bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of Fatal Outcome after Colectomy for Fulminant Clostridium difficile Colitis: A 10-Year Experience
Authors: Markelov Alexey , Livert David , Kohli Harjeet
Published: June 2020

Surgical treatment of fulminant Clostridium difficile colitis has high mortality rates. Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing. Data were retrospectively collected on patients operated on for C. difficile colitis between 2000 and 2010 at our institution. Statistical analysis was performed to identify predictors of mortality. We reviewed the records of 13 inpatients diagnosed as having C. difficile colitis and who underwent colectomy during the same admission. The in-hospital mortality rate for patients undergoing colectomy for colitis was 46.2 per cent. Independent predictors of mortality included the following: white blood cell count (34,600/μL or greater), hypoalbuminemia (1.5 g/dL or less), septic shock with requirements of vasopressors, and respiratory failure. Patients who underwent colectomy earlier (mean time from presentation to surgery 2.4 ± 1.5 days) had decreased mortality ( P = 0.019).). Longer length of hospital stay to the time of diagnosis was associated with higher rates of fatal outcome ( P = 0.031). Parameters without significant difference ( P > 0.05) included patient age, presenting symptoms, other comorbidities, creatinine levels, and CT scan findings. Identified factors can predict unfavorable outcomes after colectomy. Aggressive surgical intervention early in the course of the disease might be associated with improved survival.
Lymphovascular Invasion as a Prognostic Factor in Melanoma
Authors: Egger Michael E. , Gilbert Julianna E. , Burton Alison L. , Mcmasters Kelly M. , Callender Glenda G. , Quillo Amy R. , Brown Russell E. , Hill Charles R. St. , Hagendoorn Lee , Martin Robert C. G. , Stromberg Arnold J. , Scoggins Charles R.
Published: June 2020

The prognostic significance of lymphovascular invasion (LVI) in melanoma remains controversial. Clinicopathologic data from a prospective trial of patients with melanoma were analyzed with respect to LVI. Disease-free survival and overall survival (OS) were evaluated by Kaplan-Meier (KM) analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive sentinel nodes (SLN) and survival. A total of 2183 patients were included in this analysis; 171 (7.8%) had LVI. Median follow-up was 68 months. Factors associated with LVI included tumor thickness, ulceration, and histologic subtype ( P < 0.05). LVI was associated with a greater risk of SLN metastasis ( P < 0.05). By KM analysis, LVI was associated with worse OS ( P = 0.0009). On multivariate analysis, age, gender, thickness, ulceration, anatomic location, and SLN status were predictors of OS; however, LVI was not an independent predictor of OS. Among patients with regression, the 5-year OS rate was 49.4 per cent for patients with LVI versus 81.1 per cent for those with no LVI ( P < 0.0001). LVI is associated with a greater risk of SLN metastasis. Although LVI is not an independent predictor of OS in general, it is a powerful predictor of worse OS among patients who have evidence of regression of the primary tumor.
Pencils and Pens: An Under-Recognized Source of Penetrating Injuries in Children
Authors: Fisher Sarah B. , Clifton Matthew S. , Bhatia Amina M.
Published: June 2020

Unlike other sharp objects, pens and pencils are readily available to children both at home and school. Although case reports are published, no series of pen or pencil injuries have been reported in the recent literature. We therefore reviewed the incidence and injury profiles of writing instruments as compared with other sources of penetrating trauma. The trauma registry from a large urban pediatric hospital system was queried for nonmissile, nonbite penetrating injuries from 2005 through 2009. Retrospective data was collected on demographics, injuries, operations, admissions, and mortalities. Additionally, data regarding pen and pencil injuries from 2009 to 2010 were collected prospectively, and one case from 2003 was included retrospectively. Fourteen injuries from writing instruments were seen and involved the head and neck (9), chest (1), bladder/perineum (2), and extremities (2). Eleven children were admitted and eight required surgical intervention. One child died from a transhemispheric brain injury after intraorbital penetration by a pencil. Penetrating trauma from writing instruments is not an uncommon source of injury and often requires surgical intervention to remove the object. Injuries from pens and pencils can be severe or even fatal. Appropriate parent and teacher education regarding the potential risks may help to prevent such injuries.
Article Commentary: Late Outcomes of Carotid Artery Stenting: A Critical Review
Authors: Ross Charles B. , Yancey Andrea E. , Byrnes Kelly R. , Wayne Erik J. , Dwivedi Amit J. , Morris Marvin E.
Published: June 2020

The role of carotid artery stenting (CAS) as an alternative to carotid endarterectomy for the treatment of extracranial carotid occlusive disease for stroke prevention continues to evolve. Although technical and device refinements aimed at making CAS safer continue to this day, safety as measured by 30-day and 1-year outcomes has been the primary recipient of regulatory and practice attention. Relatively less emphasis has been placed on the incidence of recurrent stenosis after CAS and the efficacy of CAS in late stroke prevention. Data on late outcomes of CAS, including factors of potential influence, have been emerging and are addressed in this review.
Obturator Hernia Revisited: Surgical Anatomy, Embryology, Diagnosis, and Technique of Repair
Authors: Stamatiou Dimitrios , Skandalakis Lee J. , Zoras Odysseas , Mirilas Petros
Published: June 2020

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.
How Medical Alumni Now See Their Junior Clerkships in Surgery
Authors: Chapman Jason R. , Weidner Bryan C. , Nakayama Don K.
Published: June 2020

The purpose of this study is to determine the effectiveness and value of the junior medical student surgical clerkship for physicians now in practice. Questionnaires were sent to all Mercer University School of Medicine alumni (1986-2007) using a five-point Likert scale. One hundred and fifty-seven responses were received from 873 recipients (18%), 71 per cent training in nonsurgical specialties. “Scrubbing in” on cases was the most valuable activity (82%), followed by faculty rounds (76%), resident work rounds (70%), and lectures (69%). Least useful activities were question and answer sessions (54%), grand rounds (53%), and morbidity and mortality conferences (57%). The amount of time in the operating room was appropriate for 61 per cent, but to 8 per cent the operating room was a waste of time. Faculty evaluations gave the most effective feedback (75%). Alumni in surgical specialties and obstetrics and gynecology rated their experiences higher than nonsurgical physicians. Overall, only 44 per cent saw the material learned as important to general medical education. Opinions regarding the value of surgical clerkships to current practices were mixed. Undergraduate surgical education should emphasize common surgical conditions, surgical decision-making, and simple procedures relevant to a nonsurgical practice.
Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part III. Cadaveric Representation of the Course of Second and Third Cleft and Pouch Fistulas
Authors: Mirilas Petros
Published: June 2020

“Stepladder” surgery for fistula from second or third pharyngeal cleft and pouch is “blind.” Neither intraoperative methylene blue injection and probing nor preoperative imaging (fistulo-gram ultrasound, computed tomography, magnetic resonance imaging) reveal three-dimensional anatomic relations of fistulas. This article describes the most common second and third fistula courses and demonstrates representation of their tracts with wires in human cadavers. A second cleft and pouch fistula, at its external opening, pierces superficial cervical fascia (and platysma), then investing cervical fascia, and travels under the sternocleidomastoid muscle, superficial to the sternohyoid and anterior belly of omohyoid. It ascends along the carotid sheath, and at the upper border of the thyroid cartilage it pierces the pretracheal fascia. Characteristically, it courses between the carotid bifurcation and over the hypoglossal nerve. After passing beneath the posterior belly of the digastric muscle and the stylohyoid, it hooks around both glossopharyngeal nerve and stylopharyngeus muscle. The fistula reaches the pharynx below the superior constrictor muscle. The course of a third cleft and pouch fistula is similar until it has pierced pretracheal fascia; then it passes over the hypoglossal nerve and behind the internal carotid, finally descending parallel to the superior laryngeal nerve, reaching the thyrohyoid membrane cranial to the nerve.
Surgical Site Infection Rates in Laparoscopic Versus Open Colorectal Surgery
Authors: Aimaq Rahim , Akopian Gabriel , Kaufman Howard S.
Published: June 2020

The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to evaluate the incidence of postoperative surgical site infections (SSIs) between laparoscopic (LAP) and open colorectal surgery. The 2008 ACS-NSQIP Participant Use File was queried by Current Procedural Terminology codes for colorectal surgery cases. SSI rates were compared between groups using Pearson chi-square and Fisher exact tests. Univariate and multivariate analyses were performed to identify factors associated with the LAP approach and/or SSIs. A total of 7,755 LAP and 16,184 open cases were identified. The laparoscopic group had an SSI rate of 9.4 versus 15.7 per cent for the open group ( P < 0.0001). There was no statistical difference in the type of SSI (superficial, deep, and/or organ space) between the two groups. Although multivariate analysis identified several factors associated with SSIs of different types, LAP was the only factor found to decrease risk, whereas wound class and operative time were found to increase risk among all categories of SSIs. Despite a significantly lower incidence of postoperative SSI, only 32 per cent of colorectal surgery was performed laparoscopically in NSQIP hospitals in 2008. Wider adoption of LAP approaches for colorectal surgery should continue to reduce SSIs.
An Acute Care Surgery Model Improves Timeliness of Care and Reduces Hospital Stay for Patients with Acute Cholecystitis
Authors: Lau Briana , Difronzo L. Andrew
Published: June 2020

In October 2009, an acute care surgery (ACS) model was implemented to facilitate urgent surgical consults. This study examines the impact of ACS on the timeliness of care and length of hospitalization for patients with acute cholecystitis. A retrospective cohort study was performed of patients presenting to the emergency department (ED) with acute cholecystitis who underwent early cholecystectomy. Patients with choledocholithiasis, pancreatitis, biliary colic, or cholelithiasis without cholecystitis were excluded. There were two study cohorts: ACS (October 2009 to July 2010) and pre-ACS (October 2008 to September 2009). Primary outcome measures were length of stay (LOS) and time from the ED to the operating room (OR). One hundred fifty-two cases were identified: 71 in the ACS group and 81 in the pre-ACS group. Patient demographics were similar. The ACS group had a significantly shorter average time from the ED to the OR (24.6 vs 35.0 hours, P = 0.0276). Overall LOS was reduced by a mean of 14.7 hours in the ACS group (mean 3.23 vs 2.63 days, P = 0.11). There was no significant difference in OR time (2.45 vs 2.38 hours, P = 0.562). There was a significant decrease in after-hours cases in the ACS group (5.6 vs 21%, P = 0.004) and a decrease in complication rates (18.5 vs 7.0%, P = 0.032). In conclusion, the ACS model decreased time from the ED to the OR, decreased after-hours cases, decreased length of hospitalization, and decreased complications for patients with acute cholecystitis.
Associated Vascular Injury in Patients with Bile Duct Injury During Cholecystectomy
Authors: Keleman Alex M. , Imagawa David K. , Findeiss Laura , Hanna Mark H. , Tan Vicki H. , Katz Matthew H. G. , Goodwin Scott C. , Lane John S. , Vajgrt Duane , Nguyen Thong , Smith Clyde W.
Published: June 2020

Cholecystectomy remains one of the most commonly performed procedures in general surgery. Although the incidence, diagnosis, and treatment of bile duct (BD) injuries have been well described, studies characterizing associated vascular injuries are limited. The objective of this study was to analyze the frequency and management of associated vascular and BD injury after cholecystectomy. A total of 50 patients were referred to a tertiary institution for BD injuries from 1996 to 2010. Thirty-nine (78%) of the patients were female with the mean age of 49 years (range, 14 to 86 years). Seventy-five per cent of the injuries were Strasberg Type E. Nine patients (18%) had associated vascular injuries. Six patients had injuries to the right hepatic artery; in one patient, both the right and left hepatic arteries were damaged. Five patients had right portal vein injuries; three of these subsequently died. In conclusion, as a result of the high incidence of associated vascular injury, a thin-collimation CT angiogram and/or mesenteric angiogram with portal venous imaging should be considered as part of the preoperative evaluation in patients with BD injury.
The Impact of Radiation on Surgical Outcomes of Immediate Breast Reconstruction
Authors: Tran Tuan , Tran Tu , Miles Duncan , Hill Michael , Lum Sharon S.
Published: June 2020

We sought to determine the differences in surgical outcomes associated with adjuvant radiation versus no radiation in patients undergoing concurrent breast oncologic and reconstructive operations. A retrospective review of patients who underwent combined oncologic and plastic surgeries for breast diseases from January 2005 to June 2010 was compared for demographic factors and outcomes by receipt of radiation therapy. During the study period, 175 patients were identified; 25.7 per cent received radiation therapy. Mean patient age was 51 years and median follow-up was 355 days. Overall, 80.2 per cent of patients underwent mastectomy; 19.8 per cent partial mastectomy; 42.1 per cent autologous tissue reconstruction; and 54.8 per cent implant-based reconstruction. There were no significant differences between radiated and nonradiated patients in rates of overall or oncoplastic-specific complications. Lymphedema was the only complication seen more frequently in the radiated arm ( P = 0.03). In our series of carefully selected patients undergoing a variety of reconstructive techniques for repair of partial or total mastectomy defects, radiation was not associated with worse outcomes in patients undergoing immediate breast reconstruction. With careful collaboration among plastic surgeons, breast surgeons, and radiation oncologists, patients requiring breast surgery may safely be considered for reconstruction of partial or total mastectomy defects when adjuvant radiation is required.
Discordance Between Pathologic and Radiologic Tumor Size on Breast MRI May Contribute to Increased Re-excision Rates
Authors: Vanderwalde Lindi H. , Dang Catherine M. , Bresee Catherine , Phillips Edward H.
Published: June 2020

Preoperative breast MRI does not decrease re-excision rates in patients who undergo lumpectomy. We evaluated concordance of tumor size on MRI and pathologic size in patients who underwent re-excision of margins after lumpectomy. A retrospective review of patients at the Cedars-Sinai Breast Center who received breast MRI was performed. We found that MRI was performed before lumpectomy in 136 patients. Mean age was 55.2 years (standard deviation ± 12.6). Re-excision occurred in 34 per cent (n = 46). Of those undergoing re-excision, 35 per cent (16/46) were re-excised for ductal carcinoma in situ (DCIS) at the lumpectomy margin. There was no significant difference between radiologic and pathologic size of the tumor (1.94 vs 2.12 cm; P = 0.159). In those who underwent re-excision, the radiologic size was underestimated compared with the pathologic size (2.01 vs 2.66 cm; P = 0.032). Patients with pure DCIS lesions (n = 9) also had smaller radiologic tumor size compared with pathologic (0.64 vs 2.88 cm; P = 0.039), and this difference trended toward significance in those who underwent re-excision (0.55 vs 3.50 cm; P = 0.059). Discordance between tumor size on MRI and pathologic size may contribute to re-excisions in patients who undergo lumpectomy. The limitations of breast MRI to evaluate the extent of DCIS surrounding many breast cancers, and the impact on re-excision rates, should be further evaluated.
Is the Oncotype DX Assay Necessary in Strongly Estrogen Receptor-Positive Breast Cancers?
Authors: Lee Jenny J. , Shen Jeannie
Published: June 2020

The 21-gene Oncotype DX recurrence score (RS) assay quantifies risk of distant recurrence and predicts benefit from chemotherapy in tamoxifen-treated estrogen receptor (ER)-positive, node-negative breast cancer. Although clinically useful, the assay costs roughly $4650. Because the assay is weighted heavily towards expression of ER, our objective was to determine its clinical utility in strongly ER-positive tumors. This was a retrospective study of Huntington Hospital patients undergoing an Oncotype DX assay between 2007 and 2010. Data collected included patient age, expression of ER, progesterone receptor (PR), HER2/neu, ki67, and p53, tumor size, node status, lymphovascular invasion, and nuclear grade. Of 133 total patients, 84 (63.2%) had strongly ER-positive tumors (≥90% expression). Only seven of 84 patients (8.3%) had a high risk RS (>30), indicating statistically significant predicted benefit from chemotherapy. All seven had intermediate to high ki67 expression (>20%) and lower PR expression (≤50%). Our study demonstrates that the clinical utility of the Oncotype DX assay in these patients is limited as most patients with strongly ER-positive tumors will have a low or intermediate RS. Future studies are needed to identify additional predictive factors in these patients with otherwise good prognosis.
A Decade of Selective Use of Adjustable Cutting Seton Combined with Fistulotomy for Anal Fistula
Authors: Kamrava Allen , Collins J. Craig
Published: June 2020

Previous studies have demonstrated that the division of sphincter muscle in the treatment of anal fistula may precipitate fecal incontinence. Cutting setons may pose a particular risk of unrecoverable injury to the sphincter apparatus. To evaluate if the use of an adjustable cutting seton mitigates this risk, we performed a retrospective review of all patients operated on for anal fistulae in a 10-year period by a single surgeon. Adjustable cutting setons (consisting of heavy silk ligature with patient-controllable tension) were used selectively. Forty-seven patients met the study criteria. Ninety-four per cent of the fistulae treated were transsphincteric. All of the fistulae were treated with at least partial fistulotomy. Ninety-nine per cent of patients were followed to completion of treatment. One (2%) patient subsequently developed fecal incontinence, and four (9%) developed a recurrent or persistent fistula in the same location. Adjustable cutting setons have been used in our practice with a high success rate and low risk of complications. Our data support adjustable cutting setons as a useful tool in the surgeon's repertoire for treating fistulae that involve the anal sphincter complex.
Laparoscopic Enucleation or Wedge Resection of Benign Gastric Pathology: Analysis of 44 Consecutive Cases
Authors: Nguyen Ninh T. , Shapiro Caitlin , Massomi Hossein , Laugenour Kelly , Elliott Christian , Stamos Michael J.
Published: June 2020

Laparoscopic resection of gastric submucosal tumors has been described, but the role of laparoscopy for tumors within the esophagus or near the gastroesophageal junction is not clearly defined. The aim of this study was to examine the outcomes of laparoscopic or thoracoscopic enucleation or wedge resection of benign gastric tumors. The charts of 44 patients who underwent minimally invasive resection of benign esophagogastric tumors were reviewed. Surgical approaches included thoracoscopic enucleation (n = 2), laparoscopic enucleation (n = 6), transgastric enucleation (n = 2), and laparoscopic gastric wedge resection (n = 34). There were 23 males with a mean age of 57 years. There was one conversion (2.5%) to laparotomy. Mean operative time was 97 ± 52 minutes. The mean length of hospital stay was 2.6 ± 2.0 days. One patient developed gastric outlet obstruction requiring Roux-en-Y reconstruction. There were no leaks and the 90-day mortality was zero. Pathology demonstrated gastrointestinal stromal tumor (n = 31), leiomyoma (n = 6), and other benign pathology (n = 7). There has been one tumor recurrence at a mean follow-up of 4.3 years. The laparoscopic approaches to local resection of gastric tumors are safe and feasible. The type of minimally invasive surgical approaches should be tailored based on the location and size of the lesion.
Improvement in Short-Term Pancreas Transplant Outcome by Targeted Antimicrobial Therapy and Refined Donor Selection
Authors: Schnickel Gabriel T. , Busuttil Ronald W. , Lipshutz Gerald S.
Published: June 2020

Graft thrombosis and infectious complications are the main early causes of pancreatic allograft loss in recipients of whole vascularized pancreas transplants, resulting in loss rates up to 10 per cent in the first post transplant week. In this study we sought to determine if initiation of a standardized selection criteria and posttransplant chemoprophylaxis regimen could reduce the rate of early allograft loss; we compared the rate of early allograft loss after introduction of these changes. Of the 61 diabetic recipients who underwent these protocols, 50.8 per cent were female. Average age was 42.9 ± 7.4 years of age, average length of stay was 12.7 ± 8.7 days, with all transplants performed heterotopic to the right lower quadrant with venous drainage to the proximal external or common iliac vein. Organ donors were 21.4 ± 4.8 years of age, body mass index was 23.9 ± 2.8 kg/m2, with a length of stay of 3.7 ± 1.6 days. One-week pancreatic allograft survival for the protocolized versus nonprotocolized patients was 100 per cent versus 96.7 per cent, 1 month was 98.4 per cent versus 93.4 per cent, and 1 year was 96.7 per cent versus 88.5 per cent, respectively. In the protocolized group there were two graft losses due to infectious complications and none due to thrombosis. Before initiation of the protocols patient survival at 1 year was 91.8 per cent and after was 100 per cent. Pancreas transplantation is arguably the most technically demanding organ transplant from a complication and loss standpoint. However, highly successful outcomes can be obtained with standardized protocols beginning pretransplant to reduce the incidence of posttransplant complications.
Correlating the Blood Alcohol Concentration with Outcome after Traumatic Brain Injury: Too Much Is Not a Bad Thing
Authors: Berry Cherisse , Ley Eric J. , Margulies Daniel R. , Mirocha James , Bukur Marko , Malinoski Darren , Salim Ali
Published: June 2020

Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P < 0.0001). In determining the relationship between BAC and mortality, multivariable logistic regression analysis demonstrated a high BAC level was significantly protective (adjusted odds ratio 0.55; 95% confidence interval: 0.38-0.8; P = 0.002). In the largest study to date, a high (≥230 mg/dL) admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI. Additional research is warranted to investigate the potential therapeutic implications.
Squamous Cell Carcinoma Complicating Chronic Suppurative Hydradenitis
Authors: Losanoff Julian E. , Sochaki Paula , Khoury Nabiha , Levi Edi , Salwen Walter A. , Basson Marc D.
Published: June 2020

A 69-year-old male patient underwent excision of hidradenitis suppurativa (HS) affecting both gluteal areas and the perineum. The perineal specimen contained a 1-cm superficially invasive, well-differentiated keratinizing squamous cell carcinoma. The patient was free of recurrence 1 year after surgery. A 66-year-old male patient was diagnosed with massive perineal HS more than 40 years previously. More than 30 abscesses and suppurative sinus tracts were surgically treated over the years. He eventually died of unresectable pelvic squamous carcinoma. Search of the literature and available bibliography revealed 47 retrospective studies of skin carcinoma arising in HS since 1959, including a total of 64 patients together with the two patients treated by our team. Squamous cell carcinoma is a rare but potentially fatal complication of HS. Surgery is the only known treatment method that provides a real chance for cure for both HS and a carcinoma that complicates it. HS must be treated early with complete excision to avoid chronic progression of the disease that can cause cancerous degeneration. A high index of suspicion, early tissue diagnosis, and immediate referral for radical surgery carry the only hope for cure in those whose HS harbors malignancy.
Osteopontin Induced by Macrophages Contribute to Metachronous Liver Metastases in Colorectal Cancer
Authors: Imano Motohiro , Okuno Kiyotaka , Itoh Tatsuki , Satou Takao , Ishimaru Eizaburo , Yasuda Takushi , Hida Jin-Ichi , Imamoto Haruhiko , Takeyama Yoshifumi , Shiozaki Hitoshi
Published: June 2020

Even after radical surgery for stage II and stage III colorectal cancer, metachronous liver metastasis is frequently observed. The aim of this study was to identify the risk of metachronous liver metastasis with retrospective clinicopathological study. Immunohistochemistry was performed to evaluate the expression of Osteopontin (OPN), CD-68, and CD105 in 41 cases of stage II and stage III colorectal cancer tissue. Stage II and stage III colorectal cancer patients who had undergone R0 resection were classified into two groups: with metachronous liver metastasis (m-LM; n = 17) and without liver metastases (control; n = 24). Additionally, double-immunofluorescence staining was performed using antibodies to OPN and CD68. OPN-positive cells were frequently colocalized with CD68 immunoreactivity. OPN and microvascular density expression in the central area were significantly higher in the m-LM (OPN; control 4.3 ± 0.56, m-LV 10.8 ± 1.48, P < 0.05; microvascular density control 18.5 ± 2.86, m-LV 31.4 ± 4.39, P < 0.05), while CD68 expression in the invasive margin was significantly higher in the control group (control 98.9 ± 7.31, m-LV 28.2 ± 3.18, P < 0.05). These results suggest that the risk of metachronous liver metastasis could be well predicted by immunohistochemical staining of OPN in the central areas, and CD68 in the invasive margins of tumors.
Endoscopic Versus Surgical Treatment of Downstream Pancreatic Duct Stones in Chronic Pancreatitis
Authors: Hong Jianguo , Wang Jian , Keleman Alex M. , Imagawa David K. , Xu Kesen , Wang Wenhua , Liu Enyu , Niu Weibo , Wang Jinshen , Sun Iang , Wang Jiayong , Peng Cheng , Zhao Wanni , Niu Jun
Published: June 2020

Pancreatic duct stone is thought not only to be the cause of abdominal pain but also to be a risk factor for pancreatic cancer. Several treatment options have been implemented in the treatment of pancreatic duct stones. Stone location is a critical factor in selecting treatment. We present the results of 27 endoscopic treatments and 35 surgical treatments performed in three hospitals at a single university between January 2000 and January 2005. The results were compared retrospectively in terms of success rate of stone removal, length of hospital stay, complications, pain relief, and changes of pancreatic functions. In our study, endoscopy resulted in a similar success rate of stone removal and short-term pain relief rate as the surgical approach and with a shorter length of hospital stay. However, the surgical group had a more favorable long-term clinical result, as well as a lower number of hospital readmissions at the 5-year follow-up point. Based on long-term results, surgical treatment is more effective than endoscopy.
Retrocolic Spaces: Anatomy of the Surgical Planes in Laparoscopic Right Hemicolectomy for Cancer
Authors: Zhang Ce , Ding Zi-Hai , Yu Hai-Tao , Yu Jiang , Wang Ya-Nan , Hu Yan-Feng , Li Guo-Xin
Published: June 2020

To explore the regional anatomy of the fasciae and spaces around the right-side colon from laparoscopic perspective, we observed the location, extension, and boundaries of the spaces around the right-side colon in seven cadavers and in 49 patients undergoing laparoscopic right hemicolectomy for cancer, and reviewed computed tomography images from patients and healthy individuals. Between the ascending mesocolon and prerenal fascia (PRF), there was a right retrocolic space (RRCS), which extended in all directions. The anterior, posterior, medial, lateral, cranial, and caudal boundaries of the RRCS were the ascending mesocolon, PRF, superior mesenteric vein, right paracolic sulcus, inferior margin of the duodenum, and inferior margin of the mesentery radix, respectively. Between the transverse mesocolon and the pancreas and duodenum, there was a transverse retrocolic space, which was enclosed cranially by the radix of the transverse mesocolon. In CT images, healthy PRF was noted as slender line of middle density, continuing to the transverse fascia. The retrocolic spaces was unidentifiable, unless they were filled with retroperitoneal lesions. The RRCS and transverse retrocolic space are natural surgical planes for laparoscopic right hemicolectomy for cancer. The boundaries of these fusion fascial spaces are the best access, and the PRF is the best guide.
Famotidine Use and Thrombocytopenia in the Trauma Patient
Authors: Compoginis John M. , Gaspard Donald , Obaid Amal
Published: June 2020

The purpose of this study was to assess the incidence and clinical significance of famotidine-associated thrombocytopenia in the trauma patient population. A retrospective cohort study was performed between January 2003 and May 2009 comparing the consecutive platelet counts of trauma patients treated with intravenous famotidine with a similar group of trauma patients who were not. Patients were excluded if: 1) daily platelets counts for 48 hours were not drawn; 2) if platelet counts were less than 150 X 103/μL on admission or before initiation of famotidine treatment; 3) if patients received heparin or enoxaparin before or during the study period; and 4) if patients were taking famotidine before admission. Platelet counts were then recorded for the day of admission, the day famotidine was started if not on admission, and 24 hours and 48 hours during treatment. Seventy-two of 181 (39.8%) patients treated with famotidine developed thrombocytopenia compared with 23 of 126 (18.3%) untreated patients ( P < 0.001). Patients who developed thrombocytopenia were also more likely to have a longer length of stay and higher Injury Severity Scores. Intravenous famotidine therapy was the only variable found to be statistically significant after both univariate and multivariate analysis ( P < 0.001 and P = 0.003, respectively). Thrombocytopenia became clinically significant in eight of 181 (4.4%) famotidine-treated patients or 11.1 per cent of those who developed thrombocytopenia. Given these findings, we recommend the use of alternative medications for peptic ulcer prophylaxis in the critically ill trauma patient, especially those who are coagulopathic.
Treatment of Major Laparoscopic Bile Duct Injury: A Long-Term Follow-up Result
Authors: Xu Xiao Dong , Zhang You Cheng , Gao Pen , Bahrani-Mougeot Farah , Zhang Ling Yi , He Zhi Yun , Zhang Ya Wu , Ma Jian Zhon
Published: June 2020

The goal of this study is to present the multiple institutions experience comparing the outcome of management between initial laparoscopic cholecystectomy (LC) surgeon and specialist as well as the outcome of different operative procedures to major bile duct injury (BDI) after LC. We have retrospectively collected data of 77 cases of perioperatively detected major BDI in LC at 15 general surgical institutions from 1997 to 2007. We classified 42 cases treated by an experienced biliary surgeon as Group A and 35 cases treated by the initial LC surgeon as Group B. Forty-eight cases were treated with duct-to-duct anastomosis as Group C and 29 cases were treated with Roux-en-Y choledochojejunostomy as Group D. The median duration of follow-up was 62 months. The outcome of groups was compared. In Group A, 7 of 42 (16.7%) patients developed a failure. Two of seven (28.6%) patients were treated by a secondary operation. In Group B, 24 of 35 (68.6%) patients developed a failure. Seventeen of 24 (70.8%) patients were treated by a secondary operation. One of 35 (2.85%) patients died. The significant differences were observed in failure and secondary operations (16.7 vs 68.6%, P < 0.01 and 28.6 vs 70.8%, P < 0.01). There is no significant difference Group C and Group D in failure rate (28.5 vs 11.7%, P > 0.05). A multiple institutional cooperative methodology between the local surgical institution and tertiary care centers provided a good way to limit further operations, failure. The reconstructive strategy is important and should be selected according to the type of injury and the diagnosed status of major BDI.
Clinical Application of Modified Double Tracks Anastomosis in Proximal Gastrectomy
Authors: Zhao Qun , Li Yong , Guo Weijia , Zhang Zhidong , Ma Zhixue , Jiao Zhikai
Published: June 2020

We compared the outcome of two surgical alimentary canal reconstruction methods after proximal gastrectomy. Three hundred ninety-six patients who underwent a radical proximal gastrectomy were randomized into two groups. Group A was treated with modified double tracks anastomosis, and Group B was treated with esophagus-remnant stomach direct anastomosis. Outcome measures were hematological indices, prognostic nutritional index (PNI), plasma hormone concentrations, and Visick index. The operative times in Groups A and B were 210 ± 53 and 150 ± 75 minutes and the hemorrhage volume was 173 ± 67 and 150 ± 75 mL, respectively. Six months after operation, values of hemoglobin concentration, body weights, and PNI indices were significantly increased in Group A compared with Group B. Levels of gastrin and somatostatin were obviously less than preoperative values and levels of cholecystokinin and motilin were significantly higher than preoperative values in both groups. All patients of Group A were classified into Visick index Grades I and II, whereas only 70.37 per cent of Group B belonged to Visick index Grades I and II postoperatively. The overall 3-year survival rate was not significantly different in both groups. Modified double tracks anastomosis as an alimentary canal reconstructive method for radical proximal gastrectomy showed better outcomes than esophagus-remnant stomach direct anastomosis.
Management of Fasciotomy Wounds-Does the Dressing Matter?
Authors: Matt Sarah E. , Johnson Laura S. , Shupp Jeffrey W. , Kheirbek Tareq , Sava Jack A.
Published: June 2020

Fasciotomy is a limb-saving procedure in the management of ischemic extremities. Little evidence exists as to the best method of fasciotomy wound management. We hypothesized that the use of vacuum dressing (VAC) or creation of dynamic tension (DYN) would increase rates of primary closure, reducing the need for split thickness skin grafting (STSG). The records of a large urban Level I trauma center were used to identify fasciotomy recipients over a 10-year period and were retrospectively analyzed. Data collected included injury characteristics, wound management, and outcomes. Wound management was dictated by surgeon preference, and categorized as gauze packing, DYN, or VAC. The primary outcome was primary closure versus need for STSG. Wound management cohorts were compared using logistic regression. Fisher's exact test and χ2 were performed to compare proportions and categorical variables respectively. From 2000 to 2009, 227 patients had a fasciotomy performed. Mechanism, age, and incidence of fracture were different between the groups. There was a trend towards increased primary closure with DYN (83%). Average length of stay (LOS) was 21 days for those receiving primary closure and 27 days for STSG. There was a significant decrease in LOS for the DYN group (average 16 days) when compared with gauze packing and VAC. In this series of 227 patients who underwent fasciotomy, no technique of wound management produced a significant improvement in primary closure rate. A trend toward more primary closure was seen in the DYN group. LOS was longer for patients receiving STSG. The DYN cohort had a significantly shorter LOS.
Transinguinal Preperitoneal Patch (TIPP) under Local Anesthesia with Sedation
Authors: PÉLissier Edouard P. , Ngo Philippe , Gayet Brice
Published: June 2020

Transinguinal preperitoneal placement of the patch (TIPP) combines the advantages of the preperitoneal patch and the simplicity of the inguinal approach. The aim of the study was to evaluate the feasibility of TIPP under local anesthesia (LA) with sedation on a series of unselected patients. All 161 patients referred to one of us for inguinal hernia repair were included in a prospective evaluation; they were operated on for 169 inguinal hernias, in LA with sedation. TIPP was the routine method and was used in all but a few particular cases. TIPP was performed in 139 cases out of 169 (82.2%). In 21 cases (12.4%) another method was chosen, due to the patient's age, the patient's request, or the type of the hernia. In nine cases (5.3%) another technique was used because preperitoneal dissection was not possible, due to a previous preperitoneal surgery. In the 139 cases where a TIPP was performed, general anesthesia was used in four cases at the patient's request and spinal anesthesia in two cases of large irreducible scrotal hernias in old, frail patients. TIPP was begun under LA in 133 cases and conversion to general anesthesia was necessary in one case only. Therefore, TIPP under LA was possible in 132 cases out of 139 (95%). These results suggest that TIPP can be performed under LA in most cases. The expected advantages of combining preperitoneal patch repair and local anesthesia are worth being confirmed by comparative studies.
Regional Block Anesthesia for Mastectomy: A Community Hospital Experience
Authors: Neustein Charles L. , Turner Anita
Published: June 2020

This report describes a community hospital experience with regional anesthesia for mastectomy. The authors believe this is a modality deserving of wider application. This report is intended to illuminate the benefits of the approach.
Missed Inadvertent Gastrointestinal Injuries during Abdominal Operations: Characteristics, Diagnosis, and Treatment
Authors: Khoury Wisam , Abu-Abeid Subhi , Person Benjamen , Klausner Joseph M. , Kariv Yehuda
Published: June 2020

Inadvertent gastrointestinal tract injuries (IGITI) during abdominal operations increase postoperative morbidity. Common mechanisms for this type of injury are not well-defined. The risk factors associated with an increase in missed IGITI during elective abdominal surgery and a possible strategy that may contribute to early diagnosis were not previously evaluated. Between 1998 and 2006, all the patients who underwent a subsequent laparotomy within 30 days of an index operation were identified. Patients reoperated for missed IGITI, defined as perforation at sites other than previous anastomosis or bowel repair, were collected. Data pertaining to patients, disease, and primary operations’ characteristics, as well as reoperation findings and outcomes were studied. Methods of diagnosis of perforation for each particular patient were assessed. Thirty-two patients (15 females, 17 males) underwent a second operation for gastrointestinal tract leak within 30 days of an index surgery due to missed IGITI. The mean age was 59.5 ± 18.2 years (range 21–87). The average time between the first and second operation was 5.3 ± 3.5 days (range 1–13). Adhesions (27 patients), previous operations (20 patients), and laparoscopic approach (13 patients) were the most commonly documented factors that may result in missed IGITI. Diagnosis of gastrointestinal leak due to missed IGITI was made clinically in 12 patients. Twenty patients underwent contrast study before reoperation. Careful selection of patients and type of surgery in addition to awareness of this rare complication may decrease the frequency of missed IGITI, lead to earlier diagnosis, and possibly improve outcomes.
Annual Mammography Screening: Is it Necessary?
Authors: Hegar Veronica , Oliveira Kristin , Kakarala Bharat , Mangram Alicia , Dunn Ernest
Published: June 2020

Recent recommendations from the U.S. Preventative Services Task Force suggest that screening mammography for women should be biennial starting at age 50 years and continue to age 74 years. With these recommendations in mind, we proposed a study to evaluate women at our institution in whom breast cancer is diagnosed within 1 year of a previously benign mammogram. A retrospective chart review was performed over a 4-year period. Only patients who had both diagnostic mammograms and previous mammograms performed at our institution and a pathologic diagnosis of breast cancer were included. Benign mammograms were defined as either Breast Imaging Reporting And Data System 1 or 2. Analysis of the time elapse between benign mammogram and subsequent mammogram indicative of the diagnosis of breast cancer was performed. A total of 205 patients were included. The average age was 64 years. From our results, 48 patients, 23 per cent of the total, had a documented benign mammogram at 12 months or less before a breast cancer diagnosis. One hundred forty-three (70%) patients had a benign mammogram at 18 months or less prior. This study raises concern that 2 years between screening mammograms may delay diagnosis and possible treatment options for many women.
Body Mass Index is a Risk Factor of Pancreatic Fistula after Pancreaticoduodenectomy
Authors: Shimoda Mitsugi , Katoh Masato , Yukihiro Iso , Kita Junji , Sawada Tokihiko , Kubota Keiichi
Published: June 2020

Pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is still a severe complication and a challenging problem. The common risk factors are the soft pancreas and small pancreatic duct of the remnant pancreas. Those two risk factors were recognized during surgery. On the other hand, a preoperatively determined risk factor of PF is unclarified. We conducted a retrospective analysis of 203 patients consecutively treated by PD from April 2000 to October 2010. PF was defined according to the criteria of the International Study Group of Pancreatic Fistula. Clinical and pre-and intraoperative data were compared between PF and non-PF patients. The recommended cutoff value of body mass index (BMI) as 20 kg/m2 was defined by receiver operating characteristic curve analysis. PF occurred in 53 (26.1%) of 203 patients. In univariate analysis, BMI and soft remnant pancreas were found to be risk factors of PF ( P = 0.027, P = 0.005). In multivariate analysis, BMI and soft pancreas were also risk factors of PF ( P = 0.040, P = 0.005). Patients with PF had a significantly longer hospital stay than non-PF patients ( P = 0.005). High BMI and soft pancreas were significant risk factors for PF.
Incidental Findings in Trauma Patients during Focused Assessment with Sonography for Trauma
Authors: Lanitis Sophocles , Zacharioudakis Constantinos , Zafeiriadou Paraskevi , Armoutides Vasileios , Karaliotas Charilaos , Sgourakis George
Published: June 2020

During the initial assessment of trauma patients they usually undergo a Focused Assessment with Sonography for Trauma (FAST) in which there are occasionally incidental findings of other surgical conditions. In this audit we discuss the incidence, demographics, and implications of these findings and we propose a management algorithm. Within 2 years we managed 6041 trauma patients in the emergency department based on the Advanced Trauma Life Support protocols, 95 per cent of which underwent a FAST ultrasound. Incidental findings were reported in 468 patients (7.8%), whereas in a further 11.2 per cent of these patients there was a second finding. The mean age of these patients was 57.55 years (15–105), and most of them were men (51.1%). The vast majority of the findings were related to the liver and biliary tree (52.1%) followed by the urinary track (27.1% 1 8%). In multivariate analysis only the age was a significant factor associated with incidental findings ( P < 0.001) whereas in univariate analysis both the gender [men (54.1%) vs women (45.9), P = 0.013] and the mechanism of trauma ( P < 0.001) were as important as the age ( P < 0.001). The patients who had incidental findings were 15 years older than the rest. The detection of unknown surgical conditions in FAST may lead to managerial and possible medico-legal issues rendering the development of a proper algorithm mandatory.