTTE is an indicator of hypovolemia and a predictor of poor outcome.
Negative Effects of Transfused Blood Components after Hepatectomy for Metastatic Colorectal Cancer
Authors: Cannon Robert M. , Brown Russell E. , Hill Charles R. , Dunki-Jacobs Eric , Martin Robert C. G. , McMasters Kelly M. , Scoggins Charles R.
Published: June 2020

There has been conflicting evidence regarding negative effects of blood transfusion in oncology patients. This study was undertaken to determine any negative effects of specific blood product transfusion after resection of hepatic colorectal metastases (CRM). Retrospective review of patients undergoing hepatectomy for CRM from 1995 to 2009 at a single institution was performed. Specific attention was paid to the effect of blood transfusion within 30 days of operation on overall survival, disease-free survival (DFS), and complications. To mitigate the bias introduced by complications that require blood transfusion to treat, only nonbleeding complications were considered. Complications were analyzed with univariate and multivariate logistic regression. Survival was analyzed according to Kaplan-Meier and Cox proportional hazards. There were 239 patients included in the study. There were 64 (26.8%) receiving a transfusion of any kind with 25.5 per cent getting red cells (PRBCs), 7.11 per cent getting fresh-frozen plasma, and 3.77 per cent getting platelets. Multivariate analysis revealed only PRBC transfusion to be independently associated with nonbleeding complications (odds ratio, 1.980; 95% confidence interval, 1.094 to 3.582; P = 0.0239). There was no significant adverse effect of transfusion with any product on overall or DFS. PRBC transfusion appears to increase the risk of postoperative complications; thus, strategies to minimize blood use may be warranted.
Laparoscopic Heller Myotomy and Fundoplication in Patients with Chagas’ Disease Achalasia and Massively Dilated Esophagus
Authors: Pantanali Carlos A. R. , Herbella Fernando A. M. , Henry Maria A. , Mattos Farah Jose Francisco , Patti Marco G.
Published: June 2020

Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.
Robotic-Assisted Retroperitoneoscopic Adrenalectomy: Making a Good Procedure Even Better
Authors: Dickson Paxton V. , Alex Gillian C. , Grubbs Elizabeth G. , Jimenez Camilo , Lee Jeffrey E. , Perrier Nancy D.
Published: June 2020

Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive procedure offering several advantages over a transabdominal laparoscopic operation. The three-dimensional optics and articulating instrumentation offered by current robotic surgical technology potentially improve this procedure. Robotic-assisted PRA (RA-PRA) was performed in patients meeting standard criteria for minimally invasive adrenalectomy. We prospectively collected demographic, clinical, perioperative, and pathologic data on patients undergoing RA-PRA. Thirty consecutive RA-PRAs were performed in 28 patients (26 unilateral and 2 bilateral). Indications for adrenalectomy included pheochromocytoma (8), hyperaldosteronism (3), hypercortisolism (8), oligometastases (5), and nonfunctional tumors (6). Mean tumor size was 3.8 ± 1.6 cm. Mean body mass index was 30.7 ± 6.5 kg/m2. Mean operative time was 154 ± 43 minutes for unilateral total adrenalectomy. Four patients with multiple endocrine neoplasia Type 2A-associated pheochromocytomas underwent cortical-preserving procedures. Three patients experienced perioperative complications (one pneumothorax, one urinary retention, one required postoperative blood transfusion). No patient required conversion to an open procedure. Robotic surgical technology is an excellent complement to retroperitoneoscopic adrenalectomy. The three-dimensional view and ergonomic advantages of a robotic procedure promote better visualization and a more flexible approach to dissection. We believe these features may optimize the ability to maintain a vascularized remnant during minimally invasive cortical-sparing adrenalectomy.
Improved Outcomes for Rectal Cancer in the Era of Preoperative Chemoradiation and Tailored Mesorectal Excision: A Series of 338 Consecutive Cases
Authors: Pacelli Fabio , Sanchez Alejandro M. , Covino Marcello , Tortorelli Antonio P. , Bossola Maurizio , Valentini Vincenzo , Gambacorta Maria A. , Doglietto Giovanni B.
Published: June 2020

Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N1 disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.
Impact of Surgical Mentorship on Retroperitoneoscopic Adrenalectomy with Comparison to Transperitoneal Laparoscopic Adrenalectomy
Authors: Broome James T. , Solorzano Carmen C.
Published: June 2020

Retroperitoneoscopic adrenalectomy (RA) provides a direct approach to the adrenal gland. RA represents a complex approach with unique orientation that is less intuitive. The authors objectively evaluated the impact of mentorship on the performance of RA and also compared it with laparoscopic adrenalectomy (LA). After implementing the use of RA, a retrospective review of the operative experience of two high-volume endocrine surgeons was performed. Both surgeons participated in a hands-on RA mentorship. Clinical presentation and perioperative outcomes were compared. Subgroup analysis was used to compare RA pre- and postmentorship and with LA. Sixty-one LAs and 31 RAs were included in the analysis. The mean operative time was 115 for LA versus 90 minutes for RA ( P = 0.002). Blood loss was greater for LA versus RA (56 vs 22 mL; P = 0.001). Length of stay (LOS) for LA was 2.2 versus 1.5 days for RA ( P = 0.029). Ten patients were treated by RA in the prementorship era versus 21 in the postmentorship era. The mean operative time for the prementorship group was 118 minutes, which decreased to 77 minutes postmentorship ( P < 0.0001). LOS also decreased from 2.0 to 1.2 days ( P = 0.04) in the postmentorship era. RA demonstrates a shorter operative time, less blood loss, and decrease length of hospital stay as compared with standard LA. After proper mentorship and patient selection, RA may represent a superior option for removal of small, benign adrenal tumors.
Radiographic Findings of Anastomotic Leaks
Authors: Lynn Elizabeth T. , Chen Julia , Wilck Eric J. , El-Sabrout Kerri , Lo Chris C. , Divino Celia M.
Published: June 2020

Although computed tomography (CT) scans play an important role in the diagnosis and management of anastomotic leaks (AL), there is no consensus on what radiographic findings are associated with AL. The purpose of this study is to identify the most common CT scan findings associated with AL and whether the amount of extraluminal air or the density of extraluminal fluid can be correlated with the presence of an AL. A retrospective chart review of 210 patients with anastomotic leaks from 2003 to 2010 at Mount Sinai Medical Center was performed. Eighty-six patients fit our criteria and were included. All CT scans were reread by an independent radiologist not involved with patient care. Our study included 59 per cent men and 41 per cent women with a mean age of 51 years. Diagnoses included inflammatory bowel disease (53%), malignancy (21%), and diverticulitis (12%). One hundred per cent of the patients had one of three findings: extraluminal air (92%), extraluminal fluid (88%), or extravasation of contrast (32%). Eighty-one per cent (70/86) had both fluid and air simultaneously. Extraluminal air was seen in 79 patients. The estimated amounts of extraluminal air were as follows: 0 to 25 mL (49%), 26 to 500 mL (41%), 500 to 1000 mL (5%), and more than 1000 mL (5%). The Hounsfield unit (HU) measurements of the fluid ranged from 3 to 633 HUs. The most common CT findings associated with AL are pneumoperitoneum and extraluminal fluid, including extravasation of contrast, which can be seen in up to 100 per cent of patients. The amount of estimated extraluminal air and density of fluid collection have no prognostic value in predicting AL.
Expression of GLI1 Correlates with Expression of Lymphangiogenesis Proteins, Vascular Endothelial Growth Factor C and Vascular Endothelial Growth Factor Receptor 3, in Colorectal Cancer
Authors: Hong Kwang Dae , Lee Youngseok , Kim Baek-Hui , Lee Sun Il , Moon Hong Young
Published: June 2020

Aberrant activation of the hedgehog (Hh) signaling pathway is associated with tumorigenesis in various tissues. In colorectal cancer (CRC), evidence for Hh activation is inconsistent, and the relationship between the Hh signaling pathway and lymphangiogenesis has not been studied. The aim of this study was to determine the relationship between Hh signaling and lymphangio-genesis and the association of this relationship with lymph node metastasis in CRC. We investigated 189 patients who underwent curative surgical resection for CRC between 2002 and 2004 at Korea University Guro Hospital. Paraffin-embedded specimens of colorectal adenocarcinoma and adjacent normal mucosa were evaluated. Immunohistochemical staining for Sonic hedgehog (Shh), Gli1, vascular endothelial growth factor C (VEGFC), and VEGF receptor 3 (VEGFR3) was performed for each specimen. Tumor specimen showed significantly strong staining of Shh, Gli1, VEGFC, and VEGFR3 compared with a normal specimen. Shh expression was not associated with Gli1 expression. Gli1 expression correlated positively with VEGFC and VEGFR3 expression ( P < 0.05 in both) but not with lymph node metastasis. Activation of the Hh signaling pathway associated with Gli1 promotes expression of lymphangiogenesis proteins, VEGFC and VEGFR3, in CRC. Further studies are necessary to determine the association of this relationship with lymph node metastasis in CRC.
Lymph Node Ratio as a Predictor of Survival in Gastric Carcinoma
Authors: Medina-Franco Heriberto , Cabrera-Mendoza Francisco , Almaguer-Rosales Susana , Guillén Fabiola , Suárez-Bobadilla Yoli L. , Sánchez-Ramón Ariadne
Published: June 2020

According to the American Joint Committee on Cancer (AJCC), the number of metastatic lymph nodes is the main prognostic factor in gastric cancer. Lymph node ratio (LNR) has been proposed as a better predictor of survival. We included patients resected for gastric cancer in a referral center in Mexico City. Number of metastatic nodes was analyzed according to AJCC 2002 and 2010. We divided LNR into four stages. Survival was calculated with the Kaplan-Meier method and curves compared with the log-rank test. P < 0.05 was significant. Two hundred patients were included. Median number of retrieved and metastatic nodes were 18 and 2.5, respectively. Median survival was 44 months. AJCC 2010 was a better predictor of survival than the 2002 version ( P < 0.001). Median survival for LNR 0, 1, 2, and 3 was 117, 68, 44, and 14 months, respectively ( P < 0.001). In patients with less than 15 nodes removed, AJCC was not a predictor of survival ( P = 0.09) but LNR was ( P = 0.04). Nodal staging in AJCC 2010 is a better predictor of survival than the 2002 edition. LNR is useful in the group of patients with suboptimal node dissection.
Model for End-stage Liver Disease (MELD) in Predicting Postoperative Mortality of Patients Undergoing Colorectal Surgery
Authors: Hedrick Traci L. , Swenson Brian R. , Friel Charles M.
Published: June 2020

The Model for End-stage Liver Disease (MELD) score was previously shown to predict perioperative mortality in patients with cirrhosis undergoing a variety of nontransplant surgical procedures. We sought to determine its usefulness in predicting postoperative mortality in patients undergoing colorectal procedures. National Surgical Quality Improvement Program data were gathered for adult patients undergoing elective and emergent colorectal procedures (Current Procedural Terminology codes 44005 through 45563 excluding appendectomy) during 2005 and 2006 at participating centers. The preoperative MELD score was calculated for all patients and assessed using logistic regression modeling. A total of 10,033 patients met study inclusion criteria. Overall 30-day mortality was 6.6 per cent. In all patients undergoing colorectal surgery, MELD was anindependent predictor of mortality (2.95 [2.27 to 3.84]). Other independent predictors included age, functional status, American Society of Anesthesiologists classification, ascites, esophageal varices, disseminated cancer, chronic steroid use, cardiac disease, renal failure, malnutrition, sepsis, emergency, and ventilator dependence. The MELD score is an independent predictor of mortality in patients undergoing colorectal procedures. These data can be used to assign risk and assist in clinical decision-making.
Reduced CDX2 Expression Predicts Poor Overall Survival in Patients with Colorectal Cancer
Authors: Dae Hong Kwang , Lee Dooseok , Lee Youngseok , Lee Sun Il , Moon Hong Young
Published: June 2020

The homeodomain transcription factor CDX2 directs development and maintenance of normal intestinal epithelium. However, the role of CDX2 in colorectal carcinogenesis is poorly understood. Hence, we investigated the CDX2 expression in patients with colorectal cancer and its relationship to tumor cell proliferation and differentiation and evaluated the role of this molecule as a biologic marker for the prediction of poor patient survival. We retrospectively reviewed 207 patients with colorectal cancer, with an available paraffin block, who underwent surgical resection between January 2002 and December 2004 at Korea University Guro Hospital. CDX2 expression was compared between tumor tissue and the adjacent normal mucosa using immunohistochemistry and Western blot analysis. Immunohistochemical staining for CDX2, Ki-67, and CK20 was performed in each tumor tissue. Immunohistochemistry revealed that CDX2 protein is overexpressed by colorectal cancer compared with adjacent normal mucosa (P < 0.001). In the Western blot analysis, tumor tissue showed a trend toward overexpression of CDX2 protein compared with normal mucosa (P = 0.09). CDX2 expression showed a significant direct correlation with the expression of Ki-67 and CK20 in tumor tissue (P = 0.028 and P = 0.042, respectively). Survival analysis showed that reduced CDX2 expression was statistically and significantly related to poor overall survival. Reduced CDX2 expression is associated with poor overall survival in patients with colorectal cancer and may be clinically useful as a marker for poor prognosis.
Evaluating the Learning Curve Associated with Laparoscopic Left Hemicolectomy for Colon Cancer
Authors: Yamamoto Masashi , Okuda Junji , Tanaka Keitaro , Kondo Keisaku , Asai Keiko , Kayano Hajime , Masubuchi Shinsuke , Uchiyama Kazuhisa
Published: June 2020

The role of laparoscopic surgery for transverse and descending colon cancer remains controversial. The aim of the present study was to characterize the learning curve for laparoscopic left hemicolectomy including the splenic flexure and to identify factors that influence this learning curve. Data from 120 consecutive patients undergoing laparoscopic left hemicolectomy for transverse and descending colon cancer including the splenic flexure between December 1996 and December 2009 were analyzed. Patients undergoing resection combined with cholecystectomy, hepatectomy, hysterectomy, or gastrectomy were excluded. Operative time was analyzed using the moving average method. The operative time, conversion rate, and postoperative complication rate were evaluated among four groups based on the number of cases required for analysis of operative time. In addition, risk factors that influenced conversion to open surgery were analyzed. Operative time for left hemicolectomy decreased with increasing case number with stabilization at 30 cases. There was no significant difference in the conversion rate or postoperative complications over time. Significant factors for conversion to open surgery were T stage (odds ratio [OR], 5.56; 95% confidence interval [CI], 1.5 to 27.4) and previous abdominal surgery (OR, 5.38; 95% CI, 1.6 to 20.2). The learning curve for laparoscopic left hemicolectomy is steep. Thus, surgeons in the early part of this curve should carefully select patients to allow them to build experience in a stepwise manner. Laparoscopic surgery may become the gold standard for management of colon cancer regardless of stage or tumor location.
Hand-assisted Laparoscopic Spleen-preserving Total Gastrectomy for Gastric Cancer: Technical Feasibility and Early Results
Authors: Zhang Guang-Tan , Zhang Xue-Dong
Published: June 2020

To evaluate the feasibility and safety of hand-assisted laparoscopic spleen-preserving total gas-trectomy for gastric cancer, we compared the operative outcomes between two methods for dissection of lymph nodes along the distal splenic artery (No. 11d) and at the splenic hilum (No. 10). Sixty-four patients with proximal or total gastric cancer operated on in our department from October 2009 to February 2012 were divided into two groups: the extracorporeal method group (EMG) and the intracorporeal method group (IMG). Operative time, estimated blood loss, number of lymph node retrieval, times of analgesic injection, time to the first flatus, and postoperative hospital stay were compared between the two groups. Estimated blood loss, times of analgesic injection, time to the first flatus, and postoperative hospital stay were equivalent between the two groups. The operative time was significantly shorter in the IMG than the EMG. There were no significant differences in tumor size, retrieved lymph nodes, American Joint Committee on Cancer/Union for International Cancer Control staging, or resection margins between the two groups. Hand-assisted laparoscopic spleen-preserving total gastrectomy is technically feasible and safe and allows for adequate lymphadenectomy.
Risk Factors for Falls among Hospitalized Trauma Patients
Authors: Brown Carlos V. R. , Ali Sadia , Fairley Romeo , Lai Bryan K. , Arthrell Justin , Walker Melinda , Tips Gaylen
Published: June 2020

Inpatient falls lead to an injury in 30 per cent of cases and serious injury in 5 per cent. Increasing staffing and implementing fall prevention programs can be expensive and require a significant use of resources. We hypothesized that trauma patients have unique risk factors to sustain a fall while hospitalized. This is a retrospective cohort study from 2005 to 2010 of all trauma patients admitted to an urban Level I trauma center. Patients who fell while hospitalized were compared with patients who did not fall to identify risk factors for sustaining an inpatient fall. There were 16,540 trauma patients admitted during the study period and 128 (0.8%) fell while hospitalized. Independent risk factors for a trauma patient to fall while hospitalized included older age (odds ratio [OR], 1.02 [1.01 to 1.03], P < 0.001), male gender (OR, 1.6 [1.0 to 2.4], P = 0.03), blunt mechanism (OR, 5.1 [1.6 to 16.3], P = 0.006), Glasgow Coma Score at admission (OR, 0.59 [0.35 to 0.97], P = 0.04), intensive care unit admission (OR, 2.3 [1.4 to 3.7], P = 0.001), and need for mechanical ventilation (OR, 2.2 [1.2 to 3.9], P = 0.01). Trauma patients who fell while hospitalized sustained an injury in 17 per cent of cases and a serious injury in 5 per cent. Inpatient falls in hospitalized trauma patients are uncommon. Risk factors include older age, male gender, blunt mechanism, lower Glasgow Coma Score, and the need for intensive care unit admission or mechanical ventilation. Trauma patients with these risk factors may require higher staffing ratios and should be enrolled in a formal fall prevention program.
Assessment of Psychiatric Symptoms at a Level I Trauma Center Surgery Follow-up Clinic: A Preliminary Report
Authors: Conrad Erich J. , Hansel Tonya C. , Pejic Nicholas G. , Constans Joseph
Published: June 2020

At Level I trauma centers, psychiatric consultation is readily available to inpatient surgical services. This study sought to characterize the psychiatric symptoms present in the surgical follow-up clinic. Patients aged 18 years and older were assessed over one month for symptoms of posttraumatic stress disorder (PTSD) with the Short PTSD Rating Interview (SPRINT), depression with the Patient Health Questionnaire (PHQ-9), alcohol abuse with the Alcohol Use Disorder Identification Test (AUDIT), and the presence of violence using the MacArthur Community Violence Instrument (MCVIa [victimization] MCVIb [perpetration]). Twenty-five individuals participated. Using the SPRINT, 13 (52.0%) met the cutoff for PTSD. For PHQ-9 depression, 11 (44%) were in the moderate to severe range. For AUDIT, five (20.0%) likely had an alcohol problem. Using the MCVI, 15 (60.0%) reported victimization and 12 (48.0%) reported perpetration. Elevated levels of psychiatric symptoms were found in the trauma surgery follow-up clinic. Psychiatric care embedded in this setting may be warranted.
Short-term Results of Laparoscopic versus Open Liver Resection for Liver Metastasis from Colorectal Cancer: A Comparative Study
Authors: Inoue Yoshihiro , Hayashi Michihiro , Tanaka Ryo , Komeda Koji , Hirokawa Fumitoshi , Uchiyama Kazuhisa
Published: June 2020

Laparoscopic liver resection is currently performed in an increasing number of institutions as a minimally invasive treatment. However, no randomized controlled trials have compared laparoscopic and open liver resections. Twenty-three laparoscopic and 24 open liver resections for colorectal cancer liver metastases (CRCLM) were performed, and these data for both were retrospectively compared in the short-term results. The estimated blood loss was 99 ± 207 mL in the laparoscopic group and 397 ± 381 mL in the open group ( P = 0.0018); blood loss was significantly higher in the open group. There were no differences in the surgical procedure, blood loss, transfusion rate, pathological margins, postoperative complications, 30-day mortality, duration of intravenous drip, or hospital stay. On postoperative courses, the values of total bilirubin, white blood cell count, and C-reactive protein were significantly lower in the laparoscopic group. The data of the present series suggest the lesser invasiveness and safety of laparoscopic liver resection even for patients with CRCLM, and they showed that postoperative laboratory tests were better after laparoscopy than after the traditional open approach with better short-term results. Tumor diameter less than 5 cm appears to be the appropriate indication for laparoscopic liver resection for CRCLM.
Percutaneous Cholecystostomy is a Definitive Treatment for Acute Cholecystitis in Elderly High-risk Patients
Authors: Li Min , Li Ning , Ji Wu , Quan Zhufu , Wan Xinbo , Wu Xingjiang , Li Jieshou
Published: June 2020

Percutaneous cholecystostomy (PC) is an alternative treatment for acute cholecystitis (AC) in elderly patients with high surgical risk and has lower morbidity and mortality than emergency cholecystectomy. There is controversy about whether cholecystectomy should be performed after PC in elderly high-risk patients. Medical records of patients with AC admitted to the Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, China, between January 2004 and July 2009 were reviewed retrospectively. The elderly high-risk patients with AC who underwent PC were selected for further study. The safety, efficacy, and long-term outcome of PC without cholecystectomy were evaluated in these patients. The symptoms of AC resolved in 98.6 per cent of patients; drainage-related morbidity and mortality rates were 4.1 and 1.4 per cent, respectively. No patient underwent cholecystectomy after PC. The recurrence rate of cholecystitis was 4.1 per cent. The one-year survival rate was 82.2 per cent, and the three-year survival rate was 39.6 per cent. No death was related to cholecystitis, but one patient died of septic shock on the second day after PC. Considering limited survival and a low recurrence rate of cholecystitis in elderly high-risk patients with AC, we propose that PC is a definitive treatment and cholecystectomy is not necessary after resolution of AC symptoms.
Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in Peritoneal Sarcomatosis
Authors: Randle Reese W. , Swett Katrina R. , Shen Perry , Stewart John H. , Levine Edward A. , Votanopoulos Konstantinos I.
Published: June 2020

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the treatment most likely to achieve prolonged survival for peritoneal surface disease from various primaries, yet management of peritoneal sarcomatosis is controversial as a result of the propensity of sarcomas for hematogenous spread and the paucity of effective chemotherapy. Therefore, we reviewed our experience in patients with sarcomatosis. A retrospective analysis of a prospective database of 990 procedures was performed. Eastern Cooperative Oncology Group, age, type of primary, resection status, morbidity, mortality, and outcomes were reviewed. Over 20 years, 17 cytoreductions for sarcomatosis were performed. After excluding patients with gastrointestinal stromal tumor or uterine leiomyosarcoma, 10 procedures performed in seven patients remained. Median follow-up was 84.8 months. R0/1 resection was achieved in 60 per cent. The 30-day morbidity was 50 per cent; no operative mortality rate was observed. R2 resection had no long-term survivors. The reason for death was peritoneal recurrence in 57 per cent. Median survival was 21.6 months and five-year survival was 43 per cent. Median survival for patients with peritoneal sarcomatosis treated with CRS-HIPEC is similar with the historical reported survival before introducing chemoperfusion. Although a complete cytoreduction is related to improved survival, the role of HIPEC in these patients is unknown. A multi-institutional review will help define the role of CRS-HIPEC in this population.
Surgeon-performed Ultrasound for Primary Hyperparathyroidism
Authors: Schenk Worthington G. , Hanks John B. , Smith Philip W.
Published: June 2020

The role of preoperative parathyroid imaging continues to evolve. This study evaluated whether surgeon-performed ultrasound (U/S) obviates the need for other imaging studies and leads to a focused exploration with a high degree of surgical success. From July 2010 to February 2012, 200 patients presenting with nonfamilial primary hyperparathyroidism underwent neck U/S in the surgeon's office. The U/S interpretation was classified as Class 1 if an adenoma was identified with high confidence, Class 2 if a possible but not definite enlarged gland was imaged, and Class 0 (zero) if no adenoma was identified. The findings were correlated with subsequent intra-operative findings. There were 144 Class 1 U/Ss (72%); of 132 patients coming to surgery, 96.2 per cent had surgical findings concordant with preoperative U/S and all had apparent surgical cure. Twenty-nine patients (14.5%) had Class 2 U/S; the 31 per cent confirmed false-positives in this group were usually colloid nodules. Fourteen of 27 with Class 0 U/S underwent surgery after being offered dynamically enhanced computed tomography scan. All 200 patients were apparent surgical cures. Surgeon-performed U/S is expedient, convenient, inexpensive, and accurate. A clearly identified adenoma can safely lead to a focused limited exploration and avoid additional imaging 93 per cent of the time.
Treatment of Refractory Perianal Fistulas with Ligation of the Intersphincteric Fistula Tract: Preliminary Results
Authors: Campbell Michael L. , Abboud Elia Charbel , Dolberg Michael E. , Sanchez Jaime E. , Marcet Jorge E. , Rasheid Sowsan H.
Published: June 2020

Several surgical options exist for management of fistula in ano. The goal of treatment is to achieve closure of the fistula while maintaining continence. Sphincter-sparing operations to close perianal fistulas include advancement flap, anal fistula plug, fibrin glue, and fistulectomy. Variable success rates from 30 to 80 per cent have been reported. Ligation of intersphincteric fistula tract (LIFT), first described in 2007, has a reported success rate from 40 to 94 per cent. The objective of this study was to study our results of the LIFT procedure for refractory perianal fistulas. We conducted a retrospective 18-month review of consecutive patients with refractory perianal disease treated with the LIFT procedure at an academic, tertiary, colorectal practice. All patients undergoing a LIFT procedure for anal fistula from August 2010 to August 2012 were included in the study. The primary end points were success rates at 1 month and 3 months. Secondary end points were postoperative complications and maintenance of continence. Twenty patients underwent LIFT procedures of whom nine had previously failed treatments. Mean age was 45 years and included 12 male and eight female patients. Success rate at 1 month was 70 per cent (14 patients) and at 3 months was 80 per cent (16 patients). Success rates for patients with previously failed attempts were 67 per cent at 1 month and 89 per cent at 3 months. Continence was maintained in 100 per cent of patients. Our data support the use of the LIFT procedure for refractory perirectal fistulas.
Defining the Learning Curve of Laparoendoscopic Single-site Heller Myotomy
Authors: Ross Sharona B. , Luberice Kenneth , Kurian Tony J. , Paul Harold , Rosemurgy Alexander S.
Published: June 2020

Initial outcomes suggest laparoendoscopic single-site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. One hundred patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom resolution, additional trocars, and complications were compared among patient quartiles. Median data are presented. Preoperative frequency/severity scores were: dysphagia = 10/8 and regurgitation = 8/7. Additional trocars were placed in 12 patients (10%), of whom all were in the first two quartiles. Esophagotomy/gastrotomy occurred in three patients. Postoperative complications occurred in 9 per cent. No conversions to “open” operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia = 2/0 and regurgitation = 0/0; scores were less than before myotomy ( P < 0.001). There were no apparent scars, except where additional trocars were placed. LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar. Placement of additional trocars only occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, because proficiency is quickly attained.
Severe Plantar Hyperhidrosis: An Effective Surgical Solution
Authors: Reisfeld Rafael , Pasternack Glenn A. , Daniels Parviz D. , Basseri Eraj , Nishi Gregg K. , Berliner Aren I.
Published: June 2020

Severe palmoplantar hyperhidrosis both affects activities of daily living and diminishes quality of life. This study evaluated overall safety and efficacy of endoscopic lumbar sympathectomy (ELS) using a clamping method in a large series of consecutive patients. Patient data were routinely entered into a prospectively designed database. Plantar sweating was graded as cured, improved, or unchanged. ELS (using 5-mm titanium clips) was performed in 154 patients, 68.2 per cent at the third lumbar vertebrae and 31.8 per cent at the fourth lumbar vertebrae. Follow-up averaged 15 months and ranged up to 4.7 years. Anhidrosis was achieved in 97.4 per cent of patients with the remainder reporting major reduction in symptoms. All patients were discharged home within 24 hours of surgery, requiring only oral analgesics, if any. There were two surgical complications (lymphatic leak and misidentification of genitofemoral nerve for sympathetic nerve). Six early patients required conversion to an open surgical procedure. Partial recurrence, usually mild, occurred in 4.5 per cent with 2.6 per cent requiring revision surgery. Severe plantar hyperhidrosis can be safely and effectively treated by endoscopic lumbar sympathectomy using the clamping method. It can be accomplished on an outpatient basis with low morbidity, complete resolution of symptoms, and a significant improvement in quality of life.
Comparing the Cost and Outcomes of Laparoscopic versus Open Appendectomy for Perforated Appendicitis in Children
Authors: Groves Leslie B , Ladd Mitchell R. , Gallaher Jared R. , Swanson John , Becher Robert D. , Pranikoff Thomas , Neff Lucas P.
Published: June 2020

Although laparoscopic appendectomy (LA) is accepted treatment for perforated appendicitis (PA) in children, concerns remain whether it has equivalent outcomes with open appendectomy (OA) and increased cost. A retrospective review was conducted of patients younger than age 17 years treated for PA over a 12.5-year period at a tertiary medical center. Patient characteristics, pre-operative indices, and postoperative outcomes were analyzed for patients undergoing LA and OA. Of 289 patients meeting inclusion criteria, 86 had LA (29.8%) and 203 OA (70.2%), the two groups having equivalent patient demographics and preoperative indices. Inpatient costs were not significantly different between LA and OA. LA had a lower rate of wound infection (1.2 vs 8.9%, P = 0.017), total parenteral nutrition use (23.3 vs 50.7%, P < 0.0001), and length of stay (5.56 ± 2.38 days vs 7.25 ± 3.77 days, P = 0.0001). There was no significant difference in the rate of postoperative organ space abscess, surgical re-exploration, or rehospitalization. In children with PA, LA had fewer surgical site infections and shorter lengths of hospital stay compared with OA without an increase in inpatient costs.
Cystic Biliary Atresia: A Wolf in Sheep's Clothing
Authors: Hill Sarah J. , Clifton Matthew S. , Derderian Sarkis C. , Wulkan Mark L. , Ricketts Richard R.
Published: June 2020

Neonatal obstructive jaundice is frequently explained by biliary atresia (BA) or the presence of a choledochal cyst (CC). Cystic biliary atresia (CBA) has been a proposed as a subtype of BA with projected improved outcomes. We aimed to characterize these lesions further. We conducted an Institutional Review Board-approved review of all patients treated for obstructive jaundice at our tertiary children's hospital over 10 years. Over the decade we evaluated 91 children with obstructive jaundice: 13 CBA, 52 BA, and 26 CC. Patients with isolated CBA and BA were diagnosed significantly earlier than those with CC (15.9, 54, and 281 days, respectively; P = 0.0001). There was a significant delay between diagnosis and surgical intervention for patients with CBA compared with BA: 17 days versus 5.7 days ( P = 0.004). There was no difference in rate of transplant between CBA and BA (31 vs 50%; P = 0.35). The time from surgery until transplant was 13.9 and 18.6 months for CBA and BA, respectively ( P = 0.62). Although radiographically similar to CC, CBA behaves similarly to isolated BA. Delay in recognition and surgical treatment may affect outcomes and lead to an increased incidence of liver failure. The presence of a cystic biliary malformation in the setting of neonatal jaundice should be regarded as CBA until proven otherwise.
Hyperkinetic Gallbladder: An Indication for Cholecystectomy?
Authors: Lindholm Erika B. , Alberty J. Brannon , Hansbourgh Faith , Upp James R. , Lopoo John
Published: June 2020

Cholecystectomy may benefit children with biliary colic without stones on ultrasound (US) or low ejection fraction on cholecystokinin-hepatobiliary iminodiacetic acid (CCK-HIDA) scan. Children with symptomatic biliary colic and abnormal HIDA scan, specifically those with high ejection fractions, may benefit from cholecystectomy. All patients younger than 18 years old undergoing cholecystectomy from 2008 to 2012 in our practice were reviewed. Patients with a negative US and CCK-HIDA ejection fractions 80 per cent or greater were included in the study. Patient data were extracted from charts, whereas postoperative symptoms were obtained by phone interviews. Of 174 patients who underwent cholecystectomy, 12 (7%) met study criteria. All patients (12 of 12) had evidence of cholecystitis on the final pathology note. All 11 patients contacted had relief of colic after gallbladder removal with a mean follow-up of 16 months. A subset of pediatric patients with high ejection fractions on CCK-HIDA and symptomatic biliary colic may have symptomatic relief with cholecystectomy.
Ultrasound-guided Thoracoscopic Dental Extraction
Authors: Pandya Samir R. , Ruiz Rodrigo , Brudnicki Adele
Published: June 2020

Recurrent pneumonias in children may be from an unrecognized aspirated foreign body. Our patient was a 10-year-old neurologically impaired child with an aspirated tooth in the right lower lobe segmental bronchus that was inaccessible to extraction using flexible bronchoscopy because of its extremely distal location. We used intraoperative ultrasound during thoracoscopy to locate the foreign body, a tooth, and to facilitate a wedge resection of the involved lung. This combined approach with ultrasound and thoracoscopy can be useful in managing an aspirated foreign body that cannot be extracted from the airway using conventional rigid or flexible bronchoscopy.
Pyloric Stenosis after Gastroschisis Closure
Authors: Streit Stephanie M. , Dixon Jennifer A , Hebra André
Published: June 2020

Hypertrophic pyloric stenosis is a very common surgical problem in infants. It occurs most often in otherwise well babies with normal gestation and birth history. Rarely, pyloric stenosis has been described in babies with history of prior abdominal surgery. Below we discuss the management of hypertrophic pyloric stenosis in a child who remained hospitalized, recovering from repair of a congenital abdominal wall defect.
Interhospital Transfer: An Independent Risk Factor for Mortality in the Surgical Intensive Care Unit
Authors: Arthur Katherine R. , Kelz Rachel R. , Mills Angela M. , Reinke Caroline E. , Robertson Mathew P. , Sims Carrie A. , Pascual Jose L. , Reilly Patrick M. , Holena Daniel N.
Published: June 2020

Interhospital transfer (IHT) is associated with mortality in medical and mixed intensive care units (ICUs), but few studies have examined this relationship in a surgical ICU (SICU) setting. We hypothesized that IHT is associated with increased mortality in SICU patients relative to ICU patients admitted within the hospital. We reviewed SICU and transfer center databases from a tertiary academic center over a 2-year period. Inclusion criteria included age 18 years or older and SICU admission 24 hours or greater. Demographic data, admission service, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were captured. The primary end point was ICU mortality. Univariate logistic regression was used to test the association between variables and mortality. Factors found to be associated with mortality at P < 0.1 were entered into a multivariable model. Of 4542 admissions, 416 arrived by IHT. Compared with the non-IHT group, the IHT group was older (age 58.3 years [interquartile range, 47.8 to 70.6] vs 57.8 years [interquartile range, 44.1 to 68.8] years, P = 0.036), sicker (APACHE II score 16.5 [interquartile range, 12 to 23] vs 14 [interquartile range, 10 to 20], P < 0.001), and more likely to be white (82% [n = 341] vs 69% [n = 2865], P < 0.001). Mortality rates in IHT patients were highest on the emergency surgery (18%), transplant surgery (16%), and gastrointestinal surgery (8%) services. After adjusting for age and APACHE II score, IHT remained a risk factor for ICU mortality (odds ratio, 1.60; 95% confidence interval, 1.04 to 2.45; P = 0.032) in SICU patients. Interhospital transfer is an independent risk factor for mortality in the SICU population; this risk is unevenly distributed through service lines. Further efforts to determine the cause of this association are warranted.
Efficacy of Contemporary Medical Management for Asymptomatic Carotid Artery Stenosis
Authors: Chang Jason , Ahn Joseph E. , Landsman Nicholas , Rhee Katherine , Chun Linda , Patel Kaushal Kevin
Published: June 2020

In the Asymptomatic Carotid Artery Stenosis trial (1995), medical management was defined as aspirin in addition to adequate control of comorbidities. Since then, medical management of asymptomatic carotid artery stenosis (CAS) has progressed to include broader use of statins. Our purpose was to review the effect of contemporary medical management on stroke prevention. A retrospective review of the Kaiser Permanente, Southern California medical group database was performed. All patients with a diagnosis of asymptomatic CAS by International Classification of Diseases, 9th Revision codes from 2007 to 2011 were identified. Intervention for stroke prevention was the criteria for exclusion. Medications used were evaluated as was the rate of stroke. Asymptomatic CAS was noted in 7255 patients. Of these, 158 (2.2%) sustained a stroke within a mean follow-up of 37 months. Patients who were taking a statin had a statistically significant lower risk of stroke (1.6 vs 3.9%). The data support that contemporary medical management of asymptomatic CAS has decreased the incidence of stroke in comparison to previously published data. The use of statins was protective against the development of stroke. Future prospective randomized trials are needed to evaluate the efficacy of carotid intervention versus current medical management.
Outcome of Abdominal Wall Hernia Repair with Permacol™ Biologic Mesh
Authors: Cheng Amy W. , Abbas Maher A. , Tejirian Talar
Published: June 2020

The use of biologic mesh in abdominal wall operations has gained popularity despite a paucity of outcome data. We aimed to review the experience of a large healthcare organization with Permacol™. A retrospective study was conducted of patients who underwent abdominal hernia repair with Permacol™ in 14 Southern California hospitals. One hundred ninety-five patients were analyzed over a 4-year period. Operations included ventral/incisional hernia repairs, ostomy closures, parastomal hernia repairs, and inguinal hernia repairs. In 50 per cent of the patients, Permacol™ was used to reinforce a primary fascial repair and in 50 per cent as a fascial bridge. The overall complication rate was 39.5 per cent. The complication rate was higher in patients with infected versus clean wounds, body mass index (BMI) 40 kg/m2 or greater versus BMI less than 40 kg/m2, in patients with prior mesh repair, and when mesh was used as a fascial bridge. With a mean follow-up of 2.1 years, morbid obesity was associated with a higher recurrence. To date this is the largest study on the use of Permacol™ in abdominal wall hernia repair. In our patient population undergoing heterogeneous operations with a majority of wounds as Class II or higher, use of Permacol™ did not eliminate wound morbidity or prevent recurrence, especially in morbidly obese patients.