bluuebunny/crossref_metadata_2025 huggingface dataset:
Resection of Benign Esophageal Stricture through a Minimally Invasive Endoscopic and Transgastric Approach
Authors: Lucktong T.A. , Morton John M. , Shaheen Nicholas J. , Farrell Timothy M.
Published: November 2022

Recurrent benign esophageal strictures that are refractory to dilation can be difficult to manage. We report a novel technique for treatment of a recurrent esophageal stricture using a minimally invasive endoscopic and transgastric approach. The patient is a 40-year-old women who developed a recurrent distal esophageal stricture after repair of an esophageal perforation. Multiple prior dilations had been unsuccessful in achieving sustained esophageal patency, and the patient presented with a complete distal obstruction demonstrated on barium esophagram. Two flexible endoscopes were used: one placed through the mouth and another through a gastrostomy. While the transilluminated lesion was visualized from below the obstruction was traversed with an endoscopic aspiration needle from above. A guidewire was placed through the needle and pulled out the gastrostomy. Both the esophageal lesion and the gastrostomy tract were then serially dilated over the wire. After dilation the residual stricture was resected using a circular stapler placed through the dilated gastrostomy tract. After this procedure the patient maintained esophageal patency with a diminished need for dilation. Details of our technique are described and the literature is reviewed.
Unusual Presentations of Gastroschisis
Authors: Ashburn David A. , Pranikoff Thomas , Turner Charles S.
Published: November 2022

Gastroschisis is a defect of the ventral abdominal wall nearly always located to the right of the umbilicus. A relatively low incidence of associated anomalies exists with the most common being nonduodenal intestinal atresia occurring in 10 per cent of patients. Although multiple hypotheses have been proposed the pathogenesis of gastroschisis is unproven and controversial. Herein we describe four infants with rare presentations of gastroschisis: one infant with true left-sided gastroschisis and three infants with unusual patterns of intestinal atresia. At present there is a female preponderance of left-sided gastroschisis as reported in the world literature (five female:two male). These cases illustrate the anatomic spectrum of gastroschisis as well as support intrauterine spontaneous closure of the abdominal wall defect as an etiology for midgut atresia.
Breast Cancer Recurrences in Elderly Patients after Lumpectomy
Authors: Shah Shuchi , Doyle Kimberly , Lange Ethan M. , Shen Perry , Pennell Timothy , Ferree Carolyn , Levine Edward A. , Perrier Nancy D.
Published: November 2022

Approximately half of breast cancers occur in women 65 years or older. Some studies suggest that breast cancer may be a more indolent disease in this group of patients. Debate exists over the appropriate treatment of these women as they are significantly underrepresented in breast cancer research studies. As a result of comorbid conditions and patient refusal many are often treated less aggressively than their younger counterparts. This study investigated the recurrence rate in elderly breast cancer patients who had undergone lumpectomy as their primary treatment at our institution. A chart review was conducted on breast cancer patients treated from January 1, 1995 through September 26, 2000 with lumpectomy performed at Wake Forest University Baptist Medical Center. Study criteria included female gender and age greater than 65 years, first incidence of breast cancer, no evidence of distant disease at presentation, and availability follow-up assessed by clinical examination and mammogram records. Clinical and pathological features and treatments were evaluated. The Cox proportional-hazards model, Fisher's exact test, and analysis of variance were used for statistical analysis. One hundred thirteen patients met study criteria. The stage distribution was as follows: stage 0 (TIS), 16 per cent; stage I, 56 per cent; stage IIA, 24 per cent; and stage IIB, 4 per cent. With a median follow up of 30 months six (5%) patients developed locoregional recurrence, four (4%) developed contralateral cancer, and two patients (2%) developed distant disease. Mean time to recurrence was 21 months. No patient has died of breast cancer, but one patient died of a second malignancy. Radiation therapy and tamoxifen decreased recurrence as compared with no adjuvant treatment or with adjuvant radiation only ( P < 0.05). We conclude that patients treated with tamoxifen and radiation therapy had a significantly smaller risk of recurrences than those treated with lumpectomy only or those receiving radiation alone. This supports similar treatment patterns recommended for younger patients. Women over 65 years of age should be carefully evaluated for adjuvant therapy.
Intraoperative Hepatic Lymphatic Mapping in Patients with Liver Metastases from Colorectal Carcinoma
Authors: Kane John M. , Kahlenberg Morton S. , Rodriguez-Bigas Miguel A. , Gibbs John F. , Petrelli Nicholas J.
Published: November 2022

The survival of patients undergoing liver resection for colorectal metastases is poor in the presence of extrahepatic disease. Therefore identification of periportal and celiac lymph node metastases is central to proper patient selection. In this study we examined the technique of intraoperative hepatic lymphatic mapping with isosulfan blue dye in humans. Intrahepatic dye injection was performed in patients undergoing surgical exploration for colorectal liver metastases. The location of all blue-stained lymphatics and lymph nodes was recorded. All stained and unstained lymph nodes were biopsied for pathologic examination. Thirteen intraoperative lymphatic mapping procedures were performed in 11 patients. A blue-stained lymphatic was visualized in 11 of 13 injections (85%). A blue lymph node was visualized in seven of 13 injections (54%). Three of the seven blue nodes (43%) were not detected by the surgeon before the mapping procedure. There were no complications associated with the intrahepatic dye injections. All biopsied lymph nodes were negative for metastatic tumor. We conclude that intraoperative hepatic lymphatic mapping with isosulfan blue dye is a simple, rapid, and safe technique in humans. It may serve as an adjunct to random lymph node biopsy for the identification of periportal and celiac nodal metastases before liver resection in patients with metastatic colorectal carcinoma.
Immediate Postlaparotomy Small Bowel Obstruction: A 16-Year Retrospective Analysis
Authors: Fraser Shannon A. , Shrier Ian , Miller George , Gordon Philip H.
Published: November 2022

Small bowel obstruction (SBO) is a particularly vexing problem in the postoperative period. The goal of this study was to compare the results of operative versus nonoperative treatment. A secondary goal was to explore risk factors for necessitating reoperation in the immediate postoperative period. We conducted a historical cohort retrospective chart review at a university-affiliated hospital. The medical records of patients treated between 1985 and 2000 at the Sir Mortimer B. Davis Jewish General Hospital (Montreal, Quebec, Canada) who developed SBO after undergoing a laparotomy during that admission were reviewed. Postoperative SBO was defined as cessation of flatus or bowel movements after their resumption following operation. To compare operative versus nonoperative management of early postoperative mechanical SBO we used the following outcome measures: Reoperation rate, time to return of function, length of stay, and mortality. Of 52 patients who developed SBO in the immediate postoperative period 37 were male, 25 had colorectal surgery, and nine had a gastrectomy as the initial operation on admission; five had inflammatory bowel disease, six had a previous SBO, 22 had virgin abdomens before the current operation, and 11 had adhesions noted at the initial operation. The median time to the development of obstructive symptoms was 8 days (range 1–33). The reoperation rate was 42 per cent overall (67% in women and 32% in men, P = 0.02). For operatively treated patients the median time between onset of symptoms and surgery was 5 days [range 1–23, interquartile range (IQR) = 5]. The median time to the return of bowel function was greater in the operatively treated patients compared with nonoperatively treated patients [11.5 days (range 4–37, IQR = 11) vs 6 days (range 1–28, IQR = 7), P < 0.0001] as was median length of stay from onset of obstruction [23 days (range 6–60, IQR = 14) vs 12 days (range 2–45, IQR = 16), P < 0.009]. Operatively treated patients also stayed longer after their obstruction was relieved although not significantly longer [8 days (range 1–35, IQR = 11) vs 4.5 days (range 0–40, IQR = 10), P = 0.15]. There were 11 complications in nine of 22 patients who underwent operative treatment of their SBO. Immediate postoperative SBO can be treated nonoperatively in stable patients resulting in significantly quicker return of bowel function and shorter lengths of hospital stay. Definitive risk factors for immediate SBO could not be identified.
Diagnosis and Treatment of Intracystic Breast Carcinomas
Authors: Markopoulos Christos , Kouskos Efstratios , Gogas Helen , Kakisis John , Kyriakou Vasiliki , Gogas John , Kostakis Alkis
Published: November 2022

Cystic breast masses are very common in female patients attending breast clinics. Most of them are benign and managed by simple aspiration. We reviewed histology records for the last 12 years to find patients with cystic breast carcinomas and to evaluate special clinical signs that may help to identify patients with this rare entity. Eighteen patients with cystic breast carcinomas were found among 1510 new breast cancer patients (1.19%) who were seen at our Breast Unit during this period. Ten had intracystic papillary carcinoma (0.66% of all breast cancers), seven had cystic degeneration of ductal carcinoma, and one had a mucinous carcinoma. The diagnosis of intracystic papillary carcinoma was based on cyst fluid cytology and breast imaging in most patients and on open breast biopsy in two cases only. The prognosis of our cystic breast carcinoma patients was excellent regardless of the specific histologic type of the tumor. We conclude that cysts in postmenopausal women should be viewed with suspicion. Bloodstained aspirated cyst fluid should be sent for cytology and breast imaging should be carried out in all these cases. Residual mass after cyst aspiration is also an indication for open biopsy.
Effective Management of Bleeding during Tumor Resection with a Collagen-Based Hemostatic Agent
Authors: Chapman William C. , Wren Sherry M. , Lebovic Gail S. , Malawer Martin , Sherman Randolph , Block Jon E.
Published: November 2022

In a prospective controlled trial hemostatic effectiveness of a novel collagen-based composite (CoStasis®) was compared with a collagen sponge applied with manual pressure at diffusely bleeding sites after surgical tumor resection. The proportion of subjects achieving complete cessation of bleeding within 10 minutes (i.e., hemostatic success) and the time to “complete hemostasis” were determined at raw surgical sites after tumor resection among 23 experimental and 30 control subjects. There was a similar distribution in tumor types (e.g., benign vs malignant) evaluated between treatment groups. A significantly greater proportion of experimental subjects achieved complete hemostasis within 10 minutes of observation compared with controls [23 of 23 (100%) vs 21 of 30 (70%); P = 0.003]. The median time required to achieve complete hemostasis was more than three times longer for subjects treated with the collagen sponge compared with subjects treated with CoStasis® (243 vs 78 seconds; P = 0.0001). Approximately 80 per cent of experimental subjects achieved complete hemostasis within 2 minutes compared with only 35 per cent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this novel hemostatic agent to control diffuse surgical site bleeding after tumor resection at diverse anatomical locations.
The Sestamibi Scan as a Preoperative Screening Tool
Authors: Norton Kathryn S. , Johnson Lester W. , Griffen F. Dean , Burke James , Kennedy Suzanne , Aultman Donnie , Li Benjamin D.L. , Zibari Gazi
Published: November 2022

Sestamibi scan is generally recognized in the literature to play a role in the imaging of parathyroid adenoma. Most institutions quote sensitivities ranging from 80 to 100 per cent. There is still a question as to whether patients need preoperative localization studies. Preoperative localization can potentially result in less invasive surgery, shorter operative times, decreased hospital stays, and decreased need for re-exploration. Our hypothesis is that the sestamibi scan is a sensitive predictor of parathyroid adenomas. The objectives of this study are to determine the sensitivity of sestamibi scan in detecting parathyroid adenoma, and to determine whether either parathyroid hormone (PTH) level or calcium level is an independent predictor of a positive scan. One hundred patients were retrospectively reviewed at Louisiana State University Health Sciences Center-Shreveport and Louisiana State University Health Sciences Center-Monroe from March 1993 through December 2000. All patients had a preoperative sestamibi scan. This scan was performed using the dual-phase technique in which the parathyroid glands are visualized after washout of tracer from the thyroid. The scan was followed by either a unilateral or bilateral neck dissection. There were 82 female patients and 18 male patients who ranged in age from 23 to 78 years. The median weight of glands with a positive scan was 795 mg. The median weight of glands with a negative scan was 480 mg. This difference was statistically significant ( P < 0.04). Overall there were 107 adenomas. Of these 93 had positive scans and 14 had negative scans. This results in a sensitivity of 87 per cent. There were 67 glands that weighed at least 500 mg. Of these 67 glands 61 had positive scans and six had negative scans. This resulted in a sensitivity of 91 per cent. There were 40 glands that weighed less than 500 mg. Of these 40 glands 32 had positive scans and eight had negative scans. This resulted in a sensitivity of 80 per cent. Using multiple linear regression analysis calcium level correlated with the weight of the gland ( P < 0.01). Calcium level also correlated with the PTH level ( P < 0.01). However, neither the PTH level nor the calcium level correlated with a positive sestamibi scan. Sestamibi scan is a sensitive predictor for parathyroid adenoma greater than 500 mg (91% sensitivity). Even in smaller glands (<500 mg) 80 per cent sensitivity was demonstrated. Although the calcium level correlates with the PTH level neither PTH level nor calcium level is predictive of a positive sestamibi scan.
Bile Decompression in Children with Histopathological Evidence of Pre-Existing Liver Cirrhosis
Authors: Jackson Carl-Christian A. , Wu Yeming , Chenren Shi , Somme Stig , Chwals Walter J. , Liu Donald C.
Published: November 2022

Although it is agreed upon by most that adequate and timely bile decompression can preserve or even improve existing liver function much debate centers on whether pre-existing liver cirrhosis can also be reversed. To help answer this question we analyzed data on 47 children with choledochal cyst disease (CD) who underwent simultaneous liver biopsy during bile decompression surgery. We collected data on two groups of children with CD spanning two different time periods: January 1985 through November 1994 (Group A) and June 1995 through November 1999 (Group B). In Group A 37 children (16 boys and 21 girls ages 5 days to 10 years) underwent simultaneous liver biopsy during elective definitive surgery for CD. In Group B ten children (five boys and five girls age one month to 7 years) underwent liver biopsy twice: first during initial cyst decompression for acute obstruction and second during elective definitive surgery after resolution of acute disease. Degree of liver cirrhosis was based on a modified World Health Organization classification system (0–IV). In Group A 15/37 (40.5%) had significant liver cirrhosis at time of biopsy (III or IV) with altered liver function in all cases; eight of nine had normal liver function on follow-up, six were lost to follow-up. In Group B seven often (70%) had less liver cirrhosis on pathology at second operation with three unchanged; nine of ten (90%) regained normal liver function. We conclude that bile duct obstruction is the main cause of liver cirrhosis in children with CD. Adequate and timely bile decompression can restore normal liver function and even reverse severe cirrhosis.
Acute Respiratory Distress Syndrome in Blunt Trauma: Identification of Independent Risk Factors
Authors: Miller Preston R. , Croce Martin A. , Kilgo Patrick D. , Scott John , Fabian Timothy C.
Published: November 2022

Acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality in trauma patients. Although many injuries and conditions are believed to be associated with ARDS independent risk factors in trauma patients and their relative importance in development of the syndrome are undefined. The aim of this project is to identify independent risk factors for the development of ARDS in blunt trauma patients and to examine the contributions of each factor to ARDS development. Patients with ARDS were identified from the registry of a Level I trauma center over a 4.5-year period. Records were reviewed for demographics, injury characteristics, transfusion requirements, and hospital course. Variables examined included age >65 years, Injury Severity Score (ISS) >25, hypotension on admission (systolic blood pressure <90), significant metabolic acidosis (base deficit <-5.0), severe brain injury as shown by a Glasgow Coma Scale score (GCS) <8 on admission, 24-hour transfusion requirement >10 units packed red blood cells, pulmonary contusion (PC), femur fracture, and major infection (pneumonia, empyema, or intraabdominal abscess). Both univariate and stepwise logistic regression were used to identify independent risk factors, and receiver operating characteristic curve (ROC) analysis was used to determine the relative contribution of each risk factor. A total of 4397 patients having sustained blunt trauma were admitted to the intensive care unit and survived >24 hours between October 1995 and May 2000. Of these patients 200 (4.5%) developed ARDS. All studied variables were significantly associated with ARDS in univariate analyses. Stepwise logistic regression, however, demonstrated age >65 years, ISS >25, hypotension on admission, 24-hour transfusion requirement >10 units, and pulmonary contusion as independent risk factors, whereas admission metabolic acidosis, femur fracture, infection, and severe brain injury were not. Using a model based on the logistic regression equation derived yields better than 80 per cent discrimination in ARDS patients. The risk factors providing the greatest contribution to ARDS development were ISS >25 (ROC area 0.72) and PC (ROC area 0.68) followed by large transfusion requirement (ROC area 0.56), admission hypotension (ROC area 0.57), and age >65 (ROC area 0.54). Independent risk factors for ARDS in blunt trauma include ISS >25, PC, age >65 years, hypotension on admission, and 24-hour transfusion requirement >10 units but not admission metabolic acidosis, femur fracture, infection, or severe brain injury. Assessment of these variables allows accurate estimate of risk in the majority of cases, and the most potent contributors to the predictive value of the model are ISS >25 and PC. Improvement in understanding of which patients are actually at risk may allow for advances in treatment as well as prevention in the future.
Transplantation of Pediatric En Bloc Cadaver Kidneys into Adult Recipients: A Single-Center Experience
Authors: Ruff Tim , Reddy K. Sudhakar , Johnston Thomas D. , Waid Thomas , Mckeown Wade , Khan Taqi , Ranjan Dinesh , Lucas Bruce A.
Published: November 2022

Faced with an extreme shortage of organs transplant professionals continue to explore various strategies to expand the donor pool. Transplantation of kidneys from older and very young donors are two such options. Although kidneys from young donors (less than 5 years of age) have been associated with a high rate of technical complications and suboptimal results, use of these kidneys en bloc has been advocated to improve the outcomes. We reviewed our experience with en bloc kidney transplantation at the University of Kentucky over the past 10 years. Between 1991 and 2000 ten patients underwent kidney transplantation using kidneys en bloc from donors <5 years age. The mean age of the donors was 2.8 years with a mean weight of 16 kg (range 13–21). Mean age of the recipients was 42 years. One patient lost the graft on day one from venous thrombosis. One patient lost the graft 7 years post-transplant from chronic rejection. All of the remaining patients are doing well with functioning grafts (mean follow-up 4.5 years; range 6 months to 10 years). Both one-year and five-year graft survival rates are 89 per cent. The present study confirms that excellent results can be achieved with kidney transplantation using kidney transplantation using kidneys en bloc from donors younger than 5 years of age.
The Regained Referral Ground and Clinical Practice of Vena Cava Filter Placement in Vascular Surgery
Authors: Lin Peter H. , Kulbaski Mark J. , Terramani Thomas T. , Bush Ruth L. , Brinkman William T. , Chen Changyi , Conklin Brian , Lumsden Alan B.
Published: November 2022

Interventional radiologist rather than vascular surgeons have become the predominant clinicians placing inferior vena cava (IVC) filters since the percutaneous device was introduced more than a decade ago. We conducted a retrospective analysis of 592 patients treated at a single institution between 1987 and 2000 to determine the indications, referral pattern, and clinical outcome of IVC filter placement between the radiologist and surgeon groups. Before 1989 all filters were placed by surgeons in the operating room. The adoption of the percutaneous delivery method by radiologists in 1989 led to a dramatic increase in its practice volume accounting for 99 per cent of all filters placed from 1991 to 1993 ( P < 0.001). The development of an endovascular program by the vascular surgeons in 1994 led to a steady increase in its IVC filter practice annually ( P < 0.05) and accounted for 42 per cent of all filter placements in 2000. A distinct referral pattern also emerged as 74 per cent of all filter placements by surgeons were referred by surgical services. The proportion of filter placement for strict indications remained constant over time between the two groups ( P = 0.86). The complications and survival rates were not significantly different between the two groups ( P = 0.24). Percutaneous devices have dramatically increased the clinical volume of IVC filter placement by interventional radiologists. Vascular surgeons with endovascular interest are well suited to perform the procedure and can regain referral ground of IVC filter placement.
Villous Adenoma of the Extrahepatic Biliary Tract: A Rare Entity
Authors: O'Shea Michelle , Fletcher H. Stephen , Lara Jonathan F.
Published: November 2022

Patients presenting with large obstructing extrahepatic biliary tumors often are presumed to have cholangiocarcinoma and are labeled with a grim disease with a poor prognosis, given little hope for a cure, and may actually opt for palliative care only. In some instances, however, the diagnosis is that of biliary adenoma (benign until it undergoes malignant degeneration), which can be confirmed via resection and pathologic evaluation of the lesion. Removal of the tumor in its benign stage then provides curative treatment of the obstructing lesion with excellent patient recovery and overall prognosis. We present a rare instance of observation of the presence of high-grade dysplasia in a large villous adenoma arising from the left hepatic duct with relief of biliary obstruction and curative resection.
An Alternative Approach to the Treatment of Mammary Duct Fistulas: A Combination of Microwave and Ultrasound
Authors: Berná Juan D. , Sánchez Juan , Madrigal Manuel , Ródenas Javier , Berná Juan D.
Published: November 2022

Between 1994 and 1999, 11 women with recurrent mammary duct fistula underwent nonsurgical treatment with microwave and ultrasound. An initial ultrasonographic examination was performed during the recurrence of mammary duct fistula, and in ten cases it revealed a small superficial periareolar anechoic, hypoechoic, or heterogenic lesion with poorly defined edges and without posterior reinforcement (marked distal sound enhancement). Findings indicated an extraglandular inflammatory process; duct ectasia was not seen in any of the 11 patients. A combination of microwave and ultrasound was administered on an outpatient basis for 20 days. Clinical improvement was rapid after the first few sessions of treatment. In nine of the 11 patients there has been no recurrence during more than 2 years of follow-up. The two current episodes were resolved by a second application of the same treatment. In one of those patients (with recurrence at 6 months) an infiltration of steroids was also administered, and this patient is without recurrence after 23 months' follow-up.
Parathyroid Carcinosarcoma: A Previously Unreported Entity
Authors: Nacamuli Randall , Rumore Gregory J. , Clark Gary
Published: November 2022

Parathyroid carcinoma is a rare disease. The first report of parathyroid carcinoma with sarcomatous differentiation is presented. A parathyroid mass measuring 6 x 8 x 9 cm was surgically excised from the left side of the neck in a 54-year-old man who had mild hypercalcemia. Light microscopic examination of the mass showed carcinoma with areas of rhabdomyosarcoma and chondrosarcoma. Immunohistochemical studies confirmed the light microscopic impression. Resolution of hypercalcemia followed excision of the mass, but multiple pulmonary and adrenal masses subsequently developed and led to the patient's death despite aggressive trials of chemotherapy with doxorubicin, ifosfamide, and cisplatin. The sarcomatous elements of the mass excised from this patient are presumed to represent aberrant cellular differentiation previously described in uterine and other tissue but not in parathyroid glands. Sarcomatous differentiation itself appears to be a poor prognostic factor in parathyroid carcinoma.
Can Fine-Needle Aspiration Biopsy of Thyroid Nodule Help in Determining the Extent of Surgery in Follicular and Hurthle Cell Neoplasm at a Community Teaching Institution?
Authors: Hawasli Abdelkader , Rizzo Paul , Khoury Habib , Mccaffrey Joy L.
Published: November 2022

Fine-needle aspiration biopsy (FNAB) was used to evaluate cold thyroid nodules in 179 patients treated between 1990 and 1998. The purpose of this study was to see whether FNAB findings of follicular or Hurthle cells could help in planning the extent of thyroid surgery. Group I patients (47) had findings suggestive of follicular or Hurthle cell neoplasm. Group II patients (132) had inconclusive results. In group I FNAB was 100 per cent correct in diagnosing follicular or Hurthle cell neoplasm with a high percentage of malignant findings (malignancy 85 per cent and benign adenoma 15 per cent). In Group II malignancy was found in 16 per cent and benign pathology in 84 per cent. Women were more likely to have malignancy than men. The average age was over 50 years in patients with either malignant or benign nodules. In addition there was no significant difference in average size of benign or malignant nodules (2.9 vs 2.6 cm respectively). When an FNAB finding was suggestive of neoplasm malignancy was found in 85 per cent. On the other hand when an FNAB was inconclusive malignancy was present in 16 per cent. Thus we conclude that using FNAB finding can guide surgical resection and recommend performing total or subtotal thyroidectomy when FNAB is suggestive of neoplasm and lobectomy when FNAB is inconclusive.
Spontaneous Nontraumatic Hemoperitoneum Due to a Bleeding Arteriovenous Malformation on the Serosal Surface of the Transverse Colon: A Case Report
Authors: Nissman Steven A. , Mann Barry D. , Vitvitsky Eugene V. , Fyfe Billie S.
Published: November 2022

Arteriovenous malformations of the gastrointestinal tract are a very common entity and a frequently cited cause of lower gastrointestinal bleeding in adults. They are characteristically found in the mucosa or submucosa of the bowel wall, and the vast majority do not cause any symptoms. We discuss the rare case of an extraluminal arteriovenous malformation of the transverse colon in an elderly woman who presented to the emergency department in hypovolemic shock after collapsing at home. An exploratory laparotomy was performed after a diagnostic peritoneal lavage yielded gross blood. The patient was found to have a spontaneously bleeding lesion confined to the serosal surface of the right transverse colon, which histological examination revealed to be an arteriovenous malformation. The lesion was excised and the patient recovered without sequelae. To date there have been no other documented cases of an arteriovenous malformation on the serosal surface of a visceral abdominal organ.
Periappendicitis: Is it a Clinical Entity?
Authors: Mukherjee Asish , Schlenker Evelyn , Lamasters Teresa , Johnson Melissa , Brunz Jamie , Thomas Eric
Published: November 2022

The aim of this study was to identify clinical parameters that may help distinguish periappendicitis from the more common clinical entity of acute appendicitis. Serosal inflammation of the appendix without mucosal involvement constitutes the condition known as periappendicitis. In most situations this is a sequel of extra-appendicular sepsis and is likely to benefit from treatment targeted to the underlying pathology. But the majority of these cases are initially treated for acute appendicitis as clinical distinction between the two conditions is difficult. In this study some commonly used clinical yardsticks have been analyzed with respect to their value in this subtle diagnosis. We reviewed 231 successive cases clinically diagnosed as acute appendicitis; of these 18 had histologically demonstrated periappendicitis. Eight parameters were studied: age, gender, temperature, white blood cell count, location and duration of pain, associated symptoms, and peritoneal signs. Significant statistical differences were found between the two groups with regard to pain location, pain duration, and the presence of peritoneal signs. It maybe possible to suspect periappendicitis preoperatively with meticulous clinical assessment. This may be of value in avoiding missed nonappendicular pathologies.
Can Appendiceal CT Scanning be Utilized Effectively in Widespread General Surgical Practice?
Authors: Mcdonough John , Stasik Chris , Piontkowsky David , Treisman Edward
Published: November 2022

Appendiceal CT was first reported in the radiological literature, and has only recently begun to appear in the surgical literature. Much of the enthusiasm surrounding appendiceal CT has come from several publications by relatively few authors. We report the feasibility of implementing an appendiceal CT scanning technique and our initial results. The charts (940) of all patients evaluated for possible appendicitis during a 3-month period were reviewed. A new appendiceal CT scanning technique was performed when the indication was solely to exclude appendicitis. The accuracy of this new technique Was determined. Eighty-seven patients were evaluated. Twenty-nine underwent appendiceal CT scanning. The accuracy of interpretation was 85 per cent. In 58 patients who did not receive an appendiceal CT scan the accuracy of surgical decision-making was 82 per cent. These values were not statistically different We found appendiceal CT scanning to be relatively easy to implement; and its accuracy was better than expected. Our accuracy does not match that reported in the literature by the pioneers of appendiceal CT scanning. More experience with this technique will be required to achieve consistently successful accuracy; the technique can then be utilized in surgical practice and potentially change the diagnostic approach to acute appendicitis.
Surgical Management of Complicated Hydatid Disease of the Liver
Authors: Jabbour Nicolas , Shirazl Sherin K. , Genyk Yuri , Mateo Rod , Pak Eddy , Cosenza Carlos , Peyré Christian G. , Selby Robert Rick
Published: November 2022

Increased worldwide travel and immigration have led to an increase in the incidence of hepatic hydatid disease outside of endemic areas. In nonendemic areas lack of familiarity with the disease may lead to a delay in diagnosis with increased risk for development of complicated disease. Complicated disease is defined as: infected cysts, cysts with a hyperechoic solid pattern or calcified walls, or cysts with biliary rupture. Over a 6-month period six patients with complicated hydatid disease were referred to our institution. All six patients were immigrants from endemic areas and were found to have complicated hepatic hydatid disease including cholangitis and intrabiliary rupture. Patients were treated with oral albendazole for 3 weeks before operation and oral praziquantel for 2 days preoperatively. Surgical therapy consisted of subtotal cystectomy, cholecystectomy in all patients, and cystic duct biliary decompression-drainage in five patients. The one patient without biliary drainage developed a postoperative bile leak that resolved with endoscopic biliary stenting. All patients received albendazole for 3 months postoperatively and were free of disease at 6 to 24 months follow-up. We conclude that although nonoperative management with percutaneous drainage or medical management alone may be successful in patients with uncomplicated disease operation remains the therapy of choice for complicated hydatid disease.
Surgical Repair of Primary Saphenous Vein Aneurysm of the Proximal Leg after Initial Presentation as an Inguinal Hernia
Authors: Majeski James
Published: November 2022

Primary venous aneurysms of the proximal saphenous vein are uncommon. They are most frequently seen in patients referred for evaluation and treatment of an inguinal or femoral hernia. Since 1992 five patients with a proximal saphenous venous aneurysm were referred for evaluation and treatment of an inguinal or femoral hernia. Data from five consecutive patients treated for a proximal saphenous venous aneurysm were analyzed. Four of the five patients were treated successfully by replacing the proximal saphenous venous aneurysm with a 6-mm expanded polytetrafluoroethylene (IMPRAR) interposition graft. All grafts were patent 2 years after the surgical procedure by Doppler examination. A primary aneurysm of the proximal saphenous vein can be successfully repaired using a polytetrafluoroethylene interposition graft with long-term patency. Preservation of the saphenous vein should be considered in patients who have a normal distal saphenous vein. Repair of a primary saphenous venous aneurysm preserves the saphenous vein for use as a conduit for later bypass surgery of the leg or heart.
The Role of Selective Computed Tomography in the Diagnosis and Management of Suspected Acute Appendicitis
Authors: Hershko Dan D. , Sroka Gideon , Bahouth Hany , Ghersin Eduard , Mahajna Ahmad , Krausz Michael M.
Published: November 2022

The negative appendectomy rate in patients with clinically diagnosed acute appendicitis is 20 to 40 per cent. Recently CT has emerged as a powerful diagnostic tool in the evaluation of suspected appendicitis and its routine use has been advocated. The objective of this study was to evaluate the impact of selective use of abdominal CT on the negative appendectomy rate. Three hundred eight patients were enrolled in this prospective study. Abdominal CT was performed in patients with uncertain clinical signs of appendicitis. CT was not performed in patients with either a very high or a very low index of suspicion. The results were compared with a retrospective analysis of 85 consecutive patients operated by clinical diagnosis alone. One hundred twenty-seven patients had a final diagnosis of acute appendicitis. CT was performed in 198 patients (64%). The sensitivity, specificity, and accuracy of CT scans were 91, 92, and 91 per cent, respectively. Surgical management plans were altered in 54 patients after obtaining the CT results; unnecessary delay in surgical treatment or unnecessary operations were prevented in 28 and 26 patients, respectively. In addition CT detected unrelated pathologies in 23 patients. CT was not performed in patients with low index of suspicion and none were found to suffer from acute appendicitis. The negative appendectomy rate was 17 per cent (7% men and 24% women) in patients selected for surgery on the basis of very high clinical suspicion alone. Overall the negative appendectomy rate with the selective use of CT was 16 per cent, which is significantly lower than the rate achieved by diagnosing patients on clinical grounds alone (24%). CT is highly accurate in diagnosing or ruling out acute appendicitis and may substantially decrease the negative appendectomy rate as well as unnecessary delayed observation. We believe that CT should be performed routinely in women with suspected appendicitis and selectively in men.
The Role of Positive Examinations in Training for the Focused Assessment Sonogram in Trauma (FAST) Examination
Authors: Gracias Vicente H. , Frankel Heidi , Gupta Rajan , Reilly Patrick M. , Gracias Felipe , Klein Wendy , Nisenbaum Harvey , Schwab C. William
Published: November 2022

The purpose of this study is to determine whether the inclusion of known positive patients to the practical portion of a Focused Assessment Sonogram in Trauma (FAST) training course improves overall training and increases FAST accuracy. This is a prospective double-blind design. Original course participants (PRE) underwent a 2-hour didactic session and practicum with ten normal volunteers. Modified course participants (POST) additionally imaged five peritoneal dialysis (PD) patients to simulate positive examinations. The practitioners (six PRE and five POST) were compared as to their ability to detect and quantify intraperitoneal fluid (0–2000 cc) in nine PD patients during a double-blind prospective examination. Test results were reported as positive or negative. Positive results were further quantified by volume. Each practitioner performed ten examinations. Data for inexperienced clinicians are presented. Sensitivity for detecting ≤750 cm3 was 45 per cent PRE and 87 per cent POST ( P = 0.02). Accuracy in quantifying volume within 250 cm3 was 38 per cent PRE and 44 per cent POST (not significant). FAST accuracy for inexperienced sonographers—particularly in diagnosing smaller volumes—can be improved significantly by including positive studies in training. Exposure to positive FAST examinations during training improves the learning curve. With the growing dependency on FAST to accurately triage blunt abdominal trauma safe and effective FAST training should consist of didactic education and a practical portion that includes positive studies. When screened properly PD patients can be used effectively to demonstrate positive FAST studies.
Epiploic Appendagitis: An Emerging Diagnosis for General Surgeons
Authors: Boulanger Bernard R. , Barnes Stephen , Bernard Andrew C.
Published: November 2022

The increased use of sonography and computed tomography in the assessment of lower abdominal pain has led to the greater recognition of epiploic appendagitis. Although epiploic appendagitis is increasingly described and diagnosed by radiologists it is rarely discussed in the surgical literature. We describe five recent cases of epiploic appendagitis managed at our center and review the literature regarding this clinical entity. All cases were diagnosed by computed tomography and none underwent surgery. General surgeons need to include epiploic appendagitis in their differential diagnosis for abdominal pain and be aware of the natural history of this condition when considering therapy.
Nonoperative Progressive “Bogota Bag” Closure after Abdominal Decompression
Authors: Myers Jonathan A. , Latenser Barbara A.
Published: November 2022

“Bogota bags” are often used for temporary abdominal closure after damage control or staged laparotomy for trauma or release of abdominal compartment syndrome. After placement of the Bogota bag serial operative closures are required to return abdominal contents to their original location before definitive closure. Unnecessary operative procedures may be avoided when binder clips are used to facilitate the gradual approximation of the wound edges before abdominal closure.
Histologic Evaluation and Treatment Outcome after Sequential Radiofrequency Ablation and Hepatic Resection for Primary and Metastatic Tumors
Authors: Hoffman Allen L. , Wu Sandy S. , Obaid Amal K. , French Samuel W. , Lois Juan , Mcmonigle Michael , Ramos Hector C. , Sher Linda S. , Lopez Richard R.
Published: November 2022

Operative manipulation during hepatic resection (HR) causes tumor cell shedding which is a factor in disease recurrence. Radiofrequency ablation (RFA) causes coagulative necrosis and was used to destroy the tumor before HR. We evaluated tumor necrosis and recurrence of hepatic malignancies treated by sequential RFA/HR. A retrospective review of patients treated with sequential RFA/HR from April 1999 to January 2002 was performed. A Radionics 500-kW RF generator was used to ablate lesions via H2O-cooled electrodes under ultrasound guidance. Segmental HR was performed after RFA. Resected specimens were reviewed with hematoxylin and eosin staining and for apoptosis. Patient follow-up ranged from 10 to 33 months with evaluation of salient clinical, radiologic, and laboratory parameters. Seven patients (four male and three female) ages 62.1 ± 10.3 years had sequential RFA/HR. Four patients had hepatocellular carcinoma (HCC) and three had colorectal metastases (CRm). The tumors were unifocal right-lobe lesions measuring 4.1 ± 0.9 cm with a resection margin of 0.4 to 2.5 cm. Extensive necrosis was noted but intact nests of tumor cells occurred in all specimens with minimal apoptosis. Three of seven patients (two HCC and one CRm) developed pulmonary metastases at 3 to 20 months with one HCC patient developing concurrent liver metastases. Two deaths occurred in the HCC group. Sequential RFA/HR may minimize local recurrence; however, the high incidence of pulmonary metastases raises concern of transvenous migration. The histologic findings demonstrate foci of intact tumor cells after RFA. Controlled study of additional patients with long-term follow-up is necessary to better understand these findings.
Acute Diverticulitis in the Young Adult is Not “Virulent”
Authors: Schweitzer Jeremy , Casillas Robert A. , Collins J. Craig
Published: November 2022

Acute diverticulitis historically has been considered rare before the age of 40 but “virulent” when it does occur and frequently requiring emergency operation. Recent experience suggests that the demographics and management of this disease are changing. Outcomes at Kaiser Permanente Los Angeles Medical Center were reviewed. Between January 1997 and July 2001 261 patients were discharged with the diagnosis of acute diverticulitis; 46 or 18 per cent of these were aged ≤40. Patients' mean age was 35, 76 per cent were men, 65 per cent were Latino, and 72 per cent were obese (body mass index ≥30 kg/m2). An operation at initial presentation was performed on 35 per cent (16/46) patients. Only 19 per cent of these (3/16) had a correct preoperative diagnosis. The 30 patients who were treated nonoperatively all were managed successfully; one required a percutaneous drain. Given the apparent increasing frequency of acute diverticulitis in young adults and the high success rate of initial nonoperative management surgeons should consider this diagnosis in selected patients who present with abdominal symptoms. Knowledge of typical clinical features and judicious use of computed tomography may decrease the number of unnecessary emergency operations in young adults with acute diverticulitis. Our data do not support a “virulent” label for this disease in the young.
Does Gallbladder Ejection Fraction Predict Pathology after Elective Cholecystectomy for Symptomatic Cholelithiasis ?
Authors: Nakano Kathy Jean , Waxman Kenneth , Rimkus Daniel , Blaustein John
Published: November 2022

Patients with symptomatic cholelithiasis are selected for elective cholecystectomy with the expectation that their symptoms will improve after operation. However, some patients fail to improve because their preoperative symptoms were not related to gallbladder disease. A test that would indicate the severity of gallbladder disease in patients with gallstones would therefore have great potential benefit. Twenty-five patients who presented as outpatients with episodic abdominal pain and gallstones were scheduled for elective cholecystectomy. On the day before operation patients underwent nuclear medicine cholescintigraphy with measurement of ejection fraction. All patients then underwent laparoscopic cholecystectomy. Pathologic specimens were reviewed by a pathologist who was blinded to the ejection fraction results and scored for degree of inflammation on a scale of zero to three. There was a wide range of ejection fractions measured (0–84%). There was, however, no correlation between ejection fractions and degree of gallbladder inflammation. We conclude that gallbladder ejection fraction does not predict the degree of gallbladder inflammation at the time of elective cholecystectomy. This test is therefore unlikely to predict which patients with cholelithiasis will have symptomatic relief after cholecystectomy.
Wireless Clinical Alerts and Patient Outcomes in the Surgical Intensive Care Unit
Authors: Major Kevin , Shabot M. Michael , Cunneen Scott
Published: November 2022

Errors in medicine have gained public interest since the Institute of Medicine published its 1999 report on this subject. Although errors of commission are frequently cited, errors of omission can be equally serious. A computerized surgical intensive care unit (SICU) information system when coupled to an event-driven alerting engine has the potential to reduce errors of omission for critical intensive care unit events. Automated alerts and patient outcomes were prospectively collected for all patients admitted to a tertiary-care SICU for a 2-year period. During the study period 3,973 patients were admitted to the SICU and received 13,608 days of care. A total of 15,066 alert pages were sent including alerts for physiologic condition (6,163), laboratory data (4,951), blood gas (3,774), drug allergy (130), and toxic drug levels (48). Admission Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II score, SICU lengths of stay, and overall mortality rates were significantly higher in patients who triggered the alerting system. Patients triggering the alert paging system were 49.4 times more likely to die in the SICU compared with patients who did not generate an alert. Even after transfer to floor care the patients who triggered the alerting system were 5.7 times more likely to die in the hospital. An alert page identifies patients who will stay in the SICU longer and have a significantly higher chance of death compared with patients who do not trigger the alerting system.