bluuebunny/crossref_metadata_2025 huggingface dataset:
Sentinel Lymph Node Mapping for Gastric Adenocarcinoma
Authors: Becher Robert D. , Shen Perry , Stewart John H. , Geisinger Kim R. , Mccarthy Lezah P. , Levine Edward A.
Published: June 2020

The optimal extent of regional lymphadenectomy for gastric adenocarcinoma remains a controversial topic. Traditional approaches have focused on various anatomical nodal stations to define the extent of resection. In this prospective trial, we update our experience with sentinel lymph node (SLN) mapping and biopsy to augment resection of nodal metastasis in gastric carcinoma. Twenty-seven patients with gastric cancer were enrolled. SLNs were identified with isosulfan blue, resected, and sent fresh to pathology for staining and evaluation. The procedure then continued with radical gastrectomy and celiac node dissection. SLNs were identified in all cases. The average patient age was 65 years, with 12 women and 15 men. Eighteen patients had pathology-confirmed nodal metastasis. Positive SLN were found in 15 (83%); three patients had a false negative SLN mapping procedure (17%). Accuracy rate was 88.9 per cent. SLN mapping and biopsy for gastric carcinoma is feasible. However, the negative predictive value is 75 per cent, and therefore caution should be considered in using lymphatic mapping to determine extent of regional lymphadenectomy. Additionally, our study shows no utility in identifying micro-metastatic disease with immunohistochemical techniques. Although a promising modality, we do not recommend the clinical use of SLN mapping for gastric cancer.
Benefits of Mock Oral Examinations in a Multi-institutional Consortium for Board Certification in General Surgery Training
Authors: Subhas Gokulakkrishna , Yoo Stephen , Chang Yeon-Jeen , Peiper David , Frikker Mark J. , Bouwman David L. , Silbergleit Allen , Lloyd Larry R. , Mittal Vijay K.
Published: June 2020

The Southeast Michigan Center for Medical Education (SEMCME) is a consortium of teaching hospitals in the Greater Detroit metropolitan area. SEMCME pools its resources for several educational means, including mock oral board examinations. The educational and cost benefits to mock oral examinations on a multi-institutional basis in preparation for the American Board of Surgery (ABS) certifying examination were analyzed. Ten-year multi-institution data from the mock oral examinations were correlated with ABS certifying examination pass rates. Mock oral examination scores were available for 107 of 147 graduates, which included 12 candidates who failed their certifying examination on the first attempt (pass rate = 89%). Four of 31 examinees who had a low score (4.9 or less) in their mock oral exams failed their certifying examination in their first attempt. The cost of running the mock examination was low (approximately $35/resident for 50 residents). When graduates from the last 10 years were surveyed, the majority of respondents believed that the mock oral examination helped in their success and with their preparation for the certifying examination. Thus, the many benefits of administering the examination with the resources of a consortium of hospitals result in the accurate reproduction of real-life testing conditions with reasonable overall costs per resident.
Perioperative Clopidogrel is Seven Days Enough?
Authors: Grujic Dejan , Martin David
Published: June 2020

Despite the prevalence of surgical candidates on clopidogrel, no definitive guidelines exist for stopping the drug preoperatively. A 7 day off-clopidogrel period is commonly considered safe with regards to bleeding complications. We sought to put the 7-day window to the test with regards to major bleeding events requiring either blood transfusions or return trips to the operating room. We collected data for patients taking clopidogrel in the perioperative period between 2005 and 2007 (n = 170). This data was then compared with the data of all of the patients undergoing surgery at our institution for the same time period (n = 34,480). Patients taking clopidogrel experienced a significantly higher rate of return trips to the operating room (6.5%) compared with nonclopidogrel patients (0.015%). Interestingly, we found no significant difference between those stopping clopidogrel more than 7 days preoperatively and those that did not (5% and 7.5%, respectively). There did not seem to be a significant difference in blood transfusion rates between the two clopidogrel groups. Patients on perioperative clopidogrel require reoperations for bleeding at a significantly higher rate compared with patients not taking clopidogrel. Discontinuing clopidogrel 7 days before surgery is not enough to negate this difference and these patients still experience a drastically higher rate of reoperations for bleeding.
MRI versus Ultrasonography and Mammography for Preoperative Assessment of Breast Cancer
Authors: Wasif Nabil , Garreau Jennifer , Terando Alicia , Kirsch Daniel , Mund Debra F. , Giuliano Armando E.
Published: June 2020

Mammography and ultrasonography are traditional for preoperative estimation of breast cancer size; magnetic resonance imaging (MRI) is more recent but not as well studied. We compared ultrasonography, mammography, and MRI for preoperative imaging of primary breast cancer presenting as a mass in patients treated at our center over a 2-year period. Of the 61 breast cancers with all three imaging modalities performed, 52 were infiltrating ductal cancer, 5 were infiltrating lobular cancer, 2 were ductal carcinoma in situ, and 2 were other histologic types. When pathologic size was used to determine the accuracy of imaging assessments, the Pearson correlation coefficient was better for MRI (r = 0.80) than ultrasonography (r = 0.57) or mammography (r = 0.26). Mean tumor size was 2.1 cm by mammography, 1.73 cm by ultrasonography, 2.65 cm by MRI, and 2.76 cm by pathology. MRI-based tumor size was within 1 cm of pathologic size in 44 (72%) tumors, > 1 cm above pathologic size in 6 (10%) tumors, and > 1 cm below pathologic size in 11 (18%) tumors. We conclude that MRI is more accurate than either ultrasonography or mammography for assessment of the size of primary breast cancer presenting as a mass.
Inflammatory Bowel Disease in the United States from 1998 to 2005: Has Infliximab Affected Surgical Rates?
Authors: Cannom Rebecca R. , Kaiser Andreas M. , Ault Glenn T. , Beart Robert W. , Etzioni David A.
Published: June 2020

The treatment costs for patients in the United States with inflammatory bowel disease (IBD) exceed 1.7 billion dollars/year. Infliximab, an antibody to tumor necrosis factor-α, has been extensively used to treat IBD, with 390,000 IBD patients receiving the drug since its FDA approval in 1998. We sought to determine the impact of infliximab on population-based rates of hospitalizations and surgical care for patients with IBD in the United States. We used data from the Nationwide Inpatient Sample to analyze patterns of hospital-based treatment provided to patients with IBD between 1998 and 2005. Data from this analysis were combined with census data to calculate trends in population-based rates of treatment. Overall rates of hospitalization for patients with Crohn's disease and ulcerative colitis increased significantly between 1998 and 2005 (5.1%/year and 3.4%/year respectively, P < 0.001 for each). During the same time period there were no changes in the overall rates of surgical care. The expanding use of infliximab has not significantly impacted the use of surgical procedures for patients with either ulcerative colitis or Crohn's disease, and rates of nonsurgical hospitalizations have actually increased. Even in the era of infliximab, surgical care remains a mainstay in the treatment of IBD.
Surgical Anatomy of the Retroperitoneal Spaces–Part I: Embryogenesis and Anatomy
Authors: Mirilas Petros , Skandalakis John E.
Published: June 2020

Embryologically, the retroperitoneal (extraperitoneal) connective tissue includes three strata, which respectively form the internal fascia lining of the body wall, the renal fascia, and the covering of the gastrointestinal viscera. All organs, vessels, and nerves, that lie on the posterior abdominal wall, along with their tissues and surrounding connective and fascial planes, are collectively referred to as the retroperitoneum. The retroperitoneal space is the area of the posterior abdominal wall that is located between the parietal peritoneum and the fascia. Within the greater retroperitoneal space, there are also several small spaces, or subcompartments. Loose connective tissue and fat surround the anatomic entities, and, to a variable degree, occupy the subcompartments. The multilaminar thoracolumbar (lumbodorsal) fascia begins at the occipital area and terminates at the sacrum.
Fast Track Postoperative Management after Elective Colorectal Surgery: A Controlled Trail
Authors: Feo Carlo V. , Lanzara Serena , Sortini Davide , Ragazzi Riccardo , De Pinto Mario , Pansini Gian Carlo , Liboni Alberto
Published: June 2020

In the attempt to reduce postoperative complications and costs and improve outcomes, the concept of fast track surgery has been proposed. Improvements in anesthesia techniques and a better understanding of the pathophysiologic events occurring during and after surgery have made it possible. A group of patients undergoing colorectal resections with a fast track approach were investigated; specifically, the effects on postoperative morbidity, resumption of intestinal function, and duration of hospitalization. Fifty patients were managed according to a protocol, which included epidural analgesia, early ambulation, and oral feeding (fast track group); they were compared with 50 patients managed with a different protocol: no epidural analgesia, early ambulation, and early oral diet (control group). Primary outcome end-points reported include morbidity, time to passage of flatus and stool, and length of hospital stay. Fourteen complications occurred in the fast track group and 13 in the control group ( P = not significant (NS)). Resumption of intestinal function occurred after 3 days, and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients ( P = NS, P < 0.01). Patients undergoing elective colorectal resections can be managed safely with fast track protocols reducing hospital stay.
An Evaluation of Lymph Node Yield and Lymph Node Ratio in Well-Differentiated Thyroid Carcinoma
Authors: Beal Shannon H. , Chen Steven L. , Schneider Philip D. , Martinez Steve R.
Published: June 2020

It is unknown whether the number of lymph nodes harvested (lymph node yield, LNY) or the proportion of metastatic lymph nodes resected (metastatic lymph node ratio, MLNR) influence survival in well-differentiated thyroid carcinoma (WDTC). We hypothesized that overall survival in WDTC is influenced by the LNY and MLNR. We used the Surveillance, Epidemiology, and End Results database to identify all patients with primary, nonmetastatic WDTC who underwent thyroidectomy with at least one lymph node removed between 1988 and 2004. Kaplan-Meier survival curves for LNY and MLNR were compared using the log rank test. Multivariate Cox proportional hazards models included tumor and patient-specific factors. WDTC patients that met entry criteria totaled 9926. In the univariate model, LNY and MLNR had a significant impact on survival ( P < 0.001). In multivariate analysis, increasing LNY was associated with poorer survival in all patients ( P = 0.001) and node-negative patients ( P = 0.03), but not for node-positive patients ( P = 0.27). MLNR did not influence survival in node-positive patients ( P = 0.84). Among patients with WDTC treated with thyroidectomy and lymphadenectomy, increasing LNY and MLNR were associated with decreased survival. The decrease in survival associated with increasing LNY, even in node-negative patients, indicates that nodal understaging is inconsequential to WDTC survival.
Running Out of Gas but not Trauma Patients: The Effect of the Price of Gas on Trauma Admissions
Authors: Goettler Claudia E. , Schlitzkus Lisa L. , Waibel Brett H. , Edwards Melinda , Wilhelmsen Bruce , Rotondo Michael F.
Published: June 2020

As fuel costs steadily rise and motor vehicle collisions continue to be a leading cause of morbidity and mortality, we examined the relationship between the price of gasoline and the rate of trauma admissions related to gasoline consumption (GRT). The National Trauma Registry of the American College of Surgeons data of a rural Level I trauma center were queried over 27 consecutive months to identify the rate of trauma admissions/month related to gas utilization compared with the number of nongasoline related trauma admissions, based on season and day of the week. The average price/gallon of regular gas in our region was obtained from the NorthCarolinaGasPrices. com database. A log linear model with a Poisson distribution was created. No significant association exists between the average price/gallon of gasoline and the GRT rate across the months, seasons, and weekday and weekend periods. As the price of gas continues to rise, the rate of rural GRT does not decrease. Over a longer period of time and with skyrocketing prices, this relationship may not hold true. These findings may also be explained by the rural area where limited alternative transportation opportunities exist and a trauma patient population participating in high risk behavior regardless of cost.
Distal Appendiceal Dilatation in Equivocal Appendicitis May be a Useful Sign for Prediction of Normal Appendix
Authors: Park Hyoung-Chul , Jang Mi-Young , Kim In-Gyu , Jeon Jang-Yong , Lee Hae-Wan , Yang Dae-Hyun , Lee Bong-Hwa
Published: June 2020

Despite many efforts to reduce unnecessary appendectomy for appendicitis, the negative appendectomy rate remains relatively high. Here, we investigated predisposing factors for normal appendix by analyzing the surgical outcomes for patients with equivocal appendicitis. Over a 3-year period, 1516 patients underwent treatment for appendicitis and 148 (10%) were prospectively diagnosed with equivocal appendicitis. We defined equivocal appendicitis as a right lower quadrant pain with tenderness and an apppendiceal diameter of 6 to 9 mm without appendicolith or severe adjacent inflammation as radiological findings. We investigated normal appendix rates in relation to clinical and radiological features. Of the 148 patients, 48 (32%) had a normal appendix and 100 had appendicitis. A higher normal appendix rate was found for low white blood cell count than for leukocytosis (41% vs 23%, odds ratio (OR) = 2.48), and laparoscopic treatment was then open (42% vs 21%, OR = 2.58). Distal appendiceal dilatation, as determined by radiological imaging, was associated with a higher normal appendix rate than whole dilatation (60% vs 27%, OR = 3.96). Low white blood cell count, laparoscopic treatment, and distal appendiceal dilatation were significant predisposing factors for normal appendix after surgery. Radiologically determined distal dilatation of the appendix may be a useful sign for predicting normal appendix.
Surgical Treatment of Axillary Accessory Breasts
Authors: Aydogan Fatih , Baghaki Semih , Celik Varol , Kocael Ahmet , Gokcal Fahri , Cetinkale Oguz , Unal Hilal
Published: June 2020

Accessory breast tissue is a remnant persisting after normal embryological development of the breast. Although accessory breasts may be asymptomatic, they can cause discomfort during menstruation, anxiety, cosmetic problems, pain, or restriction of arm movement. The data of all patients who presented with axillary accessory breasts between January 2000 and September 2008 were recruited from a computer database. Medical charts, outpatient records, operative notes, and pathology reports were reviewed. A total of 29 patients underwent surgical treatment of axillary accessory breasts in the Department of Breast Surgery and Department of Plastic, Reconstructive and Aesthetic Surgery. The ages of the patients at the time of surgery ranged from 19 to 54 years. The mean age was 28.8 years. All patients were female. Sixteen patients had unilateral accessory breast and 13 patients had bilateral accessory breasts. Fourteen patients had breast hypertrophy. Twenty-one patients had excision, five patients had liposuction, and three patients had both. Axillary accessory breasts can be satisfactorily treated with excision, liposuction, or both. In patients with concomitant macromastia, reduction mammaplasty and removal of accessory breasts can be performed at the same time with no additional morbidity.
Are Papillary Microcarcinomas of the Thyroid Gland Revealed by Cervical Adenopathy More Aggressive?
Authors: Abboud Bassam , Daher Ronald , Sleilaty Ghassan , Abadjian Gerard , Ghorra Claude
Published: June 2020

Therapeutic attitudes for papillary thyroid microcarcinoma (PTMC) range from observation alone to aggressive management. Clinicopathologic features, therapeutic options, and follow-up results are described in a series of PTMC revealed by cervical adenopathies. Twelve patients were enrolled in this retrospective study. They were all treated by total/near-total thyroidectomy with dissection of suspect cervical lymph nodes followed by radioactive iodine (RAI) and suppressive L-thyroxine therapies. Mean age at diagnosis was 32 years with a mean elapsed time to diagnosis of 45.3 months. Fine needle aspiration cytology and excisional biopsy of the lymph node led to a diagnosis in all cases. Cervical mass was ipsilateral to primary tumor in six patients (50%). Multifocality, bilaterality, and capsular invasion were encountered in 66.7, 66.7, and 41.7 per cent of patients, respectively. Lymph node involvement was bilateral in seven patients (58.3%) of whom thyroid foci were unilateral in two. No complications of thyroidectomy were encountered. At 60-month-follow up, no recurrence or metastasis was noted. PTMC revealed by cervical lymph node metastasis shows aggressive clinicopathologic features. They must be considered as papillary thyroid cancers and managed by total/near-total thyroidectomy with bilateral lymph node exploration followed by RAI therapy and suppressive L-thyroxine doses.
The University of Oklahoma College of Medicine Department of Surgery: Indian Territory to the 21st Century
Authors: Carter Donald R. , Postier Russell G.
Published: June 2020

The Surgery Department of the University of Oklahoma College of Medicine is profiled in this article, including history, goals, opportunities, and demographics. Our research programs, clinical resources, teaching hospitals, and faculty diversity are reviewed. The local and national contributions of our faculty members and 212 chief residents who have completed our program are enumerated.
Computed Tomography versus Magnetic Resonance Imaging for Evaluation of the Cervical Spine: How Many Slices do you Need?
Authors: Brown Carlos V.R. , Foulkrod Kelli H. , Reifsnyder Andrew , Bui Eric , Lopez Irene , Hummell Matthew , Coopwood Ben
Published: June 2020

Controversy exists regarding the correlation between CT and MRI for evaluation of the cervical spine. We hypothesize that newer-generation CT scanners will improve diagnostic accuracy and may obviate the need for MRI in patients with a normal CT. We compared the missed injury rate of four-slice CT and 64-slice CT performed to evaluate the cervical spine. We conducted a retrospective study from January 2004 to June 2008 of all blunt trauma patients who underwent both a CT and MRI to evaluate the cervical spine. One hundred six blunt trauma patients underwent both CT and MRI, including 43 with four-slice and 63 with 64-slice CT. CT missed three injuries (3%), all of which were clinically significant ligamentous injuries seen only on MRI. The 64-slice CT missed no injuries (0%), whereas the four-slice CT missed all three (7%) of the ligamentous injuries ( P = 0.03). Older-generation CT scanners miss clinically significant injuries in blunt trauma patients and should not be independently relied on to evaluate the cervical spine. The newer 64-slice CT scan does not appear to miss clinically significant cervical spine injuries and may allow clearance of the cervical spine in blunt trauma patients without the addition of an MRI.
Colectomy for Fulminant Clostridium difficile Colitis: Predictors of Mortality
Authors: Perera Anton Dias , Akbari Robert P. , Cowher Michael S. , Read Thomas E. , Mccormick James T. , Medich David S. , Celebrezze James P. , Beck Sandra J. , Fischer Peter E. , Caushaj Philip F.
Published: June 2020

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using χ2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (non-survivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.
Trauma Surgeon Personality and Job Satisfaction: Results from a National Survey
Authors: Foulkrod Kelli H. , Field Craig , Brown Carlos V.R.
Published: June 2020

Personality is correlated with job satisfaction, whereas job satisfaction is linked to performance. This study examines personality of practicing trauma surgeons in relation to their job satisfaction. The dominant theory in personality research is the five-factor model, which includes: extraversion, agreeableness, conscientiousness, emotional stability, and openness. The sample was identified from American Association for Surgery of Trauma, Eastern Association for Surgery of Trauma, and Western Trauma Association membership. A web-based survey of demographics and empirically supported measures was created. Four hundred and twelve trauma surgeons (49 ± 14-years-old, 85% male) completed the survey. When comparing satisfied to unsatisfied trauma surgeons on personality variables, extraversion (5.0 ± 1.6 vs 4.4 ± 1.6, P = 0.014) and emotional stability (5.8 ± 1.1 vs 5.4 ± 1.2, P = 0.007) were significantly higher in satisfied surgeons. Moderate correlations were found for job satisfaction with emotional stability (r = 0.20, P < 0.01) and extraversion (r = 0.20, P < 0.01). Logistic regression of personality variables highlighted the significance of emotional stability and extraversion in prediction of job satisfaction. Extraversion and emotional stability are the most significant personality factors to job satisfaction of trauma surgeons. These findings may have important implications for surgical resident recruitment, job performance, and retention.
The Treatment of Radial Scars in the Modern Era—Surgical Excision is not Required
Authors: Sohn Vance Y. , Causey Marlin W. , Steele Scott R. , Keylock Joren B. , Brown Tommy A.
Published: June 2020

The clinical significance of isolated radial scars (RS) diagnosed on core needle biopsy (CNB) remains unclear. By determining the pathologic concordance rate, we sought to define the indications for surgical excision for RS diagnosed on CNB. Between January 1994 and December 2007, 38 RS were diagnosed by CNB. Twenty-eight underwent surgical excision with 27 (96%) patients having further benign diagnoses. One patient, who was found to have invasive cancer on CNB, was also found to have malignancy on open biopsy. Fourteen lesions were diagnosed by 8-gauge, 13 lesions by 11-gauge, and one lesion by 14-gauge biopsy needles. Seven studies met inclusion criteria for analysis; 341 lesions with follow-on surgical biopsy were identified. Sixteen (5%) radial scars were found to harbor malignancy and all were percutaneously biopsied with 14-gauge needles. With the inclusion of the current study, none of the isolated radial scars diagnosed by the larger 11- or 8-gauge biopsy needles resulted in upgraded lesions on follow-on surgical biopsy. Based on the current review, histologic radial scars are infrequently associated with occult malignancy and do not mandate surgical excision. Indications for excision include the mammographic diagnosis of RS and specimens associated with atypia that would otherwise require open biopsy.
Second Primary Melanomas: Incidence and Outcome
Authors: Bower Matthew R. , Scoggins Charles R. , Martin Robert C. G. , Mays Michael P. , Edwards Michael J. , Reintgen Douglas S. , Ross Merrick I. , Urist Marshall M. , Noyes R. Dirk , Sussman Jeffrey J. , Hagendoorn Lee J. , Stromberg Arnold J. , McMasters Kelly
Published: June 2020

The objective of this study was to determine the incidence of multiple primary melanomas (MPM) and other cancers types among patients with melanoma. Factors associated with development of MPM were assessed in a post hoc analysis of the database from a multi-institutional prospective randomized trial of patients with melanoma aged 18 to 70 years with Breslow thickness 1 mm or greater. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis. Forty-eight (1.9%) of 2506 patients with melanoma developed additional primary melanomas. Median follow-up was 66 months. Except in one patient, the subsequent melanomas were thinner (median, 0.32 mm vs 1.50 mm; P < 0.0001). Compared with patients without MPM, patients with MPM were more likely to be older (median age, 54.5 vs 51.0 years; P = 0.048), to have superficially spreading melanomas (SSM) ( P = 0.025), to have negative sentinel lymph nodes ( P = 0.021), or to lack lymphovascular invasion (LVI) ( P = 0.008) with the initial tumor. On multivariate analysis, age ( P = 0.028), LVI ( P = 0.010), and SSM subtype of the original melanoma ( P = 0.024) were associated with MPM. Patients with MPM and patients with single primary melanoma had similar DFS (5-year DFS 88.7 vs 81.3%, P = 0.380), but patients with MPM had better OS (5-year OS 95.3 vs 80.0%, P = 0.005). Nonmelanoma malignancies occurred in 152 patients (6.1%). Ongoing surveillance of patients with melanoma is important given that a significant number will develop additional melanoma and nonmelanoma tumors. With close follow-up, second primary melanomas are usually detected at an early stage.
The Effect of Age on Blunt Traumatic Brain-Injured Patients
Authors: Bhullar Indermeet S. , Roberts Eric E. , Brown Lianne , Lipe Heidi
Published: June 2020

An increasing number of super geriatric (age older than 80 years) patients are being hospitalized with traumatic brain injury (TBI). Although geriatric (age older than 65 years) patients have been reported to have a worse functional outcome compared with younger patients who present with the same or less severe degree of TBI; the mortality for the super geriatric (age older than 80 years) remains to be determined. Knowledge of their hospital mortality may help improve clinical decision-making protocols and resource use. A retrospective chart review of patients who sustained TBI after blunt trauma was performed over a 3-year period (June 2005 to June 2008) at a Level II trauma center. Mortality was calculated for various age groupings and data analyzed using analysis of variance test and χ2 test. We hypothesized that mortality would increase significantly with increasing age from the geriatric to the super geriatric group. A total of 2369 patients were evaluated with 744 pediatric patients in Group I (age younger than 17 years), 1297 adult patients in Group II (age 17-64 years), 185 geriatric patients in Group III (age 65-80 years), and 143 super geriatric patients in Group IV (age older than 80 years). The respective mortalities for each group were as follows: Group I (6%), Group II (9%), Group III (21%), and Group IV (6%). There was no significant difference in the Injury Severity Score for the four groups. In comparing Group III with Groups I and II, we found a significant increase in mortality with increasing age as reported in the literature (21 vs 6%, P = 0.01 and 21 vs 9%, P = 0.04). However, in comparing Group IV with the other three groups, there was no significant difference in mortality. There was a trend toward decrease in mortality from age Group III to IV (21 vs 6%, P = 0.09), which is of unclear etiology and warrants further study. In patients with blunt TBI, there is no significant difference in mortality between the super geriatric age group (age older than 80 years) and the younger pediatric, adult, and geriatric age groups. Resource use therefore should not be limited to patients older than 80 years with TBI.
Body Image Perception and Quality of Life in Patients who Underwent Breast Surgery
Authors: Medina-Franco Heriberto , GarcÍA-Alvarez Miriam N. , Rojas-GarcÍA Priscila , Trabanino Carolina , Drucker-Zertuche MÓNica , Psych Denise Arcila
Published: June 2020

Quality of Life (QoL) has become a standard measure in assessing the effectiveness of medical interventions. We compared the differences between QoL and body image scale (BIS) in a group of patients who underwent breast surgery, including lumpectomy or conservative surgery, modified radical mastectomy and radical mastectomy with breast reconstruction. We included patients who underwent breast surgery between August of 2005 and June of 2006 in two tertiary referral centers in Mexico City. Two self-administered questionnaires assessing body image perception, BIS and quality of life (SF-36), were assigned and a physician-conducted interview was done. We stratified patients by age, marital status, and scholar grade. The sample comprised 202 patients. The BIS results yielded: the group with a benign lesion demonstrated favorable body image perception when compared with the malignant lesion group. A confirmed diagnosis of malignancy hinders QoL in older and younger age groups. Conservative surgery and breast reconstruction improves QoL in younger patients without significance in the older group. The most significant variable that hinders the BIS and QoL is the cancer diagnosis. Impact of conservative surgery and breast reconstruction in body image perception and quality of life is influenced by patient age and educational level.
Is Thoracoscopic Decortication Sufficient for the Treatment of Empyema?
Authors: Manunga Jesse , Olak Jemi
Published: June 2020

Before thoracoscopy became popular in the 1990s, thoracotomy and decortication was the treatment of choice for empyema thoracis not responding to tube thoracostomy. An Institutional Review Board-approved, retrospective review of all patients treated for empyema between September 1, 2006, and August 31, 2009, at Kern Medical Center was conducted. A total of 37 patients (male = 33; female = 4) with a mean age of 43.7 years were treated. Empyema developed after community-acquired pneumonia (CAP) in 27, traumatic hemothorax (TH) in nine, and other cause in one. For 34 of 36 patients (91%), a thoracoscopic approach was successful. Two of 36 patients required conversion to thoracotomy, whereas one patient required an initial thoracotomy in each case as a result of tenacious adhesions. Mean duration of the chest tube was 4.1 days in patients with CAP and 4.6 days in patients with TH. Mean length of stay after surgery was 6 days for patients with CAP and 9.1 days for patients with TH. Five of 37(13.5%) had complications and one patient died (2.7%). Follow-up was complete for 81.1 per cent of patients, none of whom required a subsequent intervention. Compared with the literature, it appears that the conversion rate to thoracotomy, length of chest tube duration, and postoperative length of stay have decreased as experience has increased.
The General Surgery Residency at Maine Medical Center
Authors: Prabhu Ajita S. , Dreifus Jonathan F. , Whiting James F.
Published: June 2020

The surgical residency at Maine Medical Center is the only surgical residency in Maine. Established in 1947, it presently graduates four categorical residents/year. The residency is a classic example of a “hybrid” residency, retaining the benefits of a community program in terms of large operative experience in a wide variety of procedures, while at the same time allowing for academic exposure through a university affiliation.
Gender-Specific Prognostic Markers of Patients with Gallbladder Cancer after Surgical Resection
Authors: He Xiao-Dong , Liu Wei , Tao Lian-Yuan , Cai Lei , Zhou Li , Qu Qiang
Published: June 2020

The aim of this study was to elucidate gender-specific markers for postresectional long-term survival of gallbladder cancer (GBC) based on a cohort of Chinese patients. Clinicopathological records of 81 patients (27 males and 54 females) after surgical resection for GBC were reviewed retrospectively. The influence of each variable on survival was determined using the Kaplan-Meier method and log-rank test. For females, Cox regression analysis was also adopted. Univariate analysis showed that the absence of lymph node and distant metastases, differentiation grade, and curative resection were associated with prolonged survival for all males, whereas tumor size, differentiation grade, and the presence of lymph node metastases influenced the overall or disease-free survival of patients after curative resection (all P < 0.05). On the other hand, Nevin stage was an independent marker for both overall survival for all females and overall and disease-free survival for female patients who underwent curative resection. Additionally, resection type and differentiation grade were of independent prognostic significance for different subgroups of females (all P < 0.05). Our data suggested that tumor-related factors affect prognosis of both male and female patients with GBC after resection. Of these factors, tumor differentiation status might be more significant for males, but Nevin stage had a stronger predictive potential for females.
Does Prophylactic Subcutaneous Heparin Increase the Risk of Wound Infection after Colorectal Surgery?
Authors: Milanchi Siamak , Nasserl Yosef , Westhout Franklin , Murrell Zuri A. , Fleshner Phillip R.
Published: June 2020

Chemical prophylaxis using unfractionated heparin (UH) and low-molecular weight heparin is used in surgical patients to prevent venous thromboembolism. There is some evidence that prophylactic doses of heparin may increase the rate of surgical site infection (SSI) after elective orthopedic procedures. Little is known regarding the effect of heparin on SSI after colorectal procedures. We performed this study to study the effect of prophylactic unfractionated heparin on the rate of SSI after colorectal procedures. We did a retrospective analysis of 155 consecutive cases of patients of a single colorectal surgeon who underwent colorectal resection. Subcutaneous unfractionated heparin was given to 52 patients (29%). The rate of SSI in the group that received UH was 33 per cent versus 28 per cent in the group that did not receive UH ( P = 0.31). There was also no significant effect of prophylactic heparin on SSI noted among any patient subgroup. The use of prophylactic unfractionated heparin after colorectal procedures does not seem to increase the rate of surgical site infection.
Aortic Root Surgery Does Not Increase the Operative Risk of Acute Type A Aortic Dissection
Authors: Montalvo Jose , Razzouk Anees , Wang Nan , Bansal Ramesh , Rasi Alfredo , Hasaniya Nahidh , Floridia Rosario , Bailey Leonard
Published: June 2020

Controversy exists regarding aortic root reconstruction in the management of acute type A aortic dissection (AAD). One hundred fifty-four patients (mean age 56.9 ± 11.3 years) with AAD had surgical repair between 1996 and 2007. Group 1 (n = 110) required no aortic root surgery. Seventy-one patients had ascending aortic replacement. The aortic valve was repaired in 37 patients (34%) and replaced in one. Group 2 (n = 44) had aortic root surgery. Thirty-four patients had composite root replacement, and seven had a valve-sparing root replacement. Root reconstruction and separate valve replacement was accomplished in three. Hemiarch replacement was included in 39 (35.4%) Group 1 patients and in 12 (27.9%) Group 2 patients. Forty-nine of the 154 patients presented in cardiogenic shock. Multiple risk factors for operative mortality were analyzed. The overall operative mortality was 9.7 per cent: 11 per cent for Group 1 and 6.8 per cent for Group 2 ( P = NS). By multivariate analysis, preoperative shock ( P = 0.03, odds ratio [OR] = 5.48), postoperative ventricular arrhythmias ( P = 0.002, OR = 4.62), and packed red blood cell transfusion ( P = 0.002, OR = 1.15) were independent predictors of hospital death. Prompt surgical treatment of AAD before cardiogenic shock ensues can improve the outcome of patients. When indicated, aortic root surgery can be performed without increased mortality and morbidity.
Liver Cirrhosis and Traumatic Brain Injury: A Fatal Combination Based on National Trauma Databank Analysis
Authors: Lustenberger Thomas , Talving Peep , Lam Lydia , Inaba Kenji , Branco Bernardino Castelo , Plurad David , Demetriades Demetrios
Published: June 2020

The purpose of this study was to evaluate the impact of liver cirrhosis on in-hospital outcomes in victims of isolated traumatic brain injury (TBI). This was a National Trauma Databank study over a 5-year period, including patients with isolated TBI. Propensity scores were calculated to match cirrhotic with noncirrhotic TBI patients in a 1:2 ratio. Primary outcomes included mortality, hospital and surgical intensive care unit length of stay, and ventilator days. Of the 35,005 patients with isolated TBI, 47 (0.13%) had documented liver cirrhosis. After matching with 94 noncirrhotic, isolated TBI patients, no differences with regards to demographic and clinical injury characteristics were observed comparing the two groups. The mean SICU length of stay for cirrhotic and noncirrhotic patients was 5.4 ± 8.8 days and 3.7 ± 7.0 days, respectively ( P = 0.079). Cirrhotic patients experienced significantly more ventilator days compared with their noncirrhotic counterparts (2.9 ± 6.4 days vs 2.0 ± 6.4 days; P = 0.001). Overall mortality in the study population was 23.4 per cent with significantly higher in-hospital mortality among cirrhotic versus noncirrhotic TBI patients [34.0% vs 18.1%; odds ratio (95% confidence interval): 2.34 (1.05-5.20); P = 0.035]. Traumatic brain injury in conjunction with liver cirrhosis is associated with two-fold increased mortality and significantly prolonged ventilator requirements when compared with their noncirrhotic counterparts of isolated TBI.
Two-Port Laparoscopic Common Bile Duct Exploration with T-tube Choledochostomy for Management of Choledocholithiasis: An Initial Clinical Report
Authors: Sun Ding-Ping , Wang Wen-Ching , Wen Kuo-Chang , Lin Kai-Yuan , Lin Yi-Feng , Wen Kuo-Shan , Uen Yih-Huei
Published: June 2020

Laparoscopic common bile duct exploration (LCBDE) is generally performed using a four- or five-port technique. We report a unique technique of two-port transcholedochal LCBDE with T-tube placement. Twelve consecutive patients with common bile duct (CBD) stones underwent LCBDE through two entry ports, one homemade single port (Uen port) inserted in a 2-cm umbilical wound and one 5-mm subxiphoid trocar port. With the assistance of a 1.2-mm needle that was inserted through a right lower intercostal space into the abdominal cavity to facilitate the operation, two-port dome-down laparoscopic cholecystectomy, choledochotomy, choledochoscopic removal of ductal caculi, and T-tube choldochostomy were performed with conventional methods using standard laparoscopic instruments along with manually operated angled shafts. After completion of the operation, the T-tube catheter was brought out through the subxiphoid trocar wound. All operations were completed successfully without the need of additional ports. There was no complication and no residual stones. Mean operation time was 120 minutes (range, 90 to 150 minutes), and mean postoperative hospital stay was 3.5 days (range, 3 to 4 days). Scarless wound healing was achieved except one T-tube scar. Two-port transumbilical LCBDE with T-tube choledochostomy is a feasible, safe, and effective technique that allows one-scar abdominal surgery for treatment of CBD stones. Further studies and the development of better instruments are necessary before this can be recommended as a standard procedure.
Lidocaine Patches Reduce Pain in Trauma Patients with Rib Fractures
Authors: Zink Karen A. , Mayberry John C. , Peck Ellen G. , Schreiber Martin A.
Published: June 2020

Rib fracture pain is notoriously difficult to manage. The lidocaine patch is effective in other pain scenarios with an excellent safety profile. This study assesses the efficacy of lidocaine patches for treating rib fracture pain. A prospectively gathered cohort of patients with rib fracture was retrospectively analyzed for use of lidocaine patches. Patients treated with lidocaine patches were matched to control subjects treated without patches. Subjective pain reports and narcotic use before and after patch placement, or equivalent time points for control subjects, were gathered from the chart. All patients underwent long-term follow-up, including a McGill Pain Questionnaire (MPQ). Twenty-nine patients with lidocaine patches (LP) and 29 matched control subjects (C) were analyzed. During the 24 hours before patch placement, pain scores and narcotic use were similar (LP 5.3, C 4.6, P = 0.19 and LP 51, C 32 mg morphine, P = 0.17). In the 24 hours after patch placement, LP patients had a greater decrease in pain scores (LP 1.2, C 0.0, P = 0.01) with no change in narcotic use (LP -8.4, C 0.5-mg change in morphine, P = 0.25). At 60 days, LP patients had a lower MPQ pain score (LP 7.7, C 12.2, P < 0.01), although only one patient was still using a patch. There was no difference in time to return to baseline activity (LP 73, C 105 days, P = 0.16) and no adverse events. Lidocaine patches are a safe, effective adjunct for rib fracture pain. Lidocaine patches resulted in a sustained reduction in pain, outlasting the duration of therapy.
Randomized Objective Comparison of Live Tissue Training versus Simulators for Emergency Procedures
Authors: Hall Andrew B.
Published: June 2020

There is a lack of objective analysis comparing live tissue and simulator training. This article aims to objectively determine the difference in outcomes. Twenty-four Air Force volunteers without prior experience performing emergency procedures were randomly assigned to receive training in tube thoracostomy (chest tube) and cricothyroidotomy training on either a pig model (Sus scrofa domestica) or on the TraumaMan simulator. One week posttraining, students were tested on human cadavers with objective and subjective results recorded. Average completion time for tube thoracostomy in the animal model group was 2 minutes 4 seconds and 1 minute 51 seconds in the simulator group with a mean difference of 12 seconds ( P = 0.74). Average completion time for cricothyroidotomy in the animal model group was 2 minutes 35 seconds and 3 minutes 29 seconds in the simulator group with a mean difference of 53 seconds ( P = 0.32). Overall confidence was 9 per cent higher in the animal trained group ( P = 0.42). Success rate of cricothyroidotomy was 75 per cent in the animal model group and 58 per cent in the simulator-trained group ( P = 0.67). Success rate of chest tube placement was 92 per cent in the animal group and 83 per cent in the simulator group ( P = 1.00). There was no statistically significant difference in chest tube and cricothyroidotomy outcomes or confidence in the groups trained with live animal models or simulators at the 95 per cent confidence interval. Trends suggest a possible difference, but the number of cadavers required to reach greater than 95 per cent statistical confidence prohibited continuation of the study.
Hepatic Aneurysm: A Review
Authors: Hulsberg Paul , De La Garza-Jordan Julia , Jordan Robert , Matusz Petru , Tubbs R. Shane , Loukas Marios
Published: June 2020

Originally described over 220 years ago, the clinical scenario of hepatic aneurysms remains incompletely understood. Moreover, its optimal treatment has yet to be defined. The present paper reviews the literature regarding this pathological state of the abdomen and discusses what is known regarding the presentation, diagnosis, and anatomy of hepatic arterial aneurysms.
Hepatic Artery Aneurysms: Evolution from Open to Endovascular Repair Techniques
Authors: Christie Amy B. , Christie D. Benjamin , Nakayama Don K. , Solis Maurice M.
Published: June 2020

With the development of endovascular therapy, treatment for hepatic artery aneurysm (HAA) has evolved from open excision and repair to include endovascular approaches. We reviewed our recent experience with HAA to help define the treatment of HAA. From 2002 to 2010, five patients underwent treatment of HAA, all men with a median age of 63.2 years (range, 41-75). The median diameter of HAA was 5.8 cm (range, 2.4 cm-11 cm). Four lesions involved the extrahepatic portion of the hepatic artery, and one was an intrahepatic HAA that involved the right hepatic artery. Three were true aneurysms and two were pseudoaneurysms associated with trauma. Four of the five HAA patients were symptomatic, three with nonspecific abdominal pain, and one with free hemorrhage from a ruptured intrahepatic pseudoaneurysm. All five underwent computed tomography and selective arteriography. Two patients underwent open surgical aneurysmectomy and revascularization because of aneurysm location and concerns of the potential lack of collateral flow. Three patients underwent an endovascular coil embolization because obliteration of a saccular aneurysm could be achieved without compromising arterial flow of the native hepatic vessel. Re-embolization was necessary in the intrahepatic aneurysm because of recanalization of a feeding vessel. Endovascular embolization is an important minimally invasive approach in the treatment of HAA. Depending on HAA location and the adequacy of collateral arterial flow around the lesion, open aneurysmectomy and revascularization may be required.